PRIMARY CARE Feedback Form

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Question Title

* We are creating a list of names to use for advocacy and to identify potential clients should our proposal for a nurse practitioner-led clinic for older adults be approved.

Eligibility criteria to be on the list:
You are over 65 and "uncertainly attached" to primary care, in one of the following categories:
1. Are not on the roster of a regular primary care provider (family doctor or nurse practitioner); OR
2. Have a regular primary care provider who is expected to retire in the next 2-3 years; OR
3. Have a regular primary care provider but have difficulty getting service because of long wait times or travel issues.

If you meet the eligibility criteria, please provide your name and email address:

Name

Email Address

Question Title

* OPTIONAL: We would like to track the area associated with the feedback we have received. Consolidated postal code information may be shared with community organizations. Please provide your postal code.

We appreciate you completing this form. Have a great day!