Patient Secure File Upload
Patient's Name
*
First Name
Middle Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Do not put dashes
Name of file (Choose all that apply)
Valid Driver's License FRONT
Valid Driver's License BACK
Primary Insurance Card FRONT
Primary Insurance Card BACK
Secondary Insurance Card FRONT
Secondary Insurance Card BACK
Old Sleep Study Report
Other
File Upload
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: