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* 1. I want to be represented! Please use my opioid access experience for the RLS Foundation's advocacy outreach. By providing your story and required contact information, the RLS Foundation may use this information to raise awareness and educate policymakers about the disease including the appropriate use of opioids for refractory RLS.  Provide your story in approximately 150 words or less.

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* 2. Do you give the RLS Foundation permission to use your story in letters when contacting policymakers to request their support for any legislation, policies or regulations that would allow continued access to opioid therapy for patients with refractory RLS?

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* 3. My name:

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* 4. My Home address

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* 5. City:

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* 6. State:

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* 7. Zip Code

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* 8. Email address: