Appointment_Questionnaire

Do you have your red, white and blue Medicare card. Please have it at our meeting.

Yes

No

Do you have any chronic conditions such as Diabetes, Cancer or Renal Disease

Yes

No

Does the state help you pay for any part of your health coverage

Yes

No

What is the most important factor when making your health insurance decision:

Benefits such as Chiropractic, Acupuncture and Over The Counter

Keeping your Doctor's and Hospital

Price

Current Plan Information