Customer Service Survey

1. Customer Information

Please answer all questions to the best of your ability.

Date / Time

Date

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

Yes

Patient Name

Run Number (if available)

Phone Number

Name of person requesting call back (if different than patient)