Lone Star Health Appointment Setting Form

Is it a legitimate lead? (Yes/no bubble select. Include multi line text box under the selection)

Name (one line text entry)

Type of Insurance they currently have (drop down menu. Include multi line text box under the selection
choice)

 Group Insurance
 HMO
 PPO
 Medicare Supplement
 None
 Other/Not sure

Have they heard of a Medicare Supplement? (yes/no bubble select. Include multi line text box under
the selection choice)

Are they retired? (yes/no bubble select. Include multi line text box under the selection)

Age (one line text entry)

Health Issues (Multiple check options. Include multi line text box under the selection)

 Heart Attack
 Stroke
 Insulin Diabetes
 Cancer
 Other

Address (multi line text entry)

Appointment Date (simple month drop down and day drop down entry. One drop down for the month,
and one drop down next to it for the day)