Medstar Health Contribution

MedStar Montgomery Medical Center

Patient Family Advisory Application

 

 

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.

* required information

Applicant Information
First Name*
Last Name*
Street Address*
Street Address 2
City*     
State*
Zip*
Home Phone* - -
Cell Phone - -
E-Mail
Languages you speak
Choose One: *
My care at MGH was






If Other, please specify:

I have received and/or am willing to receive a Flu Vaccination*
Questions
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 MGH 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 MGH?*