Patient/Family Advisor Application - Kelsey-Seybold Clinic

Ethnicity (select all that apply) Asian Black/African-American Hispanic/Latinx Native American Pacific Islander White Other

* From which Kelsey-Seybold locations do you receive service. Select all that apply: Baytown Clinic Berthelsen Main Campus Clear Lake (Bay Area Campus) Conroe Clinic Cypress Clinic Downtown at Esperson Tunnel Downtown at The Highlight Fort Bend Campus (Fort Bend Medical and Diagnostic Center) Great Heights Clinic Gulfgate Clinic Katy Clinic Kingwood Clinic Lake Jackson Memorial City Clinic Memorial Villages Campus Meyerland Clinic North Channel Clinic North Houston Campus Pasadena Clinic Pearland Clinic River Oaks Clinic Sienna Clinic Sleep Center South Shore Clinic St. Luke's Medical Tower Stafford Clinic Summer Creek Clinic Tanglewood Clinic The Vintage Clinic The Woodlands Clinic Woodlands OB/GYN and Woman's Health West Grand Parkway Clinic Westchase Clinic Woman's Center

* How long have you been a patient (or family member of a patient) with Kelsey-Seybold? Less than 2 years 2-5 years 6-10 years More than 10 years

In the past 10 years, what care services have you used at Kelsey-Seybold Clinic? Check all that apply. Primary care (appointments with your primary care provider or pediatrician) Specialty care (appointments with a specialist, such as cardiology or dermatology) Cancer Services Ambulatory Surgery Center Radiology and imaging services Laboratory services Pharmacy

Please indicate the ways in which you would like to participate as a Patient/Family Advisor. Select all that apply. Focus Groups - Provide feedback in a group format on a particular topic. Focus groups are held as needed, both in person and virtually. Patient Advisory Council – Represent the patient voice and promote patient centered care by providing feedback on projects and initiatives. Meets quarterly in the evening. Members should be ready to commit to serving on the council for at least 1-2 years. Space is limited. Survey Participant – Provide feedback via surveys to help us gain a large and diverse response to questions on a particular topic. Education & Material Review – Review educational materials, brochures or website content to ensure patient friendliness. Story Sharing – Share your Kelsey-Seybold healthcare experience stories (positive or negative).

Why are you interested in being a patient or family advisor? Are there any areas of special interest to you?

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