Applicant Information

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

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 MMMC 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 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?*

Please note: When you register at any MedStar Health site, your information remains strictly confidential. As always, Medstar Montgomery Medical Center and our parent company, MedStar Health, respect your privacy. The information you submit is used for internal purposes only to help guide us in developing health information relevant to your needs. Read our privacy policy here...