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DDS Multipage Intake Form
  1. Please fill out the following intake form to the best of your ability.
  2. Request Date
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  3. Sales Contact
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  4.  
  1. Patient Information
  2. First Name(*)
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  3. Middle Initial
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  4. Last Name(*)
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  5. SSN
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  6. Birth Date(*)
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  7.  
  1. Injury Information
  2. Injury Date
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  3. Claim or File No.(*)
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  4. Type of Report(s)(*)
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  5. Notes and Items To Address
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  6.  
  1. Billing Information
  2. Company(*)
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  3. Client
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  4. Billing Contact(*)
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  5. Address
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  6. City
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  7. State
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  8. Zip Code
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  9. Phone Number(*)
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  10. Fax Number
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  11. Email(*)
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  12.  
  1. Type of Exam
  2. Type of Exam(*)
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  3. Request Disc
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  4. Case Manager
    (Point of Contact)
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    Please enter name,phone, fax, email and any other relevant comments.Report will be sent to this contact.
  5.   
  6. Please forward the disc or films along with the corresponding radiology report to complete your order. In the event you would like DDS to obtain the CD or films and you did not indicate your need on the order form, please contact us and we will be happy to assist.

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Contact Information

Diagnostic Dating Specialists, LLC
3330 Cumberland Blvd, suite 400
Atlanta, GA 30339
Office (404)-419-7172
Fax (404)-419-7101
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