What is your current age group?
Under 30 30-50 51-65 Over 65 Prefer not to say
What is your gender?
Male Female Non-binary Prefer not to say
Are you currently enrolled in Medicare Insurance?
Yes No Not eligible yet
How would you describe your current health condition?
Excellent Good Fair Poor Prefer not to say
Which sources do you rely on for healthcare information?
Doctors/Healthcare Providers Family/Friends Internet/Websites TV/Radio Health Magazines
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Name
Email
Phone
(Details here)
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