Name:

Street Address:

City:

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Cell Phone:

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Email:

Preferred Method of Contact: Email Cell Phone Work Phone

If you prefer to be contacted via cell phone, may we send you text messages? Yes No

Best Time to Reach You by Phone:

Have you or a family member received care from Bothwell Regional Health Center? Check all that apply:
Emergency Department
Clinic
Diagnostic Center
Hospitalization

Why do you want to serve on Bothwell’s Patient and Family Advisory Council?

What concerns would you like to see the Patient and Family Advisory Council address?

What special interests or experiences would you like to offer to the Patient and Family Advisory Council?

Bothwell Regional Health Center believes incorporating diversity and inclusion is important. Please share anything about yourself that you think would add to the diversity of the council.