Be a Patient Representative

At The Everett Clinic we strive to continually improve our services and quality of care.  In an effort to better serve you, we are asking interested patients to partner with us to improve the patient experience by joining a team for ongoing improvement.  Your involvement is invaluable and will be reimbursed with an honorarium.

If you would like to become a patient representative, please complete the form below.  Note:  A response is required for all questions except those marked "optional".  

Be a Patient Representative

Name (First & Last):
Address:
City:
Zip:
Phone number:
Email Address:
Date of Birth:
Gender:
How long have you received care at The Everett Clinic?



At which Clinic location do you receive a majority of your care?






What type of care do you receive at the Clinic? (Please check all that apply)


Do other family members receive care at The Everett Clinic, or have they in the past?
What is your overall impression of The Everett Clinic?
Please describe any challenges you may have had with The Everett Clinic (optional)
What ideas or suggestions do you have about how to improve The Everett Clinic experience for patients? (optional)
What would work best for your schedule? (Please check all that apply.)


Would you be interested in participating on a 3-4 day project improvement team?
What topics/issues are you particularly interested in? (Please check all that apply)



Questions or comments? (optional)