Request a doctor or medical student to talk about health reform at an event! We will respond to your request within 2 weeks. If this is a press inquiry or an urgent event, please contact Samantha Galing at 202-481-8219 or samantha.galing@drsforamerica.org.

Please be as complete as possible when filling out the form so we can find the best person for your event!

YOUR INFORMATION

EVENT LOCATION:

Venue (optional):

This is a virtual event :

Street Address:

City:

State:

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming

Zip:

 

EVENT DATE AND TIME:

Date:

Time:

01 02 03 04 05 06 07 08 09 10 11 12 : 00 15 30 45 AM PM

Date and Time are Flexible:

 

EVENT DETAILS:

Requested Presenter (optional):

Audience Type (e.g., doctors, seniors):

Audience Size (optional):

1-5 6-10 10-25 25-50 50-100 101-200 201-300 301-500 501-1000 1000+

Open to the Public:

Yes No

Planning to invite media:

Yes No

Facilities Provided (for talks):

Laptop Projector Projector Screen Microphone

Why are you interested in having a doctor or medical student speak?:

Additional Information:

How did you hear about us?: