Documents Secure Portal
Jolis Shoes Secure Portal for Referrals or Corrections
Date
-
Month
-
Day
Year
Date
Physician's Name
Name of Sender
Sender's Job Title
Email
example@example.com
If you are submitting more that one patient, there is not need to name them all. Simple upload the documents at the same time.
Please Select Your File(s):
Select a File
Drag and drop files here
Choose a file
If your file exceeds 1 GB, please split your file into smaller pieces of 1 GB or less.
Cancel
of
Please verify that you are human
*
Notes
Should we need to know anything about this file?
SEND
Should be Empty: