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Superbill/Travel Letter Request Form
Use this form to request a superbill or a travel letter. Please note superbills and travel letters can take up to 3-5 business days to be generated and sent to you. Unique Physique does not provide letters of medical necessity as weight loss is considered an elective/concierge service.
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I am requesting a: *
Patient First Name: *
Patient Last Name: *
DOB: *
MM
/
DD
/
YYYY
Email Address: *
Street Address: *
City: *
State: *
Zip Code: *
Dates of Service: *
FOR TRAVEL LETTER, SELECT MOST RECENT FILL DATE.
Required
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