Group and Media Summary Form

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New England Patients’ Rights Group

P.O. Box 141 –Norwood, MA 02062 - 781-769-5720 NEPRG@outlook.com

Group and Media Summary Form

Name________________________________________________________________

Street________________________________________________________________

City, State,Zip Code____________________________________________________

Phone _______________   Cell Phone ________________ E-Mail_______________

Short Summary of Problem or Health Care Interest or Concern:
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Outcome or Vision or Advocacy:
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Can you speak to the media including TV, radio and/or newspaper? 
If so, when is
the best time to reach you? Topic(s)______________________________________
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Are you able or willing to attend hearings and/or forums?  Topics or issues______
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Mail or e-mail form.  Tax deductible contributions to assist with our advocacy
can be made to the New England Patients’ Rights Group, Inc. and sent to
the above address.

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