LifeFlight® Referral Hospital Survey
Patient First and Last Name
*
:
Date of Transport
*
:
Calendar
Today
Staff Initials
*
:
Thank you for completing this survey. We are constantly improving the services we provide to you, and appreciate your evaluation of this transport.
Did the LifeFlight® Team arrive to your referral request in a reasonable time?:
Yes
No
Additional Comments:
Did you receive enough patient consultation and/or information over the telephone to help in caring for the patient?:
Yes
No
Additional Comments:
After arrival, did the LifeFlight® Team communicate appropriate feedback regarding stabilization plans and possible diagnosis?:
Yes
No
Additional Comments:
Did the LifeFlight® Team communicate appropriately with the family?:
Yes
No
Additional Comments:
Do you feel that you would benefit, at this time, from an educational program by the LifeFlight® Program?:
Yes
No
Additional Comments:
Your overall impression of this transport and the LifeFlight® Team members:
*
:
Excellent
Above Satisfactory
Neutral
Needs Improvement
Below Satisfactory
Do you have any recommendations for improving future transports?:
Referring Hospital
*
:
Telephone:
(
)
-
Second three digits
Last four digits
Name of Person
*
: