Patient & Family Advisory Council Interest Form

We appreciate your interest in a Gundersen Health System Patient & Family Advisory Council. We will contact you with current or future opportunities to serve.

Your name

Phone

Address

Address line 2

City/Town

State

ZIP code

In which Patient and Family Advisory Council would you like to participate?

How did you learn about the Advisory Councils at Gundersen Health System?

Why would you like to be a member of an Advisory Council?

What would you like for us to know about you?

Do you or a family member receive care at a Gundersen Health System location?

Yes

Please note, submission of your interest form is not a guarantee of appointment. Thank you.