Virtual Patient Advisory Collaborative (VPAC)

Application

The North York Family Health Team would like to thank you for your interest in our Virtual Patient Advisory Collaborative (VPAC). This advisory collaborative will help improve and enhance patient experiences at the NYFHT.

By submittng this application, you are agreeing to share your contact information with the NYFHT administrative staff and other members of the VPAC. This information will not otherwise be shared without your permission.

Please note, we cannot guarantee that every applicant will be selected to be a participant of the Virtual Patient Advisory Collaborative.

Thank you for your interest in supporting the North York Family Health Team in this advisory role.

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* 1. Your First and Last Name:

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* 2. I am a:

Patient

Family Member

Caregiver

Other (please specify)

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* 3. Gender:

Male

Female

Other

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* 4. Best phone number to reach you:

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* 5. Email address:

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* 6. Please select the age range that applies to you

18-30

31-45

46-60

61-75

76-85

85+

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* 7. Highest level of education received

High School

College

University

Other (please specify)

Language:

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* 8. Primary Language:

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* 9. Other Languages (Please list below):

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* 10. How do you feel you could support the NYFHT in improving patient care?

Assist in developing/evaluating new NYFHT programs and services by bringing patient and family perspectives

Provide input into patient education materials

Assist in improving the quality of the health services provided

Participate in developing patient experience strategies and/or activities

Other (please specify)

Virtual Patient Advisory Collaborative (VPAC)

Application

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* 1. Your First and Last Name:

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* 2. I am a:

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* 3. Gender:

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* 4. Best phone number to reach you:

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* 5. Email address:

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* 6. Please select the age range that applies to you

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* 7. Highest level of education received

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* 8. Primary Language:

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* 9. Other Languages (Please list below):

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* 10. How do you feel you could support the NYFHT in improving patient care?

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* 11. Do you participate in any other community activities? Please list and describe

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* 12. Use the space below to write anything else about yourself that you would like us to know