Patient Outcome Request Form
This form is for requesting patient outcome information from EMS calls. You are only entitled to make a request for patient outcome information if you were a provder listed on the EMS run sheet. We will attempt to get information to you in as timely of a manner as possible, but please undersntad that these requests can and do take a significant amount of time to complete. Please DO NOT include a patient name in the request. If we require additional information we will contact you
Date of EMS Service
Agency Providing EMS Transport
Run Number of Patient Encounter
Your answer
Hospital Patient Transported To
EMS Provider Making Request
Your answer
EMS Provider Email Address
Your answer
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms