Skip to main content
Website designed with the B12 website builder. Create your own website today.
Start for free
Vasquez Health Solutions
+16406962985
healthadvisors.joel.vasquez@gmail.com
Home
About
Services
How It Works
More
Contact
+16406962985
healthadvisors.joel.vasquez@gmail.com
Intake form
Help us serve you better
Name
*
Please provide your phone number.
Email address
*
What is your age ?
Do you have any major pre-existing medical conditions?
Select
Yes
No
What type of health insurance are you interested in?
Please select at least one option.
Individual Health Insurance
Family Health Insurance
Short-term Health Insurance
Long-term Health Insurance
What is your annual income?
Select
$70,000 - $79,999
$80,000 - $89,999
$90,000 - $99,999
$100,000 or more
Are you currently insured?
Please select at least one option.
Employer
Government
Private Insurance
Self-Pay
Any Medications now or Ever
What is your gender?
Select
Male
Female
What is your employment status?
Select
Employed
Self-employed
Unemployed
Retired
Student
Do you have any dependents?
Select
Yes
No
What is your preferred method of contact?
Please select at least one option.
Email
Phone
Text Message
Submit
Sorry, we were not able to submit the form. Please review the errors and try again.