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Patient Partner Application Form
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Careers
Physicians
Anesthesiologist
Emergency Medicine
Family Medicine – Mitchell Family Health Organization
Ophthalmology
Psychiatry
Psychiatry – Locum
Volunteers
Patient Partners
Patient Partner Application Form
Students
Join Our Team
Careers
Physicians
Anesthesiologist
Emergency Medicine
Family Medicine – Mitchell Family Health Organization
Ophthalmology
Psychiatry
Psychiatry – Locum
Volunteers
Patient Partners
Patient Partner Application Form
Students
HPHA Patient Partner Application Form
*
First Name:
*
Last Name:
*
Telephone Number:
ext.
Email Address:
*
Mailing Address:
*
City:
*
Postal Code:
Preferred Method of Contact:
Preferred Method of Contact
Telephone
Email
*
Have you been a patient, family member or caregiver of a patient at HPHA within the past two years?:
Have you been a patient, family member or caregiver of a patient at HPHA within the past two years?
Yes
No
*
Why would you like to serve as a patient partner?:
*
What areas, hospital programs or issues are you interested in? Please check all that apply.:
What areas, hospital programs or issues are you interested in? Please check all that apply.
Committee Membership
Project Participations
Patient Experience Surveying
Sharing Your Story
Other (Please specify)
Other:
We recognize that our patient partners have busy lives. Please let us know approximately how much time you may be able to commit.:
We recognize that our patient partners have busy lives. Please let us know approximately how much time you may be able to commit.
1 to 2 hours per month
3 to 4 hours per month
More than 4 hours per month
Other (Please specify)
Other:
Please read the statement below and check before submitting.
*I understand that by submitting this application and/or being interviewed does not guarantee a position as a Patient Partner
X
*
We will use personal information on this form to select and place Patient Partners at the Huron Perth Healthcare Alliance. We will not use the information in any other way without the permission from the applicant/guardian. We will protect your personal information, following the rules set out in the Public Hospitals Act and the Freedom of Information and Protection of Privacy Act (FIPPA).:
I Agree
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X
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