Join a Patient and Family Advisory Council (PFAC)

First name

Last name

Address line 1

Address line 2

City

State

Zip code

Preferred phone number

Is this a home or cell phone number

HomeCell

Email address

I am a

PatientFamily MemberBoth Family Member & Patient

Are you currently a Mass General Brigham (MGB) Employee?

YesNo

Can you generally attend monthly/quarterly meetings in the weekday evening?

YesNo

Please select which hospital you or your family member have received care from. Please note, you or your family member must have received care at that hospital in the past 3 years to be eligible for their PFAC.

Please select which PFAC you are interested in joining. Please note, you may only join a specialty area PFAC if you or your family member have received care in that specialty in the past 3 years. Otherwise, please select the General PFAC.

Please provide an overview of your experiences receiving care at the hospital you selected above, including when those experiences took place (e.g., inpatient, outpatient, etc.)

Why would you like to be a member of a Patient and Family Advisory Council (PFAC)?

Is there an area of care or a specific service at the hospital that is of special interest to you?

Do you need any special accommodations to be able to attend and participate in meetings?

YesNo

Please describe them:

How did you learn about PFACs at MGB?

Please provide:

Do you know other individuals or families who might be interested in serving as advisors? If so, please provide us their contact information.