HIP Survey

Question 1:

What Is Your Permanent Resident State?

What Is Your Permanent Resident State? *

Question 2:

Prequalifying Health Questions

(check all that apply) *

Have you been admitted to a hospital in the past 12 months?

Have you been diagnosed with serious health conditions in the last 12 months?

Any chronic conditions like COPD in the last 5 years?

Ever diagnosed with HIV/AIDS?

Has a doctor recommended surgery that you haven’t completed?

None of the above

Your Information:

First Name *

Last Name *

Date of birth *

Email *

Phone *

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