Request For Medical Documents

Medical Documentation Request

Disclaimer: Please note documentation requests take up to 5-7 business days to be completed. please be aware that there is an additional fee for letters/forms any paperwork completion. Please call or text the office to inquire about fees, payment must be sent before paperwork is sent
Patient Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
What Kind Of Documentation Are You Requesting?*

Excusal LetterFMLA LetterESA LetterSurgery ClearanceFMLA DocumentationMedication LetterSuperbill RequestDiagnosis LetterTreatment Plan letterLetter of AccomodationsOther
Select The Name Of Your Provider *
Please provide a brief description (please be specific) to what your paperwork is for *
Do you have any files to upload with your request?*

YesNo
If you said yes, how many?*

1-22-4
If you selected 'ESA Letter' then please share, what kind of pet you are requesting, the ESA letter about: Dog or Cat* . Then, please add the name of your pet, Name* the breed, Breed* , as well as your animals age Age* and lastly, the weight of your pet.Weight* .
File Upload

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File Upload

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File Upload

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File Upload

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Disclaimer: There are additional charges for letters or forms to be completed. You may need to have an appointment the same week you are requesting a letter/documentation.
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Medical Documentation Request