Medical Intake Form

Fill Out Our Medical Intake Form

Medical Intake Form

Fill in our Medical Intake Form, and a member of our team will get back to you as soon as possible.

General Information

First Name
Middle Initial
Last Name
Nickname
Select One
Date of Birth
Your Social Security Number
Spouse's Legal First Name
Middle initial
Last Name
Spouse's Date of Birth
Spouse's Social Security Number
Is anyone a regular tobacco user?
YesNo
If so, who?

Home Phone Number
Your Mobile Number
Spouse's Mobile Number
Apt or Suite
City
State
Zip Code
County
Main Email Address

Estimated Annual Adjusted Gross Income for ENTIRE household the year of coverage needed:
Amount
Number of Children you will be claiming on your tax form
If enrolling child(ren), we will need their Social Security #(s).
What is the best way for you to receive our bi-yearly newsletter?
EmailPostal Mail
Would you like us to text you your appointment reminders?
YesNo
What is your preferred form of communication?
PhoneTextEmailAll the Above
Whom may we thank for sending you here? (How did you hear about us?)
What medical network do you most frequently use for doctor visits? (Prevea, Aurora, Froedtert , etc)
Do you want/need an HSA Plan?
YesNo
Would you like info on Dental and/or Vision Insurance:
YesNo
Information on Life Insurance
YesNo
Information on Long Term Care
YesNo
Information on Travel Insurance
YesNo
Any other information you would like the agent to know such as brand prescriptions, c-pap machine, a specific doctor you need covered, etc...
Names of dependents and birth dates

Medications and Dosages

Medication Look Up

IF YOU HAVE MORE THAN 3 GENERIC MEDS or 1 EXPENSIVE MED OR MORE PLEASE FILL OUT AND RETURN RETURN WITH OTHER DOCUMENTATION BEFORE YOUR MEETING. (Please list all prescription medications you are currently taking)
Medication Name Medication Name for Medication 1
Medication Dosage
Amount Per Day
Medication Name Medication Name for Medication 2
Medication Dosage
Amount Per Day
Medication Name Medication Name for Medication 3
Medication Dosage
Amount Per Day
Medication Name Medication Name for Medication 4
Medication Dosage
Amount Per Day
Medication Name Medication Name for Medication 5
Medication Dosage
Amount Per Day
Medication Name Medication Name for Medication 6
Medication Dosage
Amount Per Day
Medication Name Medication Name for Medication 7
Medication Dosage
Amount Per Day
Medication Name Medication Name for Medication 8
Medication Dosage
Amount Per Day
Medication Name Medication Name for Medication 9
Medication Dosage
Amount Per Day
Questions, comments additional medications
Do you currently use coupons for medications?
YesNo
Enter an additional notes here for the agent to review.

Verification

Please enter any two digits *Example: 12
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Our clients Matter

Thomas Atkielski



Professional. They have products for Medicare-Medicaid supplements and advantage plans. Good people to work with.

Taylor Thielke



Kris explained everything clearly, and let me decide what is best for my specific health benefits. The office is very friendly, and was efficient on scheduling and returning phone calls. I recommend Kris to everyone!

Debra Koene



Knowledgeable personnel and they explain everything so you understand.

Mark Thomas



Very personable agents and knowledgeable.

Ann Rawlinson



The best service!

we can't wait to hear from you.

Request A Quote

FILL OUT FORM

We're ready to be your #1 insurance resource.

Tell us your story and we listen. Our office is conveniently located in the historic Mill Street Transfer in downtown Plymouth, WI in the heart of Sheboygan County. All consultation meetings are free.

Contact

info@nextstep-insurance.com
(920) 268-1600

Visit

435 East Mill Street Mill Street Transfer Building Plymouth, WI 53073

Medicare Disclaimers: “We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.”
and
“Next Step Insurance and/or it’s agents are not connected with or endorsed by the U.S. Government or the Federal Medicare Program.”

This is a proprietary website and is not associated, endorsed or authorized by the Social Security Administration, the Department of Health and Human Services or the Center for Medicare and Medicaid Services. This site contains decision-support content and information about Medicare, services related to Medicare and services for people with Medicare. If you would like to find more information about the Medicare program please visit the Official U.S. Government Site for People with Medicare located at medicare.gov.

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