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 ERYear you had an XrayYear you went to the LabYear you were born or had a babyYear you went to a Physician's office and locationYear you had surgeryYear you stayed overnight at the hospitalYear you had a procedure but went homeOther – 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?PhoneThis field is for validation purposes and should be left unchanged. Δ