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* 1. Date of your journey?

Date / Time

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* 2. Which Hospital were you discharged / transferred from or the hospital you were taken to?

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* 3. Based on your experience of our service, how likely are you to recommend us to family and friends if they needed similar transport?

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* 4. Please select the following based on your journey experience.

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* 5. Please select if you are:

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* 6. What is your ethnic group?

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* 7. Are your day to day activities limited because of a health problem or disability which has lasted or is expected to last at least 12 months (include any issues or problems related to old age)

T