Patient and Family Experience Council Member Application

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Patient and Family Experience Council Member Application

Thank you for your interest in becoming a Partner of AdventHealth's Patient and Family Experience Council for the Cardiovascular Institute. We want to work together to enhance the patient experience by hearing our partners’ stories and perspectives. Together, this partnership will help advance AdventHealth’s promise of whole-person health care.

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Help us get to know you better:

Are you a patient, a patient's family member, part of AH Staff, or a Physician?

Patient Family Member of a Patient AdventHealth Staff Physician

When was your care experience with AdventHealth? (Check all that apply)

2021 to Present 2020 2019 Earlier

Please name a personal or professional reference, or an AdventHealth team member who knows you and/or your family member.

Name

First Name

Last Name

I agree that AdventHealth may use email to communicate with me regarding the Patient and Family Experience Partners program. I understand that email is not a secure medium for sending and/ or receiving potentially sensitive personal health care information. AdventHealth cannot assure the confidentiality or protection of email communications, particularly if the emails are sent to multiple individuals participating in the Patient and Family Experience Partners program. In addition, email sent to AdventHealth may be accessed by individuals who are not directly involved (for example, by my employer if my email address is provided by my employer, or by my internet service provider).

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