ILIGAN-LANAO ACTION FOR WELLNESS
Survey & Leads Generation Program
A Health & Wellness Assistance Form
We give a hand
Name
First Name
Last Name
Email
example@example.com
Phone Number 1
*
-
Area Code
Phone Number
Alternative Contact Numbers
Have you experienced paying for your hospital bills
*
YES
NO
NOT SURE
Did you wished that you had enough savings to pay for it?
*
YES
NO
NOT SURE
Do you want that someone will shoulder your hospitalization, Just in case?
*
YES
NO
NOT SURE
Do you know anything about HMO? Maxicare for instance
*
YES
NO
NOT SURE
Would you be Willing to receive information to raise your awareness how to do it?
YES, I am very much willing
YES, I am currently doing it but I have a question
YES, I need more information.
What is your most convenient date and time to better help you and answer all your questions?
-
Month
-
Day
Year
Date
What is your desired time to be contacted?
Thank you Your wellness matters to us. We are willing to help you. Please write your comments or any questions you want to ask from us.
Submit
Should be Empty: