Event medical patient feedback form

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Thank you for participating in our feedback form.

We want to hear your feedback so we can keep improving our logistics and clinical care. Please fill this quick survey and let us know your thoughts (your answers will be anonymous).

Date and time of your encounter with Westcare Ambulance

YYYY

Time

Location of your encounter with Westcare Ambulance

Brief description of your injury or illness

How many days did it take you to recover?

1-7 days

7-14 days

Greater than 14 days

Other:

Clear selection

How satisfied were you with the treatment you received? *

Not very

Very much

Was your pain addressed appropriately? *

Not very

Very much

Additional feedback on staff members *

How were you transported to hospital? (If applicable)

St John Ambulance (Green Ambulance)

Westcare Ambulance (Blue Ambulance)

Private Car by a friend or family member

Drove myself

Other:

Clear selection

How well do you think you were listened to?

Poorly

Excellently

Clear selection

Describe the attitude of staff members?

Any overall feedback for the event?

Name (optional)

Do you identify as Aboriginal and/or Torres Strait Islander?

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, both Aboriginal and Torres Strait Islander

Clear selection

Email (optional) - however needed to receive your incentive

Submit

Clear form

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