Health Care for America NOW! | Report on your visits or contacts with Legislators

Please report on your legislative visit

The following form will be sent to the Health Care for America Now national office. The information on your visit will be shared with the partners in your state. Thanks for reporting!

If you have a signed copy of the "Which Side" Statement by a Member of Congress, please fax it to: (928)447-6189.

Please choose only the Senator or Representative that you met with. Do not choose both.

Email: *

First Name: *

Last Name: *

State: *

Name of Organization: *

Name of Org. Contact for the visit: *

Org. Contact email: *

Org. Contact phone: *

Only pick one of the following two options. If you met with a member of the Senate, Select your Senator: *

If you met with a member of the House, Select your Representative: *

Other Congressional candidate:

Date of visit: *

Did you meet with the member him or herself?:

yes
no

If, no: Please include the name and title of person you met with below:

Email for staff person in meeting:

Phone for staff person in meeting:

Did the Congressperson sign the "Which Side" statement?:

Yes
No

If, no: What were the reasons given?:

Was there any follow up plan discussed?:

Yes
No

If so, what are the details of the follow up plan?:

Please describe you visit in detail and address and comments or concerns that arose during your conversation: *

* denotes required field

If you have questions please contact Margarida at mjorge @healthcareforamericanow.org.

Health Care For America Now

Please report on your legislative visit