Harrington Patient Family and Advisory Council (PFAC) Application
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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: *
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Email: *
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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: *
Required
Have you ever received care at any Harrington location?
Do you have any special needs we should be aware of?
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Why would you like to be on the PFAC? *
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