Patient Partner Network Application

Your Name(Required)

First Last

Your Email(Required)

Phone(Required)

Mobile number preferred, but optional

Gender(Required)

Male

Female

Non-binary

My gender is not listed

Prefer not to answer

Other

Race/Ethnicity(Required)

American Indian/Alaska Native

Asian

Black/African American

Middle Eastern/North African

Native Hawaiian/other Pacific Islander

White/Caucasian

Hispanic/Latin American

Other

Prefer not to answer

Race/Ethnicity Other(Required)

Are you located in the United States?(Required)

Yes

Which US Region?(Required)

Which Country?(Required)

Country

Preferred Language

English

Spanish

Other

Surgical topic(s) of interest(Required)

Select one or more surgical topics on which you would like to offer your expertise.

Colon and Rectal(Required)

Diverticulitis

Colon and rectal cancer

Esophagus and Stomach(Required)

Achalasia

GERD (reflux) and surgeries to treat reflux

Gallbladder and Liver(Required)

Gallbladder removal (Cholecystectomy)

Complication after gallbladder removal (Bile duct injury)

Removal of portion of liver and other liver procedures

Hernia(Required)

Abdominal hernia repair

Hiatal hernia/ Paraoesophageal hernia/ Diaphragm hernia repair

Groin hernia repair (Inguinal)

Kidney, Spleen and Adrenal Glands(Required)

Peritoneal dialysis

Spleen surgery

Adrenal gland surgery

Patient Preparation and Recovery for Surgery(Required)

Patient preparation before surgery

Recovery process for patients after surgery

Preferred type of engagement(Required)

Guidelines – be part of a group who forms a set of recommendations for surgical care

Annual Meeting – be available to speak at our Annual Meeting where you have the opportunity to share your expertise with a live audience

Research – be part of a research group who is creating and performing research that impacts patient lives

Patient Education – be part of a group creating and updating educational materials for patients

Surgeon Education – be part of a group creating and updating education material for surgeons

Focus Groups – be part of a focus group that may require brief sessions looking for your feedback

Survey – be included in surveys to improve the care of patients

Advocacy/Support

Unsure

Select one or more ways you would like to share your knowledge and expertise with SAGES. Check all that apply.

By submitting your application to the SAGES Patient Engagement Taskforce, you understand that you may be contacted to volunteer your time to participate in select groups or activities but you do not have to accept the invitation to participate. Your information will be handled with care and in accordance with privacy best practices. However, while we take steps to protect your data, we cannot eliminate all potential risks. By submitting your application to the SAGES Patient Engagement Taskforce, you acknowledge these considerations.

I agree to the Terms of Service

Code of Conduct(Required)

By submitting your application, you agree to follow the Code of Conduct which includes the following:

Participants will engage in a welcoming and supportive environment.

Self-promotion and spam are not permitted.

Participants will respect everyone’s privacy allowing for authentic and expressive discussions.

I agree to the Code of Conduct

Before you go

How did you learn about the SAGES Patient Partner Network (PPN)?

Your surgeon

A member of the PPN

Other

How easy was the application to use?

Do you have any additional feedback to provide?