CLIENT RECORDS SUBMISSIONS

Please use this form to send records for upcoming scheduled appointments. If you are sending trailing records for an upcoming appointment, additional records for a previous appointment, or any other type of records please indicate in the comments section(s).
YOUR INFORMATION

Enter your information so we can contact you, if necessary.
YOUR Name

First NameLast Name
YOUR Email

Confirmation EmailPlease confirm your email.
YOUR Phone
Please enter a valid phone number.Format: (000) 000-0000.
CLIENT INFORMATION

Please enter the client's name corresponding to the records being submitted.
CLIENT NAME

Client's First NameClient's Last Name
WHEN IS YOUR CLIENT SCHEDULED TO SEE DR. POPPA?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
ATTORNEY'S NAME

ATTORNEY'S First NameATTORNEY'S Last Name
UPLOAD FILES FOR YOUR CLIENT

UPLOAD FILES FOR THE ABOVE-NAMED CLIENT, ONLY. YOU WILL HAVE AN OPPORTUNITY TO UPLOAD RECORDS FOR ADDITIONAL SCHEDULED CLIENTS IN THE NEXT STEP.
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Do the selected files represent a complete and total set of records for your client's appointment with Dr. Poppa?
Comments
Would you like to upload records for an additional client appointment? (2/4)

CLIENT 2 - NAME

Client's First NameClient's Last Name
CLIENT 2 - APPPOINTMENT

MonthDayYear
2 digit month, 2 digit day, 4 digit year
CLIENT 2 - ATTORNEY (if different)

ATTORNEY'S First NameATTORNEY'S Last Name
CLIENT 2 - FILE UPLOAD

ONLY UPLOAD THE FILE(S) FOR THE ABOVE-NAMED CLIENT. YOU WILL HAVE THE OPPORTUNITY TO UPLOAD RECORDS FOR ADDITIONAL SCHEDULED CLIENTS IN THE NEXT STEP.
Cancelof
CLIENT 2 - Do the selected files represent a complete and total set of records?
Comments 2
Would you like to upload records for an additional client appointment? (3/4)

CLIENT 3 - NAME

Client's First NameClient's Last Name
CLIENT 3 - APPPOINTMENT

MonthDayYear
2 digit month, 2 digit day, 4 digit year
CLIENT 3 - ATTORNEY (if different)

ATTORNEY'S First NameATTORNEY'S Last Name
CLIENT 3 - FILE UPLOAD

ONLY UPLOAD THE FILE(S) FOR THE ABOVE-NAMED CLIENT. YOU WILL HAVE THE OPPORTUNITY TO UPLOAD RECORDS FOR ADDITIONAL SCHEDULED CLIENTS IN THE NEXT STEP.
Cancelof
CLIENT 3 - Do the selected files represent a complete and total set of records?
Comments 3
Would you like to upload records for an additional client appointment? (4/4)

CLIENT 4 - NAME

Client's First NameClient's Last Name
CLIENT 4 - APPPOINTMENT

MonthDayYear
2 digit month, 2 digit day, 4 digit year
CLIENT 4 - ATTORNEY (if different)

ATTORNEY'S First NameATTORNEY'S Last Name
CLIENT 4 - FILE UPLOAD

ONLY UPLOAD THE FILE(S) FOR THE ABOVE-NAMED CLIENT. YOU WILL HAVE THE OPPORTUNITY TO UPLOAD RECORDS FOR ADDITIONAL SCHEDULED CLIENTS IN THE NEXT STEP.
Cancelof
CLIENT 4 - Do the selected files represent a complete and total set of records?
Comments 4

Please click submit below to send records. If you do not receive a confirmation email from JotForm, check your SPAM folder then contact tom@ocskc.com. It may take several minutes for the confirmation email to reach your inbox
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YOUR INFORMATION