Patient Request – Envy File Solutions

First Name *

Last Name *

Email Address *

Choose Delivery Method *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

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Physician To Be Sent To

Request is Being Made on Behalf of *

There will be a minimum fee of 65.00 + hst for your medical file copies to be made. This price may increase if chart exceeds average limits.

Local delivery can be arranged to save on shipping fees.

Please allow up to 2 business days for reply with confirmation of chart possession and total price of purchase due to envy file solutions.

Payment information & options will be detailed in reply email.

There will be a minimum fee of 65.00 + 25.00 for each additional family member (spouse + dependants under the age of majority) + hst for these medical file copies to be made. This price may increase if charts exceeds average limits.

Local delivery can be arranged to save on shipping fees.

Please allow up to 2 business days for reply with confirmation of chart possessions and total price of purchase due to envy file solutions.

Payment information & options will be detailed in reply email.

Enter Each Family Member/Dependent, One Per Line