Date of appointment (if applicable)

MM

DD

YYYY

Level of urgency *

Regular (3-4 weeks)

Rush (2 weeks)

Super Rush (1 week)

Type of records submitted *

Select all that apply

PDF / JPEG / Scan (most common)

Video files

Photographs

Audio files

Paper hard copy (either mailed or picked up from office in person)

USB stick (either mailed or picked up from office in person)

CD (either mailed or picked up from office in person)

Other