Family Health West
Primary Care Patient and Family Advisory Council (PFAC) Application
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
What is your preferred method to contact you?
Phone
Email
Mail
I am a:
Patient
Family member
Other
Which provider are you a patient or family member of?
Tell us about your primary care experience. What would you have improved? What impressed you about your experience?
Why do you want to be involved in the PFAC?
Are there any areas of concern you would like to have the PFAC address?
Submit
Should be Empty: