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Patients & Visitors


Name
Home Address
City
County
State
Zip Code
Phone
Best Day/Time To Call
Email Address
What is your preferred contact method?

What is your age?
What is your gender?
I am a

If you are a patient, what is your diagnosis?
If you are a family member, what is your loved one's diagnosis?
Tell us about your hospital experience(s). What would you have improved about the experience? What impressed you about your experience?
Why are you interested in joining the Patient and Family Advisory Council?
If you have participated in any organizations or committees, please share some examples: (These examples may be from work, community, church, etc.)
What improvements to patient care would you like to see as a result of your participation in the Patient and Family Advisory Council?
If you are selected to be a participant, can you commit to attend one meeting each month from 11:30 a.m. to 12:30 p.m. for at least one year?
Are you willing to interview and be interviewed by another council participant?
Are you willing to consent to a background check if selected to be a member of the Patient and Family Advisory Council?
Are you willing to sign a confidentiality agreement and go through both the Patient and Family Advisory Council orientation?

In submitting this form, I agree to my information being used for the purposes of the Patient and Family Advisory Council. Any information I provide in this form about my patient history or treatment at Phelps County Regional Medical Center may be seen by individuals who were not part of my patient care. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

I agree to the above statement