Patient and Family Advisory Council Application

* Required Fields

Date *
Example Format: MM/DD/YYYY

Name *

Home Address *

Daytime Phone Number *

Best Day/Time to Call *

Email Address *

I am a *
Check all that apply

Patient

Family Member

Community Member

Volunteer

CoxHealth Employee

Tell us about your hospital experience(s) *
What would have improved the experience? What impressed you about your experience?

Why do you want to be involved in the Patient and Family Advisory Council? *

If you have participated in any organizations or committees, please share some examples about it *
Was it a successful committee? Describe some of the challenges you faced and how you dealt with them. What would you do differently?

Tell us a little about yourself *

Which PFAC committee are you interested in? *

leave this field blank to prove your humanity

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