Join the PFAC

Name

Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Email Address

Emergency Contact - Name and Phone Number

Can we share your contact information with other PFAC members?

YesNo

What type of service did you or your family member receive?

Hospitalization (inpatient)Clinic/Outpatient Visit (lab, x-ray, rheumatology, PT, etc.)Emergency Department Care

I am/was a

PatientFamily member of a patient

My care is/was provided by

The dates of my active care experience at WNH were

Within the last 5 yearsMore than 5 years ago

Why are you interested in joining the Patient & Family Advisory Council?

When are you available to attend meetings

If you have served as an advisor, been an active volunteer, or done public speaking for other programs or organizations, please briefly describe this experience

What are some specific things that healthcare professionals did or said that was most helpful to you and your family?

What are some specific things that you or your family would like healthcare professionals to do differently in order to be more helpful?

Do you know other individuals and/or families who have experienced care at WNH who might be interested in serving as Advisors? Please list their name(s) and phone number(s) here

Please give 2 references (not your spouse or significant other). Please give name, phone, address, and their relationship to you:

The information provided in this form is correct and accurate to the best of my knowledge.

Yes