Response

First Name

Last Name

Address Line 1

City

State

Zip

Cell Phone

In the past 14 days, have you or anyone in your household been in close contact with an individual who has tested positive for COVID-19?

Yes
No

In the past 14 days, have you displayed any of the following symptoms? [check all that apply]

Fever
Cough
Shortness of breath
Lost sense of taste or smell
None

Thanks for coming! Would you like to receive occasional email updates from Rep. Phillips?

Yes, thanks!
No, not right now.

Washington, DC Office
2452 Rayburn HOB
Washington, DC 20515
Phone: (202) 225-2871
Fax: (202) 225-6351

Minnetonka Office
13911 Ridgedale Drive
Suite 200
Minnetonka, MN 55305
Phone: (952) 656-5176