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EMS Special Procedure Notification and Q/A Form

  1. BLS Procedures
    Choose procedure(s) from the following:
  2. ALS Procedures
    Choose procedure(s) from the following:
  3. Please give a brief description of the incident/procedures. Do NOT include any patient identifiers or PHI.
  4. I wish to have my call reviewed for follow-up.*
  5. Leave This Blank:

  6. This field is not part of the form submission.