Patient Advisory Cohort Application

You are invited to join Rogue Community Health’s Patient Advisory Cohort to provide constructive feedback and recommendations on a variety of topics that directly impact Rogue’s patients and family members.

The Advisory Cohort meets once a month for 3 to 4 months. Meetings generally take place online using Zoom and require the use of a computer or other smart device. Assistance with technology is available in advance of the meeting.

Today's Date

Date

Name*

First NameLast Name

Nickname

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Phone*

Please enter a valid phone number.

Email*

example@example.com

Preferred Contact*

PhoneEmailText

My Clinic*

AshlandMedfordWhite CityOther

I am a:*

PatientFamily Patient/Caregiver

Best time/day of week to attend meetings/events (Choose all that apply)*

Do you feel comfortable working in groups, speaking up, and/or providing input?*

YesNo

Please tell us why you are interested in joining*

Do you have access to a computer/smart device to attend Zoom meetings?*

YesNo

Gender

MaleFemalePrefer Not to Answer

Age

Ethnicity

Language

EnglishSpanishOther

Please read before signing:

As a PAC member, I will:

• Make every effort to attend meetings

• Try my best to be on time and fulfill my responsibilities

• Be courteous and considerate of others

• Consider all information to be confidential

I have read and understand the information above.*

For more information contact:
Kim Handloser
Rogue Community Health
541-973-1564

Patient Advisory Cohort Application

Please tell us about yourself

Statement of Confidentiality