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Online Order Form

Please fill out the form below. You request will be reviewed upon submission and you will be contacted within 24 hours. You may also access the word document of this form by clicking here and then fax the form to 720-554-7864. Thank you.

Enjoy the convenience of having your contact information automatically filled out for you by simply registering with us, click here to register now.

All fields with * are required.
Contact Information Billing Information
Contact
 * Bill to:
Company
 *
Address
 *
Client File #
 *
City
 *
Patient Name
 *
State
 *
Patient DOB
Zip
 *
Insurance Co.
Phone
 *
Claim #
Email
 *
Adjuster
Copy Services
# of Films
# of Film Copies
# of CD Copies
# of CDs
# of Film Copies
# of CD Copies
Other Services
Positive Copies
Enlargements
Enhancments
VHS/DVD
Supplies
X-Ray Jackets
Photo Sleeves
X-Ray Mailers
View Box Rentals
# of Days
# of Boxes
Special
Instructions
( same as contact ) PICK-UP LOCATION
( same as contact ) DELIVERY LOCATION
Contact
Contact
Company
Company
Address
Address
City
City
State
State
Zip
Zip
Phone
Phone
Email
Email

Disclosure: Through submission of this form, as the customer, contact or patient listed above I have authorization to release, deliver, and/or disclose protected medical information to Acuity Services for the purpose of duplication.
 

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