Patient & Family Advisory Council Application
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred contact method:
Home Phone
Cell Phone
Email
No Preference
Gender: How do you identify?
*
Man
Non-Binary
Woman
Prefer to self identify:
When was your care experience at this hospital or clinics? (Check all that apply.)
*
2023
2022
2021
2020
2019
2018
Which departments provided care for you or your family member? (Check all that apply.)
*
Inpatient (Medical-Surgical)
Obstetrics
Emergency Room
Oncology
Cardiopulmonary
Laboratory
Sleep Center
Imaging
Rehabilitation (Physical Therapy, Occupational Therapy, Speech Therapy)
General Surgery (Ambulatory Surgery)
Urgent Care or Mountain Clinic
Other
We recognize that our patient and family advisors have busy lives. How much time are you able to commit to being a patient and family advisor?
*
Less than 1 hour per month
1 to 2 hours per month
3 to 4 hours per month
More than 4 hours per month
Are you available to serve as an advisor for at least 1 to 2 years?
*
Yes
No
Please tell us a little about yourself.
Please describe any experience you had with doctors or hospital staff while you or your family member were in the hospital.
*
Please share anything about yourself that you think would add to the diversity of our team of advisors.
*
What do you think is the most important thing you could help us accomplish as an advisor?
*
Submit
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