info@melham.org

Melham

Medical Center

Broken Bow, NE

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Patient Family Advisory Council

Patient and Family Advisory Council Application

Employment Application

Free Text

PERSONAL INFORMATION

Name

Address

City

State

Zip

Phone Number

Email Address

Where did you hear about us?

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The following questions will help us get to know you better

Please choose one of the following that best describes you.

Patient

Family member of a patient

Community member

When was your care experience at Melham Medical Center? (Check all that apply)

2023 to current year

2022

2021

2020 or before

Which area(s) provided care for you or your family member? (Check all that apply)

Hospital Stay

Emergency Department

Specialty Clinic

Surgery

Lab

Radiology

IV Infusion

Would you be available to do rounds or attend meetings once a month? What days/times work best?

Are you available to serve as an advisor for at least 1 to 2 years?

Yes

No

Why do you want to become a patient and family advisor?

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SIGNATURE DISCLAIMER

Opt-In

By checking this box, I certify that my answers are true and completed to the best of my knowledge and ability.

Type Your Signature

Date

Thank you for submitting your application.

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CONTACT

(308) 872-4100
info@melham.org

Privacy & Accessibility Information

ADDRESS

Jennie M. Melham Memorial

Medical Center

145 Memorial Drive

Broken Bow, NE 68822

© 2025

Jennie M. Melham Memorial Medical Center

VISITING HOURS

Front entrance doors are open from 6:00 AM to 5:30 PM. Please check with the patient's nursing staff for more information.

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