Patient and Family Advisory Team

If you are interested in serving on this team or nominating someone to join the team, please fill out the form below to register for this opportunity.

 Name: Mailing Address:City: State:  Zip:Home Telephone: Work Telephone:Cell Phone:Email Address:Have you or a family member received care at UnityPoint Health within the past year? Area(s) where care was received (please check all that apply). Are you signed up for My UnityPoint/Patient Portal Website? Have you used My UnityPoint/Patient Portal Website? Age: Why would you like to be a member of the Patient and Family Advisory Team? What area(s) of concern do you have that you would like to see the Patient and Family Advisory Team address? What special interests or experiences would you like to offer the Team? We believe the Patient and Family Advisory Team should reflect the diversity of the patient population that UnityPoint Clinic serves. In light of this, please share anything about yourself that you think would add to the diversity of the Team. What is the best time to meet during the day?