Patient and Family Advisory Council Application

Patient and Family Advisory Council Application
Please review the Patient and Family Advisory Council page to learn more about the council before applying. When you're ready, complete this application to be considered as a candidate.
1. What are some of the specific things that health care professionals at Ridgecrest Regional Hospital do/ have done to help you or your family? The health care professional can be a nurse, a physician's assistant, a doctor, or someone at the front desk.
2. What are some of the things you would like Ridgecrest Regional Hospital to do differently to better help patients and their families?
3. Are there certain topics or areas of the clinic in which you have a special interest?
4. Why are you interested in joining the Patient and Family Advisory Council?
5. What positive improvements to patient care would you like to see as a result of your participation in the Patient and Family Advisory Council?
6. Is there anything else that you would like to add?
7. If you are selected to be a participant, can you commit to attend the meetings? (The meeting schedule TBD.)

YESNO
Please provide your contact information:
Name:
Email address:
example@example.com
Address:
Phone:
Format: (000) 000-0000.
What is your preferred contact method?

EmailPhoneMail
What is your preferred contact time? (Check all that apply)

M-F morningM-F afternoonM-F evening
Should be Empty: