Merit Records Service

Order Attorney

Ordering Atty:

Ordered By:

Firm Name:

Firm Address:

Address

Phone #:

City

Bar #:

State Zip

Email #:

Represents:

Plaintiff Defendent

Case Info

In the case styled:

Judicial District:

Case Number:

County Suit
Pending:

Date Needed:
(dd/mm/yyyy)

Instructions

Record Since:

Accident Date:

All Records:

Yes No

Admissable Form:

Yes No

Affidavit:

Yes No

Non Addmissible:

Yes No

Medical Records:

Yes No

Prepare Notice:

Yes No

Complete Chart:

Yes No

Billing Records:

Yes No

Employmet Type:

Yes No

X-Ray Film:

Yes No

Patient Info

First Name:

(Also Know As)

Last Name:

Date Of Birth:

Social Security #:

Record Provider Info

Name	Address	Phone	Record Type
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Special Instructions (If any)

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Special Instructions (If any)

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Special Instructions (If any)

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Special Instructions (If any)

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Special Instructions (If any)

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Special Instructions (If any)

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Special Instructions (If any)

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Special Instructions (If any)

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Special Instructions (If any)

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Special Instructions (If any)

If more than 10 providers required, please contact us by phone.

Opposing Attorney

Name Of Opposing Attorney:

Name Of Opposing Firm:

Address:

Phone #:

Client Represented:

Plaintiff

Defendent

Name Of Opposing Attorney:

Name Of Opposing Firm:

Address:

Phone #:

Client Represented:

Plaintiff

Defendent

Name Of Opposing Attorney:

Name Of Opposing Firm:

Address:

Phone #:

Client Represented:

Plaintiff

Defendent

If more than 3 Opposing Attorneys are required, please contact us by phone

  (800) 335-4148
  (817) 335-5332
  (972) 445-6428

  309 W. 7th Street, Suite 610
  Fort Worth, TX 76102