Client Needs Form

Client Full Name:(Required)

Client Date of Birth:

Client Phone Number:

Client Email:

Medicare Card?

Yes

What would you like to accomplish in today's appointment?

Tell me about your health history.

Tell me about your current insurance.

Do you currently have dental insurance?

Do you know the difference between Medicare Advantage & a Medicare Supplement?

Do you have any doctors you prefer? Any medications?

Have you and/or your family had any experience with home healthcare or long term care?

Do you have any family history or experience with cancer, heart attacks or strokes?

When was the last time you reviewed your life insurance? Who is it with and how much are you paying for it?

Has anyone helped you with retirement planning?

Extra information, notes or follow up items:

Agent Name:(Required)