Patient and Family Advisory Board Application

All fields with an asterisk (*) are required.

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2020-NTX-Medical City Arlington-Family Advisory Board Application-PI

Name*

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

What is your preferred way of receiving communication about the Board?

E-mail Regular Mail Telephone

Phone

Have you or a family member received care at Medical City Arlington?

Yes No

If yes, when was the care provided?

Why would you like to be on the Board?

What issues would you like to see the Board address?

What special interest, expertise or experiences would you like to offer to the Board?

The completion of this application does not bind the applicant or the hospital in any way. The Patient and Family Advisory Board reserves the right to choose participants that best meet the needs of the program. If selected to participate on the Board, you will be asked to sign a confidentiality agreement. Please call (682) 509-6033 if you have questions.