Note: This Form is HIPPA Complaint
Email
*
First Name
*
Last Name
*
Patient's Age (Adults 18+ Only)
*
Phone
*
Please choose how you will submit your X-Ray (Include name and email address)
*
1. Upload X-Ray below
2. Email
[email protected]
3. Text a picture to 248-705-6967
4. Mail an x-ray CD to 504 West Orange St., Lititz PA 17543.
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Submit your X-Ray.
Upload JPEG/PDF/PNG Images Only - Max of 10
Previous SAS Owner?
*
Yes
No
Submit