Patient Family Advisory Council - Advisor Application
Basic Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How do you prefer to receive communications about the council?
*
Phone
Email
Have you or a close relative ever been employed by LCHC?
*
Please Select
Yes
No
Are you willing to sign a HIPAA confidentiality agreement?
*
Please Select
Yes
No
The following questions help us get to know you better.
Are you a....
*
Patient
Family member of a patient
When was your most recent care experience at Lucas County Health Center?
*
Within the last year
Within the last two years
Within the last five years
More than five years ago
What language(s) do you speak?
*
Which department(s) provided care for you or your family member?
*
Medical Clinic
Emergency Room
Radiology
Laboratory
Med/Surg (Inpatient)
Physical Therapy
Surgery
Respiratory Therapy
Cardiac/Pulmonary Rehab
Wound Care
Infusion Services
Other
Are you able to serve as an advisor for more than 1 year? (You can still apply if you answer is no.)
*
Yes
No
Why do you want to become a patient and family advisor?
What would you like to see the council address?
Our council should 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.
Are you able to openly listen and discuss opinions and points of view that are different than you own?
What special interest or experiences would you like to offer to the council?
Do you have any other comments you'd like to add?
Submit
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