How was your "medical bill" drop off?

Name*

Email address*

ZIP Code*

Postal code

Phone*

Whose office did you visit?

Tell us about your drop by. Who was there? Who did you talk to? Was anything surprising?

Will your representative oppose repealing the Affordable Care Act?
Yes

No

Don't know yet

Do you feel that this drop off was an effective way of getting the message about the Affordable Care Act to your representative?
Yes

Somewhat

No

Would you be interested in hosting UltraViolet events (like demonstrations, protests, petition deliveries, or house parties) in the future?
Yes! Definitely.

Maybe. It depends on the type of event.

No

On a scale from 1-10 (1 = awful, 10 = awesome), how would you rate this experience?

Anything else you'd like to share?

UltraViolet