File a Complaint

Susquehanna Township EMS, Inc. is always eager to hear feedback from our Patients and Family Members. This includes Positive and Constructive Negative feedback. We request that you complete all aspects of this form so that we can properly investigate and correct deficiencies that you or a loved experienced during our treatment.
Name of the Person Making the Complaint
First Last
Not required, but strongly recommended in order to evaluate your complaint. While anonymous complaints will be evaulated, complaints may require follow up in order to determine the extent and severity of the issue. If Management is unable to follow up, we may not be able to properly address the complaint.
Date of Service*
MM slash DD slash YYYY
Time of Service*

: Hours

Minutes

AM/PM

Approximate time of the incident
Location the Incident Occured*
Street Address Address Line 2 City State ZIP Code
Description of the Complaint*
May We Contact you about the Complaint?*
Contact Number
Contact Email
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