Healthcare professionals - use this form to recount instances of discrimination you have experienced, from applying to medical school through your professional career

 Patients - use this form to explain why you value the freedom to choose a life-affirming physician or institution.

1.	First Name *
2.	Last Name *
3.	Email
4.	City
5.	State
6.	Your Story *
	Please enter your personal story here in 250 words or less.
7.	May your story be shared publicly? *
	Yes  No
	* Required