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First Name
Last Name
Address
City
State
Zip
County
Cell Phone
Email
Gender
DOB
Best time for appointment
Do you currently have any insurance?
Smoke
Pregnant
Legal Status:
Marital Status
Number of Family Members that appear on your Income Tax Form
Are you planning to file a joint tax return


Dependant 1 Age
Dependant 1 DOB:
Dependant 1 Gender
Dependant 1 Smoker:


Dependant 2 Age

Dependant 2 DOB:
Dependant 2 Gender
Dependant 2 Smoker:


Dependant 3 Age

Dependant 3 DOB:
Dependant 3 Gender
Dependant 3 Smoker:


Dependant 4 Age

Dependant 4 DOB:
Dependant 4 Gender
Dependant 4 Smoker:
Are you currently working
W2 (Employee)
1099 (Self employed)
Household Income / Gross
Does Your Employer offer/provide Health Insurance
If yes, is the cost of this insurance more than 9.5% of your income
Please include any other informaiton: