Athens Regional Health System
706.475.7000

Patient Family Advisors

Thank you for your interest in the Patient Family Advisor Program. Please fill out the application below and the Patient Experience Department will follow up with you within two weeks.  

* Indicates required information
Applicant Information 
Full Name * 
Relationship to Patient * 
Email Address * 
Current Address 
Contact Phone Number * 
Patient Information 
Patient Full Name * 
Patient Date of Birth *   Calendar (mm/dd/yyyy)
Date of Last Visit   Calendar (mm/dd/yyyy)
Which Facility? 

If Other, please specify:

Areas of Interest 



If Other, please specify:

Availability 



If Other, please specify:

How often are you available? 


If Other, please specify:

 
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