Free Ambulance Complaint Form Template
Ambulance Complaint Form
Please complete all sections to ensure we can address your complaint promptly and professionally.
Personal Information
Name
Address
Phone Number
Complaint Details
Date of Incident
Location (Pickup or Drop-off Address)
Ambulance ID or Vehicle Number (if known)
Staff Member(s) Involved (if applicable)
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Contact Number |
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Nature of Complaint
Check all that apply:
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Delayed Response Time
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Unprofessional Behavior
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Equipment/Vehicle Issue
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Billing/Charges Concern
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Incorrect Destination
Description of Incident
Provide a detailed account of what occurred. Include relevant times, locations, and interactions. Attach additional pages if necessary.
Action Taken
Have you reported this issue to anyone else?
If yes, please specify:
Desired Resolution
Describe how you would like this to be resolved.
Supporting Document
Upload a file to support the complaint.
By signing below, I affirm that the information provided is accurate to the best of my knowledge.
Name:
Date:
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