Healthcare Survey

1

Your Name* This field is required.

First Name

Last Name

2

Have you or a loved one had to visit urgent care or the ER in the past 12 months? * This field is required.

YESNO

3

Do you or a loved one use prescription or over-the-counter medication and/or supplements? * This field is required.

YESNO

4

Do you or a loved one suffer from stress, feelings of sadness, anxiousness, lack of sleep, difficulty concentrating, or any other concerns?* This field is required.

YESNO

5

Have you or a loved one ever had to wait days or weeks to see a primary care physician for something as simple as a note, form, or prescription refill? * This field is required.

YESNO

6

Could you or a loved one benefit from discounts on dental, vision, chiropractic, labs, and/or medical supplies?

YESNO

7

What other wellness benefits might you or a loved one have need of?* This field is required.

Dermatology

Weight management

Men's health care

Women's health care

Easy access to medical records

Email consultations with primary care physicians, holistic doctors, and specialists

A dedicated concierge line for assistance and discounts

Virtual urgent care and prescriptions discounts for all of your household pets

8

What is your greatest challenge right now when it comes to healthcare?* This field is required.

I don't have any coverage, paying out of pocket

I have coverage but my premiums are sky high

I have affordable coverage but the benefits are inadequate

My healthcare plan is complicated to use (finding in network doctors, co-pays, deductibles, etc.)

I'm paying too much for medications

I just avoid getting sick because if I do, I'm screwed!

9

Would a convenient and affordable healthcare membership, which is NOT insurance that offers all the mentioned benefits—plus no medical exams, no open enrollment, no co-pays, no deductibles, and no paperwork—be helpful to you or someone you know?* This field is required.

YESNO

10

Do you have a partner and/or dependents you'd like to add AT NO ADDITIONAL COST?You can add up to 7 additional people on your plan—one adult friend, partner, or family member and/or dependents up to the age of 25. If you have no one, who else do you know who could benefit from these services?

Name

11

Our membership offers unlimited virtual urgent care, 24/7 on-demand talk therapy, and the most common medications INCLUDED for free; for up to 8 people at no additional cost. What do you believe is the value of such a membership?* This field is required.

$499/month

$399/month

$299/month

$199/month

12

Please keep in mind that THIS IS NOT INSURANCE, so there are no contracts or commitments. You don't even need a social security number to join! Would you like to find out how much this healthcare membership costs and how you and your loved ones can start using these benefits immediately?* This field is required.

Absolutely!Maybe

13

Thank for completing the survey. We will email your results !* This field is required.

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

••••

14

Who should we thank for sending you this survey?* This field is required.Enter the name of the person who invited you to take this survey

15

You will be automatically redirected to the link to download your free prescription card. Please share your phone number if you'd like to receive a follow-up call and an additional free incentive.3 Nights luxury hotel accommodations!

Area Code

Phone Number