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NEW PATIENTS · No-Fault

No-Fault Intake

Were you injured in a car accident? Complete the form below

PATIENT AND ACCIDENT INFORMATION

Patient was
Driver
Passenger
Pedestrian
Other
Seatbelt
Yes
No
Airbag deployed
Yes
No

NO-FAULT INSURANCE AND ATTORNEY

EMPLOYMENT / LOST WAGES

Employed
Yes
No
Missed work
Yes
No

INJURY DETAILS

Symptoms and Body Areas Injured

POLICE REPORT INFORMATION

Police report
Yes
No

VEHICLE INFORMATION

Where Was the Vehicle Hit?
Where Did the Accident Occur?

UPLOAD DOCUMENTS

CONSENT AND SIGNATURE

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Date
Month
Day
Year
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