Bellevue whiplash centerat Back in ACtion 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
Briefly Describe Your Pain or Discomfort
*
What Part of Your Car was Hit?
*
Front
Left Side
Right Side
Rear
Front Corner (Left/Right)
Rear Corner (Left/Right)
If Other please specify:
*
Where you Driving the Car?
*
Yes
No
If NO Where Were You Sitting?
*
Front Passenger
Rear Passenger
Other
Where There Any Passengers in the Car?
*
Yes
No
Step 2- General Info about you
Full Name
*
Home Phone
*
Cell Phone
*
E-Mail Address
*
Submit
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