Timeframe for Submission:

Start Date: {{mediaRequest.startDate}} End Date: {{mediaRequest.endDate}}

Requesting Provider:

{{mediaRequest.authorizingProvider.firstName}} {{mediaRequest.authorizingProvider.lastName}}

Purpose of Video:

{{requestedMedia}}

Take a Video Of:

{{mediaRequest.requestReason}}

Detailed Instructions:

{{mediaRequest.patientInstructions}}

Patient's Video Description:

{{evaluation.images[0].imageDescription}}

Note from Provider:

{{mediaRequest.summaryNote}}