TEXAS HEALTHCARE SPECIALISTS, INC. TEXAS LICENSE NUMBER 1442099

FIRST NAME:     LAST NAME:     GENDER: Male Female     EMAIL:     PHONE NUMBER:     ZIP CODE:               TOBACCO   BIRTH DATE   HEIGHT WEIGHT YES NO             PRIMARY               SPOUSE   GENDER: Male Female             CHILD 1   GENDER: Male Female             CHILD 2   GENDER: Male Female             CHILD 3   GENDER: Male Female             CHILD 4   GENDER: Male Female             CHILD 5   GENDER: Male Female               IF YOU DO NOT CURRENTLY HAVE COVERAGE, PLEASE FILL IN THE FIELDS WITH WHAT YOU WOULD LIKE YOUR CURRENT COVERAGE TO HAVE.     CURRENT INSURANCE CARRIER NONE INDIVDUAL GROUP COBRA     CURRENT INSURANCE DEDUCTIBLE     CURRENT INSURANCE MAXIMUM OUT OF POCKET     CURRENT INSURANCE DOCTOR COPAY AMOUNT     CURRENT INSURANCE PRESCRIPTION COPAY AMOUNT       PLEASE LIST ANY PRE-EXISTING CONDITIONS THAT YOU ARE AWARE OF AND ANY MEDICATIONS TAKEN IN THE PAST 12 MONTHS.               PRE-EXISTING CONDITIONS   MEDICATIONS         PRIMARY           SPOUSE           CHILD 1           CHILD 2           CHILD 3           CHILD 4           CHILD 5