Ambulance owners sign up

Fill in the correct information

Organization Name: *

Contact Person *

Position/Title *

Email Address *

Phone Number *

Alternate Contact Person (if applicable):

Email Address

Phone Number

Organization's Address: *

Address Line 1

City

State / Province / Region

Country

Service Area(s) Covered: *

Types of Ambulance Services Offered:

(Select all that apply)

Please specify

Number of Ambulances *

Staff Qualifications *

(Select all that apply)

Languages Spoken by Staff *

Equipment and Features *

Stretchers
Medical Supplies (bandages, dressings, gauze, etc.)econd Choice
Oxygen Delivery System (tanks, masks, tubing)
Defibrillator
Suction Device
First Aid Kit
Splints
Monitoring Equipment (cardiac monitor, pulse oximeter, blood pressure cuff)
Airway Management Equipment (oral/nasal airways, endotracheal tubes, laryngoscopes)
Medications
Diagnostic Tools (glucometers, thermometers)
Personal Protective Equipment (gloves, masks, goggles, gowns)
Lighting Equipment (flashlights, portable lights)
Communication Devices (radios, cell phones)
Emergency Transportation Equipment (spinal immobilization device, stair chair)
Emergency Obstetric Kit

(Select all that apply)

Additional Comments or Questions?

Multiple Choice *

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