Preferred Contact Method
    Home PhoneWork PhoneCell PhoneEmail

    When are you available?
    DaytimeEveningWeekend

    How did you hear about this opportunity?
    NewspaperRadioWord of mouthHealth Care ProviderBrochureWebsiteOther

    Have you received care, or supported a loved one in receiving care over the last 5 years?
    YesNo
    Some programs may need more specific information about type of diagnosis or type of care.

    Which of the following opportunities would interest you?
    Ongoing and regular commitment to an advisory bodyParticipating in periodic focus groupsParticipating on committees with health professionals to help improve servicesParticipating from home (e.g. answering surveys, reviewing educational documents)Participating in program and policy developmentSharing my personal health care story to help improve servicesOther:

    Would you be interested in participating in any other type of initiatives?
    YesNoMaybe

    If you live in rural Manitoba, would you be interested in participating virtually, such as via Telehealth?
    YesNo

    Employment Status
    Employed Full-TimeEmployed Part-TimeUnemployedRetiredHomemaker/CaregiverStudent

    I am willing to sign a confidentiality form

    Questions? Call: (204) 687-9320

    Toll-free: 1-888-340-6742

    Send your completed form to:

    Patient Experience Coordinator
    Box 340
    Flin Flon General Hospital
    3rd Avenue & Church Street
    Flin Flon, Manitoba R8A 1N2
    Or via email to patientexperience@nrha.ca