U.S. Telemedical Solutions, LLC (FortuneTelemed.com)
REQUEST FOR
CONFIRMATION OF IDENTIFICATION
*** URGENT ***
To
allow U.S. Telemedical Solutions, LLC to complete the
processing of your order and to better service you and all your medical
requirements, please provide us with some further information.
Please
assist us in continuing to provide you with the high quality service, by
providing us with a copy of your Driver’s License or other State or Government issued
identification documents (such as Military I.D. or Passport). This step will help stop online fraud and
other illegal activities and help keep cost low instead of incurring higher
costs.
All
information that you provide U.S. Telemedical
Solutions, LLC with will be completely confidential and will remain so. No information will be used for any other
purpose than as stated above. Please FAX this page, along with a copy of the
information to us at 1-877-415-1757. When doing so, please include your Name, Most
Recent Order number (if available), the email address that you used when you
registered and your customer ID if you have it.
Place License Here and Photocopy
Driver’s
License or Other Identification
Name
Order
Number Email
Address
Signature
DL # or ID #
Date
Thank you in advance,
The U.S.Telemedical
Solutions, LLC Team