* 1. Which hospital were you visiting? Please enter the full name of the hospital and location below

* 2. Can you confirm the date your journey took place? Please use the format dd/mm/yyyy, for example 19/03/2015

* 3. If you know the crew members names, please enter them below

* 4. We would like you to think about your recent experiences of our service. How likely are you to recommend our service to Friends and Family if they needed similar care or treatment?

* 5. Based on your response to the previous question please tell us why you gave this response

* 6. Please could you tell us how you would rate our service based on the following areas of your journey, if the question is not applicable then please choose this option

  Extremely satisfied Satisfied Neither satisfied or dissatisfied dissatisfied Extremely dissatisfied Not applicable
The reminder call/message I received to confirm my booking
The time I was picked up was within reasonable time limit of the one confirmed when I booked the journey
The crew introduced themselves and explained clearly what would happen during the journey and allowed me to ask any questions
I was treated as an individual with dignity and respect while I was with the crew members and they understood my needs
I arrived at my destination in time for my appointment and/or the journey tool a reasonable amount of time
The vehicle used to transport me was suitable for purpose, easy to access, clean and comfortable
When I arrived at the hospital/clinic, I was booked in, introduced and handed over to a named member of the team, or if going home I felt comfortable, safe and secure
Thinking about the care I received from the team today, I believe the service met my needs and my expectations of the service

* 7. Are you?

* 8. Please enter the numbers from your postcode

* 9. What is your gender?

* 10. What is your age?

* 11. Which race/ethnicity best describes you? (Please choose only one.)

* 12. 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?

* 13. We would like to share you comments anonymously on our website. Please confirm if you are happy for us to share the results and feedback of this survey on the ERS Medical website?

* 14. Do you have any other comments you would like to share with us about the service you received today?

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