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Bill number **

Total **

First name **

Last name **

Email **

Phone number **

On a scale of 1 to 5, how would you rate our team’s service?

1 being "excellent", 5 being "very disappointing"

Name of the person transported/treated

City where the patient was taken care of by our professionals

Date of transportation

Comments / Details

Payment information*

Street Address * City * Province * Country *

Billing comments

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Amount charged

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