Send a Prescription Drug Valentine

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Prescription drugs don't work if people can't afford them!

This Valentine's Day, tell us about the outrageous cost of your prescription drugs. We'll be tweeting your comments to your Reps. on Friday, February 12th!

*Don't worry, PHAN will never use your name without your permission!

Fill in the blank "I'd buy you flowers and chocolates, but my prescriptions cost ____ a month, so all you're getting is this lousy card."*

If you've had to give things up to pay for medications, ration or cut your pills, or leave them at the pharmacy, tell us more here:*

Email Address*

First Name*

Last Name:

City*

Zip Code*

Phone number where we can reach you:

Can PHAN share this story on Twitter with your Rep., using only your first name?*

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If you want us to tag you on Twitter, enter your twitter handle here:

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ORGANIZATION NAME
ORG ADDRESS LINE 1 ORG ADDRESS LINE 2
ORG CITY, ORG STATE ORG ZIP
ORG CONTACT PHONE
ORG CONTACT EMAIL

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Thank You!