Micro Quick
Order
PDF Records Request Form

PDF Pick Up to Copy Form

PDF Messenger Request Form

PDF Process Form

Place an Order With Microquick

If you have any questions, please contact us at (714) 542-2200. We will be happy to assist you.
New: If you have an account, you can also login to the Client area for easy order management.


CLIENT INFORMATION:



ORDER DATE
Saturday, March 13, 2010
COMPLETE BY


REGULAR
RUSH
SAME DAY RUSH
ARRANGED



PREFIX
FIRST NAME*
LAST NAME*


PHONE #
EMAIL ADDRESS*


FIRM NAME


ADDRESS


CITY
STATE
ZIP


FILE NO.*


BILLING INFORMATION:



Same as Shipping


SEND THIS INVOICE TO:


PREFIX
FIRST NAME
LAST NAME


PHONE #
EMAIL ADDRESS


FIRM NAME


ADDRESS


CITY
STATE
ZIP


CLAIM FILE#


COPY RECORDS PERTAINING TO:



RECORDS OF (Name)
AKA


BIRTH DATE
SOCIAL SECURITY #
DATE OF LOSS/INJURY


NUMBER OF COPIES:

Hardcopy:*
CD:*
Online:*


ADDITIONAL INFORMATION


DELIVERY TO
REQUESTING PARTY
OTHER
BOTH



DELIVERY INFORMATION:
(if it's other than the requesting party)

PERSON'S NAME OR BUSINESS NAME


LOCATION ADDRESS


CITY
STATE
ZIP


RELEASE INFORMATION:



CASE CAPTION
vs.


CASE NO.
COURT/DISTRICT
REPRESENTING



OPPOSING COUNSEL/SELF-REPRESENTED INFORMATION

OPPOSING COUNSEL


ADDRESS


CONTACT
CITY
PHONE #


STATE
ZIP




Authorization Enclosed

OR Prepare:

Civil SDT
W.C.A.B.
Public Records


Appearance Date:


OBTAIN RECORDS:



Please enter one or more locations from which to obtain records.

FIRST LOCATION:

LOCATION


ADDRESS


CITY
STATE
ZIP
PHONE


ADDITIONAL INFORMATION

Medical
Billing
X-Rays
Employment
Payroll
Insurance


Other:


SECOND LOCATION:

LOCATION


ADDRESS


CITY
STATE
ZIP
PHONE


ADDITIONAL INFORMATION

Medical
Billing
X-Rays
Employment
Payroll
Insurance


Other:


THIRD LOCATION:

LOCATION


ADDRESS


CITY
STATE
ZIP
PHONE


ADDITIONAL INFORMATION

Medical
Billing
X-Rays
Employment
Payroll
Insurance


Other:


FOURTH LOCATION:

LOCATION


ADDRESS


CITY
STATE
ZIP
PHONE


ADDITIONAL INFORMATION

Medical
Billing
X-Rays
Employment
Payroll
Insurance


Other:


SEND A COPY TO:



If you wish this information to be forwarded to anyone else, please provide their e-mail addresses in the 'To:' field below.
Multiple entires must be separated by a comma.

TO: