Patient and Family Advisor Application

Providence Medical Group Patient and Family Advisor Application

At Providence Medical Group, your voice counts. Join us as a Patient and Family Advisor and share your perspective of how we can improve health care for you and your family.

	Name*

	Address:*

	Phone*

	Email:*

How may we contact you?*

	Phone
	Email

	Please answer the following questions so that we may learn more about you.

Please check all that apply:*

	I am a Providence Medical Group patient.
	I am a family member of a Providence Medical Group patient.
	I have a chronic health condition (diabetes, heart failure, asthma, depression, arthritis, persistent pain).
	I am a patient, or a family member of a patient, who receives preventive care at a Providence Medical Group clinic.

	At which Providence Medical Group clinic do you, or your family member, receive care?*

	Please use this space to tell us more about yourself, including any special training, interests in health care, hobbies, affiliations or experiences you feel could be valuable to your work as a Patient or Family Advisor with Providence Medical Group.*

What days and times are you available to meet for an interview?*

	Please click here to visit the Providence Medical Group Patient and Family Advisory Program website to learn more. If you have questions concerning the program or this application, please contact the Patient and Family Centered Care Program Coordinator, Chantell Fitz-Amado, at 503-893-6613 or via email.