PFAC Outpatient Physician Office 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 Preferred Contact Method:* Home Phone Cell Phone Email Address Home Phone*Cell Phone*Email Address*Have you used any of these services at Metro Health? Please state the year. (check all that apply). Emergency Room Xray Lab Birthplace 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 state the year you went to a Metro Health Physician Office.Please select the Physician Office you visitPlease ChooseAlger HeightsAllendaleCaledoniaCascadeCedar SpringsCommunity ClinicComstock ParkGrand Rapids NortheastHudsonvilleJenisonLowellRockfordSouthwestWaylandPlease answer the following questions so we can get to know you better:Describe your patient/family experience at Metro Health – University of Michigan Health.Why would you like to join the Patient and Family Advisory Council?CommentsThis field is for validation purposes and should be left unchanged. Δ