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Patient Family Advisory Councils Application

First Name *:
Last Name *:
Mailing Address*:
City*:
State*:
Zip*:
Home Phone:
Cell Phone:
E-mail address *:
Past patient experience in the last three years?:
Which regional council are you interested in serving on?:
Are you a Franciscan employee?:
Are you a current Franciscan volunteer?:
Please enter the letters and numbers:
 
Advisory Councils

  • We look for patients and family members who:
  • Have used Franciscan services within the past three years as an inpatient, ourtpatient or family member (Outpatients are defined as anyone using our Franciscan Medical Group clinics, same day surgery services, outpatient radiology and all other outpatient services)
  • Represent our diverse communities and patient population
  • Are willing to collaborate in a team setting and offer constructive advice
  • Are willing to attend one evening meeting a month, October/November through June
  • Are willing to sign a confidentiality agreement

Recruitment ends October 12, 2012.