Patient and Family Advisory Council Membership Application
  * = Required
* Name:
* Mailing Address:
* City:
*State:  *Zip:
* Home Telephone:
Work Telephone:
Cell Telephone:
E-Mail Address:
* 1. Have you or a family member received care at Bridgeport Hospital within the past year?
  Yes     No
  Area(s) where care was received (please check all that are applicable):
Fairfield Urgent Care
Outpatient infusion
Emergency Department
Huntington Walk-in
* 2. Why would you like to be a member of the Patient and Family Advisory Council?
* 3. What area(s) of concern do you have that you would like to see the Patient and Family Advisory Council address?
* 4. What special interests or experiences would you like to offer the Council?
* 5. We believe the Patient and Family Advisory Council should reflect the diversity of the patient population that Bridgeport Hospital serves. In light of this, please share anything about yourself that you think would add to the diversity of the Council.

* Security Code:
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