Dantzler Health Solutions 
Dantzler Health Solutions Coverage Intake
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Section 2: Coverage Interest - What is the main reason you are contacting us?
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Section 3A: 
Medicare - Which description best fits your situation?
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What type of Medicare help do you need?
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When would you like help?
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Medicare compliance notice *
Dantzler Health Solutions is not connected with or endorsed by the United States government or the federal Medicare program. 

A separate Scope of Appointment may be required before discussing specific Medicare Advantage or prescription drug plan details.
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Section 3B: 
Health Insurance - Who needs coverage?
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What type of help do you need?
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When do you need coverage?
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Section 3C: 
Life Insurance - What would you like life insurance to help protect?
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Which type of coverage interests you?
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When would you like help?
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Section 3D: 
Supplemental Insurance - Which supplemental coverage interests you?
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When would you like help?
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Section 3F: 
General Coverage - What would you like help with?

Please provide a short summary. Do not include medical records, diagnoses, Medicare numbers, Social Security numbers, or payment information.

8. When would you like help?
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Section 4: 
Contact Preferences - How would you prefer to be contacted?

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What time works best?
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What days usually work best?
Would you prefer a phone or virtual consultation?
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How did you hear about Dantzler Health Solutions?
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Section 5: 
Acknowledgments - Contact request
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