Individual Questionnaire

Sandbrook Individual and Family Questionnaire
Thank you for taking the time to complete this questionnaire. It is designed to help us find the right medical plan for your unique situation. If you are unable to answer any of the questions or do not wish to supply the information at this time, please complete the Contact Information and submit this form to Sandbrook Group. We really look forward to talking to you soon!
Contact Information
First Name *
Last Name *
Email *
example@example.com
Street Address 1
Street Address 2
City
State
Zip Code
Phone Number *
What County do you reside in?
What type of coverage are you interested in?

Medical Dental Vision
How many people are in your household (whether or not they are going to be covered under this plan)?

Who would you like to cover (including yourself)?

Name

Age

Date of Birth

Tobacco User (including Vaping)?

Gender

What is your annual HOUSEHOLD adjusted gross income?
Please include entire household income, even if only insuring a partial household
What type of insurance do you currently have?
Primary Physician Name
Specialist Physicians Names
Current Prescriptions and Dosage

Please include all prescriptions for everyone being covered

Please list current prescription medications, dosage, and frequency taken

Drug Name

Dosage

Frequency Taken

Rx #1

Rx #2

Rx #3

Rx #4

Rx #5

Rx #6

Rx #7

Rx #8

Rx #9

Rx #10

Sandbrook Individual and Family Questionnaire