District Meeting Materials Request Form

Thank you for your interest in holding a district meeting with your Member of Congress! Please fill this form out to the best of your ability and we will help you plan your meeting.

Your Name: *

Your Street Address: *

Your City: *

Your State: *

Your Zip: *

Who are you trying to meet with in your district? *

Let us know which legislators you would like to reach out to.

If other, then who?

What type of meeting are you planning on holding? *

Sit-down meeting at the district office.

Tour of a local dialysis facility.

What date are you planning on holding this meeting?

Year

Month

Day

What would you like to discuss during this meeting?

Your Phone Number: *

Your Email:

Leave this field blank

Want to become a better advocate? Join us next Thursday at 2pm ET for our Patient Ambassador call. We will discuss… https://t.co/lPRFsrWK26

Dialysis Patient Citizens
1012 14th Street, NW, Suite #1475
Washington, DC 20005

Toll free: 1-866-877-4242
Fax: 888-423-5002
Email: dpc@dialysispatients.org

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