Registration/Login - Healthcare Questionaire


Welcome to the Pre-Sale Health Questionnaire. This survey will take approximately 20 minutes to complete.

Before you begin, be sure you have the following information gathered for both you and your dependents:

  • Birthdates, Height/Weight measurements
  • Health conditions: diagnosed, treated for, consulted on, or hospitalized for during the past 5 years
  • Current prescriptions: drug name(s) and dosage (include any oral, topical, optical, nasal, injected or IV infused therapies)

Note: once the survey has been completed you will not be able to return to this site to update your responses.

First Time User? Please Register

Provide your company email address and select your employer name from the drop down box below. First time users will need to answer three security questions and create a password in order to login to the secure Pre-Sale Health Questionnaire.

Email Address    
Registration Pin  

Returning User? Login

To finish completing your online health questionnaire, input the login ID that was provided to you and the password you created in the space below. Then select your employer's name from the drop down box and select Login.

Email Address    

Forgot your password?

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