Fill in the fields on the form by using the tab key to move from field to field. When you have completed the form, click on the SUBMIT FORM button at the bottom of the page. Once you submit this form you will have the option to upload up to 5 x-rays images.
If X-Rays are attached, what date were they taken:
Once this form is submitted, you will have the option to print a copy of this submitted form in a PDF format.