Share Your Story- PULSE is very often contacted by journalists, researchers, healthcare organizations or reporters about specific areas of interest. This information should only be shared if you are willing to be interviewed. This information sometimes can be kept confidential but that is between you and the requester.

Share Your Story- PULSE is very often contacted by journalists, researchers, healthcare organizations or reporters about specific areas of interest. This information should only be shared if you are willing to be interviewed. This information sometimes can be kept confidential but that is between you and the requester.

Name
E-Mail (if you want to be contacted)
Phone Number (If you want to be contacted)
City, State, Zip
Please tell us the month and year of your experience
Was your experience related to medication?	Yes No
Surgery?	Yes No
Hospitalization?	Yes No
Diagnosis?	Yes No
Infection?	Yes No
Other? Explain
Please explain briefly what happened. No more than 100 words.
Please let us know if we can share your information with reporters or journalists who are researching similar stories.	Yes No
Would you speak to a health system, doctor or researcher?	Yes No
Do you have a website or webpage that can be shared? If so, please let us know the website.