Patient and Family Advisor Application Form*

To become an advisor for patients and families at Sidra Medicine, kindly take a few minutes to fill out this form.

    • Preferred contact (the best way to contact you for any future inquiries)

  • To help us get to know you better, please complete the following questions.

    • 1. Are you a …
    • 2. What language(s) do you speak?
    • 3. Do you or your family member have any chronic health conditions?
    • 4. When was your or your family member’s care experience at this hospital? (Check all that apply)

  • 5. Which unit(s) provided care for you or your family member? (Check all that apply)

    • Pediatric and Adolescent Medicine Services
    • Surgery Services
    • Women’s Services
    • Clinical Services
    • Health Promotion Programs
    • 6. We recognize that our patient and family advisors have busy lives. How much time are you able to commit to being a patient and family advisor? (Check one)
    • If yes, what times would work best for you? (Select all that apply)
    • 7. Are you available to serve as an advisor for at least 1 to 2 years? (You can still be an advisor if you answer “No”)
    • 8. Would you be available to participate in a meeting for 90 to 120 minutes every other month? (You can still be an advisor if you answer “No”)
    • If yes, what times would work best for you? (Select all that apply)
    • 9. How do you want to help? I want to: (Check all of your interest areas)
    • 10. Have you received any of the following vaccines? (Check all that is applicable)
    • 11. If you have not been vaccinated with the above, would you be willing to take the required vaccinations?

  • Please tell us more about yourself.

    • 5. Have you or a family member experienced health care services outside of Qatar?
    • 6. Have you ever been convicted by the courts or cautioned, reprimanded, or given a final warning by the police?
    • 7. Is there anything in your personal experience you would like to declare that might conflict with your participation in the PFAC?