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* 1. Please explain how RLS has impacted your social, emotional and physical well-being, how long you have taken opioids to manage your RLS and how opioids have improved your overall quality of life: (in approximately 150 words or less)

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* 2. Do you give the RLS Foundation permission to use your story in letters to legislators requesting their support for policies that allow continued access to opioids for RLS treatment?

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* 3. I give the RLS Foundation permission to use my name.

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* 4. Name:

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* 5. Address

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* 6. City:

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* 7. State:

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* 8. Zip Code

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* 9. Telephone number:

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* 10. Email address:

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