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ViaCord Release Inquiry Form
Complete and submit the form below. ViaCord’s Clinical Affairs team will review your submission and reach out to discuss next steps, including when your request will be sent to the treating facility or doctor. You will need your ViaCord Child ID for the form. This ID number is associated with your ViaCord account. If you do not know it, don't worry. Our Customer Service team is happy to assist. Please call 800-998-4226