Customer Survey

Kalitta MedFlight Customer Survey

Date: Trip:

Patient Name:

Name of Person completing form and relationship, if not patient:

Thank you for calling Kalitta MedFlight. We appreciate your confidence in our program.

In order to provide the best possible care, we would appreciate your comments about our service.
Thank you for your time and cooperation.

Please rate our services using the drop-down boxes.

Professionalism
and courtesy of the
Customer Service Rep

Professionalism
and courtesy of the
Medical Crew

Patient care
provided by
Medical Crew

Follow-up information
provided on
patient condition

Timely response
of the Medical Crew

Your comments and/or suggestions:

If you have any questions or concerns you would like to discuss, please contact:

Lori Shaneck RN, CFN, Program Director at 800.525.4882 extension 7207.

Kalitta Charters, LLC.

Testimonial Release Form

Date of Service:

Testimonial Statement, Customer Survey Statement, and/or Inventory of Testimonial Materials:

Authorization and Release Information

I understand my testimonial as outlined above (the "Testimonial") and made on behalf of Kalitta Charters, LLC. (hereinafter called "The Company") may be used in connection with publicizing and promoting The Company. I authorize The Company to use my name, brief biographical information, and the Testimonial as defined on this form.

I hereby irrevocably authorize The Company to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing The Company's programs or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites or in any other distribution media. I agree that I will make no monetary or other claim against The Company for the use of the statement.

In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my likeness or my testimonial appears.

I hereby hold harmless and release The Company from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I have read the authorization and release information and give my consent for the use as indicated above.

Signature: Date: