1.Do you currently have health insurance for yourself and/or family?

Yes

No

Other (please specify)

2.If you are a business owner, do you offer health insurance to employees?

Yes

No

Not Applicable 

3.If you have health insurance, is it a:

High Deductible Health Plan

Catastrophic Plan

Other (please specify)

None of the above

4.If you are either not insured, have a high deductible or catastrophic plan, would you be interested in a primary care program for a monthly fee? (to include up to 30 visits/year for $50/month with the option to be covered by individual or employer)

Yes

No

Not applicable

5.If you are interested in the program would it be for:

Yourself only

You and your family

6.If interested in learning more about a primary care program or exploring other healthcare options, please leave your contact info below:

Name

Company

Address

Address 2

City/Town

State/Province

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP/Postal Code

Email Address

Phone Number