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EXPRESS MEDICAL SERVICES
PHONE/FAX: (516) 825-0112
            Cell: 646-752-2642

1) Ordering Customer
      
Direct order: yes / no
Order date:
Account number/carrier name: Order time:
Agency name:
Account address:
Agency code:
Agent name:
Agency phone:
Agent code:
Agent phone:
Language:
       
2) Applicant Information
      
UW Class:
DOB:
Face amount:
SSN:
Applicant first name:
Smoker: Yes / No
Middle name:
Email:
Last name:
 Age: Gender: F /M
Home address:
Office address:
Home phone:
Office phone:
Best time to contact:
Interpreter: Yes / No
Exam location:
UW State:
       
3) Requirements:
      
PARAMEDICAL
EKG
M.D. EXAM
X-RAY (if required)
4) Special Requests:
Blood & Urine
TVC
Upload document:  
     
   
Referred by :

 

 

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