Membership Application | Patient Advisors Network

First Name:*

Last Name:*

Email:*

Phone:

City/Town:*

Province/Territory:*

Country:*

Have you ever worked in healthcare or are you currently employed in healthcare?:*

Yes No

Current status:*

I am interested in becoming a patient and family advisor
I am currently a patient and family advisor

I have been referred to PAN by:

I am a:*

Patient or Resident or Client

Family Caregiver

Friend Caregiver

I have experience taking care of the following people with health issues.

A child

A parent

A spouse or partner

An adult relation (sibling or other relative)

ACUTE CARE

As a PFA (Patient and Family Advisor) in my local hospital

On an advisory or community council at my local hospital

PRIMARY CARE

As a PFA (Patient and Family Advisor) in my primary health provider's practice

As a PFA (Patient and Family Advisor) in my specialist health provider's practice

On a council for a primary care group or team

COMMUNITY CARE

As a PFA (Patient and Family Advisor) in my community and home care provider's organization

On an advisory or community council at a community or home care provider organization

LONG TERM CARE

On a residents' council in my long term care facility

On a family council in my loved one's long term care facility

As an advisor on an association of councils for long term care

MENTAL HEALTH CARE

As a client or family advisor (in my provider's organization)

On a council for a mental health organization or care team

REHABILITATION FACILITY

On a resident's council in my facility

On a family council in my loved one's facility

As an advisor on an association of councils for a rehab facility

FOR THE HEALTH SYSTEM On an advisory group or council for

My local health authority

My provincial quality council

My provincial ministry

Other

RESEARCH (NOT as subjects of research but as partners)

As a partner on a research team or teams

Reviewing research applications for a funding organization

Setting research priorities for a funding organization

EDUCATION

For healthcare professionals

For patient and family advisors

Mentoring others and peer support

Mentoring other advisors

SECTOR INTERESTS My sector interests are in:

Acute Care

Primary Care

Specialist Care

Community care

Long Term Care

Mental Health

Rehabilitation

Education

System - health authorities, ministries, quality councils

Research in a role other than as subject

HEALTHCARE INTERESTS My healthcare interests are:

Disease specific

Health System

Evidence - based medicine

Medications - Polypharmacy,

Shared decision-making

Care coordination and transitions

Adverse events and complaints

eHealth and digital health information

Other

PARTNERING ISSUES I am interested in the following partnering issues:

Tokenism

Compensation (not just expenses)

Levels of engagement

Other

Please describe other partnering issues you are interested in.:

KEY WORK and VOLUNTEER BACKGROUND What are the key things you have done that help you in your partnering.:

Patient Advisors Network Membership Request

Do you have experience as...

Areas of Experience and Interest