Patients - Patient and Family Advisory Council

Name (First and Last)

Street Address

City

State

ZIP Code

Home phone

Cell phone

Preferred contact

Home phone Cell phone Email

Why do you want to become a patient and family advisor?

Please briefly describe any experience you may have as an advisor, as an active volunteer, or as a public speaker

Please describe any specific things that doctors or hospital staff did or said while you or your family member were in the hospital that were helpful to you or your family.

Please describe any specific things that doctors and hospital staff could have done differently to be more helpful while you or your family member were in the hospital

Our patient and family advisors reflect the diversity of the patients and families we serve. Please share anything about yourself that you think would add to the diversity of our team of advisors

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Patient and Family Advisory Council (PFAC)

Patient and Family Advisor Application Form