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