FEDEX PICKUP REQUEST
SUBMITTER INFORMATION
Name
*
First Name
Last Name
Email
*
example@example.com
PICKUP INFORMATION
Practice Name
*
Pickup Address (Include City, State, ZIP)
*
Package Location
*
i.e. Front Desk
Contact Name at the Facility
*
Contact Email
*
example@example.com
Contact Phone
Contact Fax
Preferred Pickup Days
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Preferred Pickup Time
*
2-Hour Window
Submit
Should be Empty: