Patient & Family Advisory Council

Application Form

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Preferred Pronouns

Age Range

Place of Residence

Which PFAC are you applying for?

*The Patient-journey includes diagnostic imaging, outpatient clinic, OR/Surgery, Medicine, and Critical Care
**The Pediatric includes NICU, Mother & baby

What level of experience did you have in the PFAC for which you are applying for?

How long ago was your experience in this particular unit?

Do you have access to the Internet?
Do you have access to E-mail?
Could you commit to being on this council for 2+ years?
Will you be able to attend quarterly meetings to discuss your patient experience insights?

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