PFAC Candidate Registration Form

Patient and Family Advisory Council

Thank you for expressing interest in adding your voice through our Patient and Family Advisory Councils (PFAC). Please complete the below information and the PFAC Leader at your chosen hospital will contact you to share more information on their PFAC, meeting dates and times.
Hospital Location or PFAC group you would like to join
Have you or a family member been admitted to a ProMedica hospital in the past?

Yes No
Have you or a family member experienced any of our outpatient services in the past year?

Emergency Room Outpatient Surgery Laboratory Diagnostic Services Cardiac or Pulmonary Rehab
Your Name

First Name Last Name
E-mail
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Are you over 18?

Yes No
Best form of contact

Phone email Mail
Please briefly describe what has sparked your enthusiasm to join our PFAC:
If you have served as an adviser, been an active volunteer, or done public speaking in the past, please briefly describe this experience:
What are some specific things that you have noticed healthcare workers doing that was helpful to you or your family member?
If you have any other questions regarding our ProMedica PFAC, please email pfac@promedica.org
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Patient and Family Advisory Council