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Once we receive your order , you will get a conformation within 24HR, if you do not receive a conformation please email us at maryann@apsassist.com or Call 626.544.9822

Your Name *

Company Name *

Email *

Phone *

Client's Order Information

Clints Name *

First

Last

Date of Birth *

Medical Record Number

In required , by medical facility

Is your file ready to copy

If you have checked no, we will contact location for you

Location phone number

Location Address

Address Line 1

Address Line 2

City

State

Zip Code

Request Upload

Please upload your medical authorization for request