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Home
HPHA Intranet
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Contact Us
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Facebook
Twitter
Linkedin
Instagram
About HPHA
Our Organization
Board of Directors
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Performance & Public Reporting
Vendor Information
Contact Us
Land Acknowledgement
Stratford General Hospital Archives
Programs & Services
Patient, Family & Caregiver Experience
Getting Here
While You Are Here
Family & Caregiver Presence Guidelines
Leaving the Hospital
Patient, Family & Caregiver Experience Feedback
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Join Our Team
Patient Partners
Patient Partner Application Form
SECTIONS
Careers
Huron & Perth Counties
Physicians
Anesthesiologist
Emergency Medicine - Clinton & Seaforth
Ophthalmology
Pediatrician
Plastic Surgeon
Volunteers
COVID-19 Reorientation
Patient Partners
Patient Partner Application Form
Students
Student Welcome Package
Join Our Team
Careers
Huron & Perth Counties
Physicians
Anesthesiologist
Emergency Medicine - Clinton & Seaforth
Ophthalmology
Pediatrician
Plastic Surgeon
Volunteers
COVID-19 Reorientation
Patient Partners
Patient Partner Application Form
Students
Student Welcome Package
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
*
Please tell us why you would like to partner with HPHA and become a Patient & Caregiver Partner?:
*
How did you hear about the HPHA Patient & Caregiver Partner Program?:
(select one)
Poster or brochure
HPHA Staff / nursing / doctors
Website
Family/Friend
At which site(s) have you or a family member received medical care (please check all that apply):
(select one)
Clinton Pubic Hospital
Seaforth Community Hospital
St. Marys Memorial Hospital
Stratford General Hospital
*
What was your involvement when coming to one of our HPHA sites? (please check all that apply)::
(select one)
Patient
Family member
Caregiver
*
Which unit(s) did you or your loved one receive care? (please check all that apply)::
(select one)
Inpatient
outpatient (clinics, dialysis, x-rays, chemo, bloodwork/lab, mental health services etc.)
Emergency Department
Inpatient Mental Health
Mat/Child
Pediatrics/Special Care Nursery
*
Please tell us about your healthcare journey experience:
*
Please indicate the type of Patient & Caregiver Partner role that you wish to apply for:
Please indicate the type of Patient & Caregiver Partner role that you wish to apply for
Communications - Co-Writing, reading and reviewing organizational guidelines, brochures, pamphlets, patient information, policies, practices & procedures. Level of Commitment: partner flexibility, virtual participation
Operations - Active members on hospital committees and councils etc. Level of Commitment: Commit to be an active participating member on a hospital committee/board/council. Frequent meetings
Projects - Active participants in experience-based co-design initiatives and decision-making projects with care providers. Level of Commitment: commit to be an active participant on special projects, frequent meeting, may be a "one-time" commitment until completion of project
*
Do you have experience working on projects or as a committee member?:
(select one)
No
Yes
If yes, Please explain:
*
Are there particular hospital areas or health topics that you have a special interest in? :
Please add anything else you wish to share about yourself (professional experience/skills, other volunteer work etc.):
I have access to a computer, tablet or smart phone
I understand that HPHA requires all Patient & Caregiver Partners & Volunteers to obtain a Vulnerable Sector Check (Police Check).
*
All applications collected are kept private and confidential. The hospital is committed to accessibility for persons with disabilities. If you require assistance completing this application, please contact the Patient Experience Office at 519-272-8210 Ext. 2423.:
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