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Health Insurance Census
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First Name
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Last Name
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Date of Birth
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Sex
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Untitled
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Untitled
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City
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Starting April 1, 2022, would you like to accept Health Insurance through H&H X-Ray Services?
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Accept
Decline
If you Declined, Skip to the end and click the Submit button otherwise continue answering the questions below.
What is your age?
*
Less than 13
13-18
19-25
26-35
36-50
Over 50
Prefer not to say
What is your household income?
*
Less than $10,000
$10,001 - $25,000
$25,001 - $40,000
$40,001 - $70,000
$70,001 - $100,000
Greater than $100,000
Prefer not to say
Submit
