Patient & Family Advisory Council (PFAC) Application

Patient Representation Information
Patient Name

First NameLast Name
Relationship to Patient

Other
If other, please describe your relationship to the patient
Department where patient's treatment was received
I/My family member have been treated most often in:

Other
If other, please list the department/clinic where patient was most often treated.

Additional Information
Please tell us which services have been utilized during the last two years.
Example: Primary Care, Gastroenterology, General Surgery, Rheumatology, ER, etc.
What interested you in becoming a Patient Family Advisor?
What areas of Nor-Lea do you feel could be improved?
Should be Empty: