Take the First Step To Recovery

After you fill up the form below, you will be contacted by an experienced Patient Representative from Unique Access Medical. All information and medical records will be held in the strictest confidence. 

  • Patient Representative

  • Patient Information

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  • Contact Person Information (if different from patient)

  • Medical Conditions & History

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  • Medical Questions

    Please answer the questions about the patient's condition in as much detail as possible. Every question requires an answer, so if you are unsure please just choose "Unsure".
  • File Doctor’s Reports

    Please attach any doctor’s reports, medical test results, and discharge summaries that pertain to the patient’s Medical Conditions & History.PLEASE NOTE: Large files may require extra time to upload, so after you’ve clicked “SUBMIT” below, please do not close your browser window until you’ve received the message confirming a successful submission.
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf, Max. file size: 20 GB.

    Contact Details