PATIENTS ONLY

(Health Care Providers and Others please click on the appropriate link to the left)

You must enter all PATIENT information below;

Name of Physician or Practice

Account # Your account number can be found on the upper right hand portion of your bill.

Street Number (number only)

 State AL AK AZ AR CA CO CT DC DE FL GA HI ID IA IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NJ NE NH NM NY NV OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY Zip

Email address

Phone number (day time preferred) --

Your relationship to patient Self Parent of patient Son or daughter of patient Other relitive of patient Friend of patient Legal representitive of patient

!!!CAUTION!!! Patient information is highly confidential - you may be required to prove that you are authorized to obtain information about this account!  Unauthorized attempts to obtain patient information may result in SEVERE criminal and/ or civil penalties!

Would you like to be added to our emailing list? Yes

Would you like to receive emails about special offers from our affiliates? Yes

Enter your message, request or question in the box below;

By submitting this request you are irrevocably declaring that you are the patient or the patient's parent or
legal guardian and that you are legally and morally authorized  to obtain this information.
  This is a non-secure e-mail transmission; for security purposes you are advised not to include
 your last name or other personal  information.  You are hereby granting us permission to respond to you by e-mail.
I understand and agree to the above (your initials please)
If you are unsure about this please call us at 215-947-2023