Summa Health System - Patient & Family Advisory Council Nomination Form

Patient & Family Advisory Council Nomination Form

Please fill out the following application. If you wish to fill out the paper application, please download, print and fill out the Nomination Form (PDF) and return it via mail (instructions are on the form).

Nominee Information
*Name of nominee:
Address 1:
Address 2:
City:
State:
Zip:
Phone Number:
Patient/Family Member Name:
Services used (i.e. Inpatient, Outpatient, Ambulatory Surgery, Emergency Department):
I am recommending this patient and/or family member to be a member of the Patient and Family Advisory Council becase:
Name of person making this recommendation:
Phone:

Nominee Information