1-800-Autopsy

Financial Agreement


Autopsy/Post Services, Inc. 2629 Foothill Blvd. La Crescenta, CA 91214

Direct: 818-957-2178 Email: info@1800autopsy.com Fax: 818-957-3672

CONFIDENTIAL

Authorization & Contract for Postmortem Services

CASE NO.
CASE NO.
Decedent’s Name:
Date of Birth: Approx. Weight:
Date of Death: Approx. Height: ft inch
Ethnicity:
Next-of-Kin:
Funeral Home:
Email: Phone :
Phone: Home Address:

1). I certify that I am the (relationship) of the deceased

Funeral Home Return Address:

1) (Autopsy procedure):
2) (Tissue/DNA/Appliance procurement)
3) Transportation/Shipping:
4) Toxicology Analysis:
5) Neurological Diagnosis (Brain-Only Autopsy):
6) Mesothelioma Diagnosis (Lung-Only Autopsy):
7 X-Ray:
TOTAL:
Financial Agreement:

1). The undersigned recognized that the Pathologist furnishing services to the decedent/family is an independent contractor and is not an employee or agent of 1-800-AUTOPSY/Autopsy Post Services, Inc. Please be advised that the total cost for postmortem procedure must be paid to the order of (Pathologist)

2). The undersigned agrees, in consideration of services rendered, that he/she individually obligate himself/herself to pay the amount in accordance with the rates and terms. Should the account be referred to an attorney or collection, the undersigned shall pay reasonable attorney’s fees, court fees and collection expenses. All delinquent account bear interest at the legal rate. Autopsy results will not be available until check is cleared by financial institution.

3). Photographs are not automatically returned to families with completed report unless specifically requested due the graphic nature and subject matter. We will forward photographs to a designated person upon written request.

4). If Toxicology analysis is necessary there will be an additional charge.

5). If paying with a credit card, there will be an additional surcharge of 2.5%.

6). This contract provides for postmortem services only. It does not retain the Pathologist as an expert witness.

7). Make Cashier’s Checks payable to for fee listed above.

Payment info

Name on Card:      
Card Type:   Money Order No:
Credit Card No:   Cashiers Check:
Exp. Date:   Cash:
Security Code:      
 
Phone Number:      
Address:   State:
    Zip:
 

1-800-AUTOPSY

2629 Foothill Blvd. Suite 387,
La Crescenta, CA 91214
Phone : 818.957.2178
Mail: info@1800autopsy.com

Electronic Signature

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Signature Certificate
Document name: Financial Agreement
lock iconUnique Document ID: 4b651bcfaaa7b323b5debb80200d7ea369c2d7b9
Timestamp Audit
December 31, 2018 6:50 am PSTFinancial Agreement Uploaded by Vicki Herrera - info@1800autopsy.com IP 2a02:26f7:c010:5c00:0:15ba:52e0:d5ae
April 12, 2019 5:25 am PSTJack Sathiya - sathiyamurthy@izaaptech.in added by Douglas pxmedia - info@1800autopsy.com as a CC'd Recipient Ip: 210.18.157.20