logo

SCAN ON DEMAND ORDER FORM
St. Pete./Clwtr. - Phone:
(727) 573-3900
Fax:
(727) 573-0085
Tampa - Phone:
(813) 231-0900
Fax:
(813) 231-0600
mm/dd/year
CLIENT’S EMAIL

Scan On Demand (Within 72 hrs of request date)

Rush Scanning (Within 8 business hrs*) – (Additional charge may apply ) 2 per month no charge
* Normal Business Hours – Monday-Friday 8:00am-5:00pm
Container #
(Barcode)
Description of Filefolder Requested
(Include Patient Name, Date of Birth, Yr Last Seen, Dr. Name)
RUSH
SCAN
DATE/TIME
(Date & Time the file is needed)
Normal request is within 3 business days.
mm/dd
morning/2:00 p.m.
mm/dd
morning/2:00 p.m.
mm/dd
morning/2:00 p.m.
mm/dd
morning/2:00 p.m.
mm/dd
morning/2:00 p.m.
mm/dd
morning/2:00 p.m.
mm/dd
morning/2:00 p.m.
mm/dd
morning/2:00 p.m.
mm/dd
morning/2:00 p.m.
mm/dd
morning/2:00 p.m.

PICKUPS:

 Please enter total quantity of containers or filefolders we will be picking up: (When adding “New Containers” to Storage, please also provide the Long, or Short Transmittal Form information to your Service Provider at time of pickup.)
Quantity of Filefolders/Interfiles

Special Instructions:

captcha

Reload Image