Patient and Family Advisory Council Application

The mission of the Patient and Family Advisory Council is to collaborate with Middlesex Health System on opportunities to achieve the highest quality, safest, and most respectful and compassionate care for everyone served.

All fields are required unless otherwise noted.

Membership Application

First Name

First name is required

Middle Initial (optional)

Middle initial is required

Last Name

Last name is required

Address

Address is required

City

City is required

State

State is required

ZIP Code

ZIP Code is required

Preferred Phone

Preferred Phone is required

Alternate Phone (optional)

Alternate Phone is required

Best time to reach you?

Best time to reach you is required

May we leave a message?

May we leave a message is required

Email Address (optional)

Email Address is required

I am/have been a

Patient

Family Member of a patient

Other

I am/have been is required

Have you or a family member received care at Middlesex Health System within the past 2-3 years?

Please indicate if you or a family member has received care

My experience has been mainly

Hospital Inpatient

Emergency Room

Outpatient Services

Cancer Center

Other

Please indicate your experience with Middlesex Health System

If other, please describe

Please indicate your experience with Middlesex Health System

Please provide some brief comments related to your experience of the care you or your family has received within the Middlesex Health System

Please provide some brief comments on your experience

Why would you like to be a member of the Patient and Family Advisory Council?

Please describe why you would like to be a member

As a person who has been a patient or family member of a patient at the Middlesex Health System, what might you like to see changed?

Please indicate what changes you'd like to see

What personal skills, background, or experiences do you have that would help the Middlesex Health System Patient Family Advisory Council achieve its mission?

Please describe your personal skills

What organizations or committees have you been involved with in the past? (work, school, civic, church, charitable, etc.)

Please indicate which organizations you've been involved with in the past

Is there anything else you would like to tell us about yourself? (optional)

Please provide any additional comments

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