Membership Application | Patient Advisors Network

Patient Advisors Network Membership Request

Please tell us a bit about yourself, your healthcare interests, and your experience of being an advisor in healthcare.

Once we receive the form, we will be in contact with membership details.

Regards, the PAN team

First Name *

Last Name *

Email *

Phone *

City/Town *

Province *

Country

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

Current status *I am interested in becoming a patient and family advisorI am currently a patient and family advisor

I have been referred to PAN by

Do you have experience as...

(Check all that apply.)

I am a *Patient or Resident or ClientFamily CaregiverFriend Caregiver

I have experience taking care of the following people with health issues.A childA parentA spouse or partnerAn adult relation (sibling or other relative)

Areas of Experience and Interest

ACUTE CAREAs a PFA (Patient and Family Advisor) in my local hospitalOn an advisory or community council at my local hospital

PRIMARY CAREAs a PFA (Patient and Family Advisor) in my primary health provider's practiceAs a PFA (Patient and Family Advisor) in my specialist health provider's practiceOn a council for a primary care group or team

COMMUNITY CAREAs a PFA (Patient and Family Advisor) in my community and home care provider's organizationOn an advisory or community council at a community or home care provider organization

LONG TERM CAREOn a residents' council in my long term care facilityOn a family council in my loved one's long term care facilityAs an advisor on an association of councils for long term care

MENTAL HEALTH CAREAs a client or family advisor (in my provider's organization)On a council for a mental health organization or care team

REHABILITATION FACILITYOn a resident's council in my facilityOn a family council in my loved one's facilityAs an advisor on an association of councils for a rehab facility

FOR THE HEALTH SYSTEM On an advisory group or council forMy local health authorityMy provincial quality councilMy provincial ministryOther

RESEARCH (NOT as subjects of research but as partners)As a partner on a research team or teamsReviewing research applications for a funding organizationSetting research priorities for a funding organization

EDUCATIONFor healthcare professionalsFor patient and family advisorsMentoring others and peer supportMentoring other advisors

PARTNERING ISSUES I am interested in the following partnering issuesTokenismCompensation (not just expenses)Levels of engagementOther

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.

Thank you for sharing your experience and interests. You will hear from us soon.

Regards, The PAN Team