BELLEVUE WHIPLASH CENTER AT BACK IN ACTION INJURY CHIROPRACTIC
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If you have been injured in a motor vehicle accident we would love to help you. Simply fill out the virtual consultation below and we will contact you shortly.
STEP 1- Tell us what happened
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Indicates required field
Briefly Describe Your Pain or Discomfort
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What Part of Your Car was Hit?
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Front
Left Side
Right Side
Rear
Front Corner (Left/Right)
Rear Corner (Left/Right)
If Other please specify:
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Were you Driving the Car?
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Yes
No
If NO Where Were You Sitting?
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Front Passenger
Rear Passenger
Other
Were There Any Passengers in the Car?
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Yes
No
Please list any physicians, medical/therapists offices you have seen for this injury.
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Step 2- General Info about you
Full Name
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Home Phone
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Cell Phone
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E-Mail Address
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Submit
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