Voice of the Patient Advisory Council Membership Application

Please fill out and submit the form below if you are interested in serving the Advisory Council.

Not all fields are required, but please fill out the form as completely as possible.


 Full Name:  
 Address:  
 City:  
 State:  
 Zip Code:  
 Cell Phone:  
 Home Phone:  
 Work Phone:  
 Email Address:  

1. Have you or a family member received care at a Premier facility (Atrium Medical Center, Good Samaritan Hospital, Miami Valley Hospital or Upper Valley Medical Center) within the past year?
 

Area(s) where care was received:
   

2. Why would you like to be a member of the Advisory Council?
   

3. What area(s) of concern do you have that you would like to see the Advisory Council address?
   

4. What special interests or experiences would you like to offer the council?
   


      

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