1. Customer Information

Please answer all questions to the best of your ability.  

My experience with Gold Cross Ambulance took place on the following date:

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* My experience with Gold Cross Ambulance took place on the following date:

Date / Time
I experienced Gold Cross Ambulance in the following way:

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* I experienced Gold Cross Ambulance in the following way:

I would like someone to contact me regarding my experience.

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* I would like someone to contact me regarding my experience.

Contact information (required if call back is requested)

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* Contact information (required if call back is requested)

T