MedWest | PAC Application

Date: *

Name (first and last): *

Mailing Address: *

City: *

State: *

Zip Code: *

Telephone Number: *

Email Address: *

What is the preferred way of receiving communication about the Patient Advisory Council?

Email
Regular Mail
Telephone

Are you 18 years or older (or parent of a minor) and have received care at any MedWest Emergency Department in the last THREE months?

Yes
No

Have you received care at any MedWest facility before your Emergency Department experience?

Yes
No

If you answered yes, please list the location(s) where you received care

Do you have any dietary needs we should be aware of? (i.e. vegetarian, diabetic, or kosher)

Do you have any special needs that we should be aware of?

Why do you want to be a member of the MedWest Patient Advisory Council?

What special interest or experience would you like to offer to the MedWest Patient Advisory Council?

Please note any questions or concerns you have about the MedWest Patient Advisory Council.