We would like to ask you a few short questions about your experience with Falls Co. EMS.

YOUR IDENTITY WILL BE KEPT STRICTLY CONFIDENTIAL.

We Welcome and value all responses.

We very much appreciate your assistance with our work to continuously improve the level of
emergency medical services to our community.
1. Date of Service/Incident. (Please approximate if you do not know the exact date.)
Date
 Year
Time
Month
2. Patient's Name (Not required but very helpful.  STRICT CONFIDENTIALITY WILL BE MAINTAINED)
First Name:
Last Name:
3. Were you the:


403 Bridge Street - Marlin, Texas 76661
Office: 254-883-5445 - Fax: 254-803-2024