Customer Service Survey 1. Customer Information Please answer all questions to the best of your ability. Question Title * My experience with Gold Cross Ambulance took place on the following date: Date / Time Date Question Title * I experienced Gold Cross Ambulance in the following way: 911 call / emergency need (including general medical or injury/trauma) Inter-Facility transport (hospital to hospital) I just needed help up / assistance in moving (invalid assist) Gold Cross evaluated me for an illness or injury, but I decided not to be transported to the hospital Gold Cross transported me home (or to nursing / rehab / residential facility) from the hospital Question Title * I would like someone to contact me regarding my experience. Yes No Question Title * Contact information (required if call back is requested) Patient Name Run Number (if available) Phone Number Name of person requesting call back (if different than patient) Next