• Personal Information
  • Health Information

Personal Information

Health Information

Heart attack, brain tumor, heart disease or heart problems?

Cancer, tumor, lymphoma, or any type of transplant?

Any surgery or hospitalization in the last 5 years? Or any current pending, planned or recommended?

Emphysema or COPD?

Kidney failure, dialysis, or disorder of the liver, stomach, pancreas, colon or bladder?

Seizure, epilepsy, hemophilia, sleep apnea, or blood disorder?

Diabetes, endocrine, auto immune, Chron's disease, or arthritis, or pituitary disorder, growth disorder, lupus, MS, AIDS, or HIV?

Currently pregnant, premature delivery, or multiple births?

Are you taking or have you taken any medications in the last 12 months? If yes, you must list them below.

Dergalis Associates , Alex Dergalis does not sell or service these healthcare offerings. They are sold and serviced by third party licensed vendors.

Duly registered and licensed Financial Professionals offer securities through Equitable Advisors, LLC (NY, NY 212-314-4600), member FINRA, SIPC (Equitable Financial Advisors in MI & TN), offer investment advisory products and services through Equitable Advisors, LLC, an SEC-registered investment advisor, and offer annuity and insurance products through Equitable Network, LLC (Equitable Network Insurance Agency of California, LLC in CA; Equitable Network Insurance Agency of Utah, LLC in UT; Equitable Network of Puerto Rico, Inc.). Financial Professionals may solicit and transact business and/or respond to inquiries only in state(s) in which they are properly qualified. The information in this website is not investment or securities advice and does not constitute an offer. For more information about Equitable Advisors, LLC you may visit https://equitable.com/crs to review the firm’s Relationship Summary for Retail Investors and General Conflicts of Interest Disclosure. Dergalis Associates is not owned or operated by Equitable Advisors or Equitable Network. PPG-6470215.1 (03/24) (Exp. 03/28)