New Health Insurance Client Intake Form Fill out this form ahead of time to make your appointment as smooth as possible New Health Insurance Client Intake Form Your Personal & Family InformationName(Required) First Middle Last Date of Birth(Required) MM slash DD slash YYYY Other Household MembersFirst NameDate of BirthRelationship to YouTobacco User? (Y/N) Add RemoveUse the + button on the right to add more lines.Cell Phone(Required)Email Address(Required) Home Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Insurance & Financial InformationEstimated Household Income (current calendar year)(Required)Current Insurance CoverageEmployer-provided health planCOBRAOther ACA Marketplace planNo coverageOtherYour Medical InformationDoctors and Other ProvidersProvider NameClinic Name Add RemoveStart with your Primary Care Provider and list as many others (dentist, specialists, etc) as necessary. Use the + button on the right to add more lines.Prescription MedicationsRx Name (e.g. simvastatin)Dosage (e.g. 10mg)Quantity (e.g. 30)Frequency (e.g. every month) Add RemoveUse the + button on the right to add more lines.NotesAre You a Robot?NameThis field is for validation purposes and should be left unchanged.
