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Medical Records Upload
Please use this form to your medical records for our office to review.
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HIPAA
Compliance
1
Patient's Name
*
This field is required.
First Name
Last Name
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2
Patient's Birth Date
*
This field is required.
/
Date
Month
Day
Year
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Enter
3
Upload Records
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 50.0MB
Browse Files
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