MMMC Organic PFACQS Application Form-5148590

Patient and Family Advisory Council for Quality and Safety (PFACQS) Application

MedStar Montgomery Medical Center

We require that Council members commit to a minimum six month term. The council will meet one time a month for a two-hour period. If you are interested, please complete the application below.

Contact Information

Name*

First Name

Last Name

Home Phone*

Cell Phone

Email Address

Languages You Speak

Address

Address 1*

Address 2

City*

State*

Postal Code*

Choose One:*

Past Patient Family Member/Care Giver of Past Patient

My care at MMMC was:

Hospitalization Outpatient Emergency Other

If Other, please specify:

I have received and/or am willing to receive a Flu vaccination*

Yes

Why would you like to be on the Council?*

What areas of concern would you like to discuss?*

What are some of the specific things that the MMMC staff did or said that were most helpful while receiving care at the hospital?*

What would you have liked to have seen done differently while you received care at MMMC?*

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