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Patient Partner Application Form

Patient Partner Application Form

Thank you for your interest to join Sepsis Canada as a Patient Partner. As a Patient Partner your insights and lived experience will help us conduct research that is relevant and of importance to sepsis patients and their families. Help us get to know you better by completing this form.

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Please select a time(s) of day you are available to participate in Patient Partner activities (e.g., meetings). Please check all that apply.
There are many ways to participate as a Patient Partner. Please check the potential roles/responsibilities that are of interest to you.
There are many areas that Sepsis Canada conducts research within. Please check the research areas that are of interest to you:

Please ensure you have completed one method of preferred contact on your form (telephone or email) so we may respond to your submission.

A member of the Sepsis Canada Patient Council will contact you via email or telephone within 2 weeks of receiving this application form.