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Client Intake Form

- Step 1 of 11

Primary Contact

Name

First

Last

Phone Number

Zip Code

Are you a...

New Client
Current Client
Past Client

Home Address

Would you like to provide your full home address?

Address

Address Line 1

Address Line 2

City

State

Zip Code

Your Information

You can add other family members in the next steps.

Are you wanting coverage for yourself?

Yes, for myself (or myself AND others)
Not for myself, only for others.

Your Date of Birth//

Your Gender

Your Height

Your Weight

Are you an expectant parent?

Have you regularly used tobacco or nicotine in the last 12 months?

Spouse's Information

Does a spouse need coverage?

Spouse's Date of Birth//

Spouse's Gender

Is your spouse an expectant parent?

Has your spouse regularly used tobacco or nicotine in the last 12 months?

Kid's Information

Do you need coverage for any children?

Health History

How often does each person go to the doctor on average each year?

Never
1-2 times
3-5 times
6+ times

Does anyone have any pre-existing conditions or health concerns?

Please tell me about your health history:

Preferred Doctors

Are there an specific doctors that are important to be in-network?

Please provide first and last name of all important doctors:

Preferred Dentists

Do you have any preferred dentists you want in-network?

Please provide first and last names of all important dentists:

Current Prescriptions

Is anyone currently taking or need to be taking any prescriptions?

Please list all important prescriptions:

Income & Household Information

Would you like to provide income and household information?

Are you legally married?

How many child dependents do you claim when filing taxes?

What is your estimated annual household income?

only include the income of who you file taxes with.

Additional Information

Would you like to provide any additional information?

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