Tell us your story!

Are you the star of our next TV ad?

Or if you know the perfect person -- including Republicans who support the public option -- please send this page to them.

First Name: Last Name:
ZIP/Postal Code:
Phone Number:

Check all that apply to you:

I have a health care story involving
a current condition that shows why we can't afford
to wait 5 years for reform to kick in.
I have a compelling health care story.
I'd be a good local voice on this issue.
I don't have health insurance.
I am a Republican or former Republican.
I voted for my (R) Senator or House member.
I voted for my (D) Senator or House member.
I work in the insurance industry.
I am a doctor or nurse.
I am a small business owner.
I am a local elected official.
I am a local party officer.
I am a veteran.
I want to help find others who have stories.

Your Senators and House member (if you know):
If you have a health care story, tell us here:
What is your message to your representatives in Congress?