New Health Insurance Client Intake Form Fill out this form ahead of time to make your appointment as smooth as possible Your Personal & Family InformationName(Required) First Middle Initial Last Date of Birth(Required) MM slash DD slash YYYY Tobacco User?(Required)NoYesVeteran?NoYesOther Household MembersNameDate of BirthRelationship to YouTobacco User? (Y/N)Veteran? (Y/N) Add RemoveUse the + button on the right to add more lines.Cell Phone(Required)SMS Opt-In Opt-in to receive SMS messages By submitting this form and opting-in to receive SMS messages, I consent to receive customer care and account notification messages (appointment reminders, enrollment assistance and/or client service communications) from Ulness Health LLC at the number provided. Consent is not a condition of enrollment. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help. Review our Privacy Policy and Terms & ConditionsEmail 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 CountyCounty (Outagamie, Winnebago, Calumet, etc.)Your Insurance & Financial InformationEstimated Household Income (2025 calendar year)Current Insurance CoverageEmployer-provided health planCOBRAOther ACA Marketplace planNo coverageOtherYour Medical InformationDoctors and Other ProvidersProvider NameSpecialtyClinic 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)Refill Frequency (e.g. every month) Add RemoveUse the + button on the right to add more lines.Prescription Medications I don't take any prescription drugs NotesAgent InformationAgent(Required)John Ulness NPN: 6530356Marit Ulness NPN: 15887658Erik Ulness NPN: 15952162Don Bachaus NPN: 6493416James Boland NPN: 20305616Who are you meeting with?How did you first hear of Ulness Health?Referred by Family/FriendReferred by AdvisorInternet SearchAppleton Farm MarketBuilding SignsMedicare Workshop/PresentationOtherName of Family/FriendName of AdvisorNotes on "Other"Are You a Robot?CommentsThis field is for validation purposes and should be left unchanged.
