Aetna Survey 2025 | LFA - Launched 2023

First Name:

Last Name:

Email

Name of gym you utilize or indicate "no gym".

Is your dentist in network?

Yes

No

Unsure AFTER contacting my dentist

Dentist First Name:

Dentist Last Name:

Name of Dental Practice:

Which covered procedure is most important to you/most frequently used by you?

Preventative: cleanings, check ups, etc.

Basic/Major: crowns, fillings, root canals etc.

All of the above.

How much did you spend in 2024 out-of-pocket on medical expenses including co-pays and premiums (EXCLUDING prescriptions)?

Less than $1,000

More than $2,500

More than $5,000

If your plan requires a change, can you complete a quick online application? If not, we will be in contact.

Yes

No