Pre-Screen
Individual Health Form
Please complete the form below to the best of your ability. If you have any questions while completing the form, don't hesitate to contact us at: 440.247.2229 or e-mail at: info@HealthHelpOhio.net. Before submitting the form, make sure you give us at least one way to contact you with the quotes you requested! Fax the completed form to: 440.247.8860.
THANKS !
To print this form, place your pointer on the questionnaire and after the print icon appears in the left, click the print icon. The form is printed on our default printer. Follow these steps to print page 2 of this form also.
