New Client Demographics

Please complete the information below. Better Health Advisors complies with all government privacy standards, and your health and demographic information is kept private and confidential.

Name:
DOB:
Address (where client lives & insurance bills):
Phone Number:
Email:
Primary Contact Name:
Primary Contact Phone Number:
Main Issue to Address:
Secondary Issues:
Insurance Card (front and back):
Max file size 10MB.
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