Order a Report Medical Provider Information (Client) Office Contact * Medical Provider * Email * Telephone Have You Submitted An Assignment to Us Before Yes No Patient Information Name * First Name Last Name Patient’s Last Known Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Telephone Email Patient Social Security Number (If available) Patient Date of Birth Patient Race Patient Sex Male Female Other Potential Relatives (covers known or rumored family) Thank you!
