Feedback Leave this empty Date Time 1. Were you treated with dignity and respect? (5 = Excellent, 4 = Very Good, 3 = Good, 2 = Satisfactory, 1 = Poor) 5 – Excellent4 – Very Good 3 – Good2 – Satisfactory1 – Poor 2. Were the ambulance crew helpful, polite and efficient? (5 = Excellent, 4 = Very Good, 3 = Good, 2 = Satisfactory, 1 = Poor) 5 – Excellent4 – Very Good 3 – Good2 – Satisfactory1 – Poor 3. Were the ambulance crew on time? (5 = Excellent, 4 = Very Good, 3 = Good, 2 = Satisfactory, 1 = Poor) 5 – Excellent4 – Very Good 3 – Good2 – Satisfactory1 – Poor 4. Was the ambulance clean and tidy? (5 = Excellent, 4 = Very Good, 3 = Good, 2 = Satisfactory, 1 = Poor) 5 – Excellent4 – Very Good 3 – Good2 – Satisfactory1 – Poor 5. Did the ambulance crew communicate efficiently with you? (5 = Excellent, 4 = Very Good, 3 = Good, 2 = Satisfactory, 1 = Poor) 5 – Excellent4 – Very Good 3 – Good2 – Satisfactory1 – Poor 6. Did the ambulance crew listen carefully to you? (5 = Excellent, 4 = Very Good, 3 = Good, 2 = Satisfactory, 1 = Poor) 5 – Excellent4 – Very Good 3 – Good2 – Satisfactory1 – Poor 7. Were the ambulance crew professional? (5 = Excellent, 4 = Very Good, 3 = Good, 2 = Satisfactory, 1 = Poor) 5 – Excellent4 – Very Good 3 – Good2 – Satisfactory1 – Poor 8. Were the ambulance crew caring and respond to your needs? (5 = Excellent, 4 = Very Good, 3 = Good, 2 = Satisfactory, 1 = Poor) 5 – Excellent4 – Very Good 3 – Good2 – Satisfactory1 – Poor 9. How would you rate the overall experience with Reliance Ambulance? (5 = Excellent, 4 = Very Good, 3 = Good, 2 = Satisfactory, 1 = Poor) 5 – Excellent4 – Very Good 3 – Good2 – Satisfactory1 – Poor Comments Client's initials Crew initials Signature (patient or authorised representative) Clear I consent to my feedback (without my full name) being used on the Reliance website and printed materials. Submit