Become a "Very Influential Physician" today!

Be a "Very Influential Physician"

The AMA has developed a program to help physicians, residents and students take on a leadership role in grassroots activities on behalf of organized medicine. Our Very Influential Physicians (VIP) program helps physicians, residents and students learn how to create, maintain, and effectively leverage relationships with members of Congress and their staff in order to advance our shared agenda on Capitol Hill.

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1. Please tell us about yourself:

Name: *

Address: *

City/Town:

State:

ZIP/Postal Code: *

Email Address: *

Phone Number:

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2. I am a...

Physician

Resident

Student

Other (please specify)

Please tell us about the FIRST person in Congress you know. If you know more than one person in Congress you will have the opportunity to tell us about it on the next page.

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3. Who do you know?

Congressman/Senator

Staff member

Please specify person's name

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4. How would you categorize your relationship? I am a… (check all that apply)

Personal friend

Personal acquaintance

Constituent

Financial donor

Campaign advisor (kitchen cabinet, health care advisory committee, finance committee, etc)

Other (please specify)

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5. Do you know anyone else in Congress you would like to tell us about?

Yes