Hospital Discharge Order Form

1
Name* This field is required.
First Name
Last Name
2
Date Seen
Date
Month
Day
Year
3
MRN# IF YOU DO NOT PROVIDE ONE, I WILL MAKE ONE UP
4
Date of birth
Date
Month
Day
Year
5
Age
6
Weight
7
Height
8
Doctor NameIF YOU DO NOT PROVIDE ONE I WILL
First Name
Last Name
9
Reason for Visit* This field is required.PLEASE BE AS SPECIFIC AS POSSIBLE
10
Is there anything else you would like for me to add ?CT SCANS XRAYS MEDICINE ETC
Huge
Large
Normal
Small
Ok
Ok
11
Would you like your order expedited ?
YES EXPEDITE FOR $50
NO
12
PAYMENT OPTIONSCONTACT FOR APPLE PAY & ZELLE
CASHAPP $poohapprovals
APPLE PAY
ZELLE
CHIME $poohapprovals
PAYPAL
13
HAVE YOU SUBMITTED PAYMENT ?* This field is required.ALL ORDERS GO IN THE ORDER OF PAYMENT RECEIVED. PLEASE BE AWARE THERE MAY BE OTHERS BEFORE YOU!
YESNO
14
UPOAD PROOF OF PAYMENT* This field is required.IF YOU DO NOT PAY, YOUR ORDER WILL NOT BE STARTED ! I WILL NOT PROCEED WITHOUT SCREENSHOT
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