PFEC Application | AdventHealth

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Patient and Family Experience Partner Application

Thank you for your interest in becoming an AdventHealth Patient and Family Experience Partner. We want to work together to enhance the patient experience by hearing our partners’ stories and perspectives. Together, this partnership will help advance AdventHealth’s promise of whole-person health care.

Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email*

Phone*

Personal Reference

Please name a personal or professional reference, or an AdventHealth team member who knows you and/or your family member.

Examples could include a doctor, nurse, therapist or social worker.

Name*

First Name

Last Name

Department*

Phone*

Email*

I certify the information presented in this application is true and complete to the best of my knowledge.
I understand that any misrepresentation or omission of facts on this application will be sufficient cause for disqualification of this application.
I give AdventHealth my permission to verify any information provided in this application. I authorize my references or any other person to answer all questions from AdventHealth concerning my ability, character, reputation, and previous employment record. I release all such individuals from liability damages resulting from having furnished such information.
I understand that AdventHealth is not liable for injuries I sustain at AdventHealth while participating on the Patient and Family Experience Council.
I will uphold the AdventHealth standards as they are expressed in their mission, vision, values and service standards.
I agree that AdventHealth may use email to communicate with me about matters regarding the Patient and Family Experience Council. I understand that email may or may not be secure and agree to talk with AdventHealth about alternate communication methods if desired.

Signature

[clear]

Use your mouse or finger to draw your signature above

Date

Patient and Family Experience Partner Application

Help us get to know you better.

Personal Reference