Motown Children's Secure File Upload

Secure File Transfer
Please upload a copy of the patient's referral form, medical and dental insurance cards (front & back), medical clearance forms (if requested), and a copy of the guardian's photo ID.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Notes (optional)
File Uploader:

Please upload any files you would like to send Motown Children's Surgery Center here (including photos uploaded from your mobile phone).
Cancelof
To maintain your privacy, all files are securely transferred to Motown Children's Surgery Center.
Should be Empty:

Secure File Transfer