Medical Treatment to Report - Social Security Lawyers

TELL US ABOUT YOUR DOCTOR VISIT

Your Name (required)

Your Email (required)

Your Phone Number

Your Full Mailing Address

Date of Your Doctor Visit

Where Did You Go?
doctor visitemergency room visitinpatient hospital visitspecial testingOther

Full Name of Doctor

Full Name of Practice, Clinic or Hospital Where Test was Performed

Full Address of Practice, Clinic or Hospital

Was Special Testing Performed?
YesNo

Which Doctor Ordered the Test?

Date Test Was Ordered

Name of Special Testing Clinic
BIOTAP Medical

Address of Special Testing Clinic
716 W Main St Suite 100A, Louisville, KY 40202

What Special Test Was Performed?
xrayMRICTbloodworkcolonoscopyendoscopyEKGechocardiogramdopplerbone density studyother

Is There Anything Else You Want to Share With Us?

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Please fill out the form on this page so we can have the most recent medical information pertaining to your case.

As always we appreciate your time. Thank you for stopping by.

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