Quick additional information questionnaire.
This form should only take 2-5 minutes to complete.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Cell Phone Number
Please enter a valid phone number, cell phone is preferred.
How did you hear about our company? If it was a specific person, please give us that person's name (First and Last name), as we like to thank anyone who refers us.
What is the current Health Insurance / Medicare situation you are looking to solve?
What is your timeframe to have a solution in place?
What is the name of the plan(s) you are currently on? What are the premiums for these plans?
Which of the following options sounds closer to your ideal outcome?
I would prefer to pay higher premiums and have lower out-of-pocket costs
I would prefer lower premiums and have higher out-of-pocket costs
I am open to either of the above, I am just focused on getting the best value for my money
Please let us know if there is any additional information you would like to share with us. This may include specific prescriptions not previously mentioned, or any other health conditions that we should be aware of that will play a factor in customizing a solution for you.
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