Harrow Health Centre Family Health Team (HHC) must be able to leave messages pertaining to the PFAFG’s efforts and freely provide any information regarding HHC’s PFAFG meeting. Please ensure contact details are private. 

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* 1. Full Name:

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* 2. Email Address:

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* 3. Telephone Number:

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* 4. Have you been a patient (or family member of a patient) at the HHC within the past 5 years?  

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* 5. Are you able to attend a one-time event on Saturday, June 24 from 10-12:30pm?

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* 6. Do you require any special assistance during this event?

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* 7. Please read the following and then check the box at the end to agree to our Confidentiality Agreement.


The advisor may be exposed to events involving patients of the HHC. 

The advisor may be exposed to information that is considered confidential by the policies of the HHC 


IN CONSIDERATION OF, and as a condition of the review of the HHC, the advisor Confidential Information in addition to other valuable consideration, the receipt and sufficiency of which consideration is hereby acknowledged, the parties to this Agreement agree as follows: 



I. The advisor acknowledges their obligation to maintain Patient Confidentiality. 

II. Except where otherwise indicated and provided, the advisor must keep the Confidential Information confidential. 

III. Except where otherwise indicated and provided, the Confidential Information will remain the exclusive property of the HHC or the Patient on request. 

IV. The confidential Information will only be used by the advisor for the Permitted Purpose. 

V. The advisor will not use the Confidential Information for any purpose which might be directly or indirectly detrimental to the HHC, the Patient, or any of their affiliates or subsidiaries 


The obligations and requirements to protect the CONFIDENTIAL INFORMATION imposed on the advisor in this Agreement and any obligations to provide notice under this Agreement will survive the expiration or termination, as the case may be, of this Agreement. 

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* 8. Please read the following and check the box at the end acknowledging our Code of Conduct.


The Harrow Health Centre Family Health Team (the “HHC”) is committed to ensuring that in all aspects of its affairs it maintains the highest standards of public trust and integrity. 


This Code of Conduct applies to all advisors. 


Respectful Conduct 

It is recognized that advisors bring diverse backgrounds, skills, and experiences to the focus group. Advisors will not always agree with one another on all matters. All debates shall take place in an atmosphere of mutual respect, collegiality, and courtesy. The authority of the facilitator must be respected at all times wherever the focus group convenes by all advisors. The PFAFG will be conducted within the best interests of the HHC and as such for the purpose of these meetings, the facilitator will be designated as the Executive Director.

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* 9. Personal information contained on this form is collected pursuant to the Personal Health Information Protection Act (PHIPA) and will be used for the purpose of Patient and Family Advisor assembly and placement at HHC. We will not use this information otherwise without permission from the applicant.

By submitting this form, I have read and understand (please checkmark the boxes):

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We would like to share the outcome of this event to all our patients and the community.