Patient Family and Advisory Council (PFAC) Application
Today's Date:
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Name:
Your answer
Street Address
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City
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State
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Zip
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Best Contact Phone Number:
Your answer
Email:
Your answer
What is your preferred method of communication about the Council?
Is it OK to share your information (e-mail, phone) with other members of the council? (We will NOT give your information to anyone else!)
Please check all that apply. I am:
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Please choose the best day(s) of the week to attend meetings. As a reminder our meetings are no more than once per month for 60 minutes. (Check all that apply)
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Please choose the best time(s) of day to attend meetings: (Check all that apply)
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Have you ever received care at any Harrington location?
Do you have any special needs we should be aware of?
Your answer
Why would you like to be on the PFAC?
Your answer
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