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Top Surgery Photo Submission
Top Surgery Photo Submission
Please note, when you submit your photos they are encrypted and stored in a secure server.
Your name as it appears on your insurance policy
(Required)
First
Last
In case you are not the primary holder.
Please enter your date of birth
(Required)
Month
Day
Year
Please enter your zip code
(Required)
Your primary email address
(Required)
You will only be contacted by Dr. Rahal’s Practice. You can unsubscribe at any time through the footers of our emails. View our
Terms of Service
and
Privacy Policy
.
Compliant
I agree to receive updates via email from Dr. William Rahal.
Your best call back phone number
(Required)
Compliant
I agree to receive updates, informational, and sales SMS text messages from William Rahal, MD, PC about my inquiry at the phone number provided from both live staff and automated software. Message frequency is no more than 3 messages per week. Message & data rates may apply. Text HELP for help. Text STOP to cancel. View our
Terms of Service
and
Privacy Policy
.
Compliant
I agree to receive phone calls from Dr. Rahal’s Office regarding my inquiry.
Please upload an image of the FRONT of your insurance card
(Required)
Max. file size: 256 MB.
Clicking “Choose File” allows you to take a picture.
Please upload an image of the BACK of your insurance card
(Required)
Max. file size: 256 MB.
Clicking “Choose File” allows you to take a picture.
