Appointment Feedback - Medical Freedom Act

NameYou can use a fake name if you want.

Email Address *We need a valid email address that you can receive email from us, in case we have questions.

Date Visited *

What kind of representative did you visit? *US SenatorUS RepresentativeState SenatorState Representative

Name of Representative *The name of the representative that you visited with.

What district are they in?

On a scale of 1 to 5, did the representative commit to action? *1 = representative didn't care, 5 = representative committed to action

Please describe how the meeting went. Tell us whatever you can. *