Patient Advisory Council

PAC Application

The Patient Advisory Council (PAC) is a collaborative, goal driven initiative that focuses on enhancing the environment of care to provide the best patient experience. The group is made of key stakeholders, including members of the hospital leadership team, to hear directly from patients and family members on systems and processes and to identify opportunities for improving and consistently providing excellent patient care.

If you or a family member are interested in sharing your experience, opinions and insight, we invite you to fill out a brief application. Once reviewed, a member from our Advisory Council will reach out to schedule a brief interview.

Thank you for your interest!

First Name*

Last Name*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Date*

Date

Email*

example@example.com

Phone Number*

You are a:*

Patient (current/former)Family Member

Primary Language*

Which hospital PAC are you interested in joining?*

Which councils are you interested in?*

GeneralMother Baby

Why you are interested in applying for membership and what you can bring to the Patient/Family Advisory Council. *