Medevac Alaska Feedback Form
Please complete this brief form of how we did. While not required we request you leave name and phone number so we may follow up with you when needed. In the feedback and comments section please leave specifics of any concerns or other information you would like us to know.
Date of transport or issue:
Patient's Name or Initials (optional):
Name and title of person completing form (i.e. John Doe, or Jane Doe RN). Optional but requested.
Contact phone (Optional):
Role of individual completing survey:
Referring Facility Staff
Receiving Facility Staff
Other Flight Crew/Health Care Provider
Type of Service
Names of crew members (if available):
Did the Medevac Alaska Transport Team arrive at the bed side at or before the expected time?
Did the Medevac Alaska transport team arrive with all the necessary equipment to provide care during your transport?
How professional was the crew from Medevac Alaska?
Not at all Professionally
Neither satisfied or dissatisfied
Do you have any specific concerns, Incident details, or feedback you would like to provide? Please include positive and/or negative experience as appropriate. You may also copy and paste longer text into this field.
Would you like a supervisor to contact you regarding this survey?
Send me a copy of my responses.
Never submit passwords through Google Forms.
This form was created inside of Medevac Alaska.
Terms of Service