New Client Intake Form

- Please have your medical records ready before completing this form: Insurance, prescriptions, and doctor/physician information.

- All fields marked with an asterisk ( * ) indicates a required field.

- All information will be treated as confidential and used solely for Medicare enrollment purposes through our office.

- Questions? We are here to help! Call our office at 810-534-3008 to speak with an agent.

First Name: *First Name
Middle Initial: Middle Initial
Last Name: *Last Name
Street Address: *
City: *
State: *
Date of Birth: *Date of Birth
Gender: Gender
Marital Status: Marital Status
ZIP Code: *ZIP Code
County: *County
Email Address * Email
Home Phone: Home Phone
Cell Phone:
Work Phone:
Emergency Contact Name: *Emergency Contact
Relationship: *Relationship:
Phone Number *Contact phone
Have You Applied For Medicare Parts A & B?: *Applied for Medicare A and B?
Medicare ID #: Medicare ID
Part A Effective Date: Part A Effective Date:
Part B Effective Date: Part B Effective Date:
Are You A Smoker?: *
Employment Status: *Employment
# Of Employees At Company (if applicable):
Name Of Your Health Insurance Plan:
What Is Your Monthly Premium Cost?:
Is Current Health Insurance Through Your Employer?: Is Current Health Insurance Through Your Employer?:
Are You Currently On Medicare?: *On medicare?
Do You Have Medicare Advantage or Medigap Policy?:

Please List ALL Prescription Medications You Currently Take:
 

Medication Name

Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8

Generic (Y/N)

Generic?
Generic?
Generic?
Generic
Generic
Generic?
Generic?
Generic?

Dosage

Dosage 1
Dosage 2
Dosage 3
Dosage 4
Dosage 5
Dosage 6
Dosage 7
Dosage 8

Frequency Taken

Frequency 1
Frequency 2
Frequency 3
Frequency 4
Frequency 5
Frequency 6
Frequency 7
Frequency 8
What Pharmacy Do You Use?: *
Are Pharmacy Options Limited In Your Area?: *
Are You Interested In Mail Order Prescriptions?: *

Please List ALL Of Your Doctors / Physicians (Medical, Dental, Specialists):
 

Physician's Name

Physician 1
Physician 2
Physician 3
Physician 4
Physician 5

Address

Address 1
Address 2
Address 3
Address 4
Address 5

Specialty

Specialty 1
Specialty 2
Specialty 3
Specialty 4
Specialty 5
Are You Opposed To Switching Doctors?: *
Are You Opposed To Switching Pharmacies?: *

Please Answer The Following Questions To The Best Of Your Ability:
 

Do You Have Any Chronic Medical Conditions?: *
Do You Travel?: *
Do You Need Assistance With Your Premium Costs?: *
Do You Have Funds In Place To Cover Unexpected Medical Bills?: *
Is There Anyone Else In Your Household That Is Eligible For Medicare?: *
Do You Want More Information About Dental, Vision, & Hearing Coverage?: *
Please List Any Questions You Would Like Answered During Our Consultation:
How Did You Hear About Tyrone Carr & Associates?:
If Applicable, Please List The Name Of Your Referral Source:

SUBMIT

SCHEDULE A FREE CONSULTATION WITH TYRONE CARR & ASSOCIATES

 

Let's have a conversation today! Call us to speak with an associate or schedule an appointment online.

 

 

Tyrone Carr & Associates
10299 E. Grand River Ave. Suite K
Brighton, MI 48116