Online Order Form

To submit your order, please complete the online order form below, or download a PDF or Microsoft Word version, fill it out and email it to orders@realtimerecs.com:

General Information

ADJ Number / Case Number

Letter Of Rep Date

Client/Applicant

Full Name *

AKA

Date of Birth

SSN

Date of Injury

Employer/Insured

Full Name

Address

City

State

Zip Code

Requestor

Requestor Full Name

Requestor Email Address *

Attorney

Firm

Address

City

State

Zip Code

Phone Number *

Fax Number

For

Billing / Carrier Information

Carrier

Adjuster

Address

City

State

Zip Code

Phone Number

Fax Number

Claim Number

Case Caption

Plantiff

Defendant

Court System

Address

City

State

Zip Code

Date

Time

Department / Division

Opposing Counsel

Attorney

Firm

Address

City

State

Zip Code

Phone Number

Fax Number

Delivery Instructions

Deliver To

Attn

Firm / Office

Address

City

State

Zip Code

Copying Instructions

Location 1

Facility Name

Type

Other

Location / Address

City

State

Zip Code

Phone Number

Dates

Special Instructions

Add Location

Location 2

Facility Name

Type

Other

Location / Address

City

State

Zip Code

Phone Number

Dates

Special Instructions

Add Location

Location 3

Facility Name

Type

Other

Location / Address

City

State

Zip Code

Phone Number

Dates

Special Instructions

Add Location

Location 4

Facility Name

Type

Other

Location / Address

City

State

Zip Code

Phone Number

Dates

Special Instructions

Add Location

Location 5

Facility Name

Type

Other

Location / Address

City

State

Zip Code

Phone Number

Dates

Special Instructions

Add Location

Location 6

Facility Name

Type

Other

Location / Address

City

State

Zip Code

Phone Number

Dates

Special Instructions

Add Location

Location 7

Facility Name

Type

Other

Location / Address

City

State

Zip Code

Phone Number

Dates

Special Instructions

Add Location

Location 8

Facility Name

Type

Other

Location / Address

City

State

Zip Code

Phone Number

Dates

Special Instructions

Add Location

Location 9

Facility Name

Type

Other

Location / Address

City

State

Zip Code

Phone Number

Dates

Special Instructions

Add Location

Location 10

Facility Name

Type

Other

Location / Address

City

State

Zip Code

Phone Number

Dates

Special Instructions

NOTE: To submit additional locations, please resubmit the form with additional locations

Fields marked with * denotes a required field.