Huron Perth Healthcare Alliance - Patient Partner Application Form

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 ContactTelephoneEmail

*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?YesNo

*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.

*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

Patient Partner Application Form

HPHA Patient Partner Application Form

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