Patient & Family Advisory Council Application Salutation*Please ChooseMr.Mrs.Ms.Name* First Last Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone* Email Address* Have you used any of these services at UM Health-West? Please state the year. (check all that apply). Emergency Room Xray Lab Childbirth Center Physician Office Surgery Inpatient Service (stayed overnight) Outpatient Service (had surgery/procedure and went home same day) Other Year you went to the ER Year you had an Xray Year you went to the Lab Year you were born or had a baby Year you went to a Physician's office and location Year you had surgery Year you stayed overnight at the hospital Year you had a procedure but went home Other – Please explainPlease answer the following questions so we can get to know you better:Describe your patient/family experience at University of Michigan Health-West.Why would you like to join the Patient and Family Advisory Council?How did you hear about PFAC?NameThis field is for validation purposes and should be left unchanged. Δ