Patient Ambassador Advocacy Activity Report Form

Use the form below to report your latest advocacy activities to DPC as a Patient Ambassador.

If you have performed multiple activities recently, please report each activity separately.

DPC is already notified when you 1) email your local lawmaker through DPC's Action Center, 2) participate in DPC's Annual Member Survey, 3) submit a blog to DPC and 4) apply for DPC's Advocacy Day. As a result, no need to report those activities again below.

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

Toll free: 1-866-877-4242
Fax: 888-423-5002