First Name
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Phone
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Accident Basics
When did the accident happen?
Today
1 to 3 days ago
4 to 14 days ago
15 to 30 days ago
31 to 90 days ago
More than 90 days ago
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What type of accident was it?
Car or truck crash
Rideshare (Uber or Lyft)
Motorcycle
Pedestrian or bicycle
Other
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Were you taken to the ER or urgent care?
Yes
No
Not Sure
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Pain level today
1 to 3 mild
4 to 6 moderate
7 to 10 severe
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What are you feeling right now? (multi-select)
Neck pain or stiffness
Back pain
Shoulder or arm pain
Hip or knee pain
Headache
Dizziness
Numbness or tingling
Chest discomfort
I feel worse since the accident
Not sure, I just know something is off
How was fault determined so far?
Other driver at fault
I may be at fault
Shared fault
Not determined yet
Not sure
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What kind of help are you looking for right now?
Medical evaluation and treatment
Medical treatment or rehab
Imaging or diagnostics
Legal guidance (attorney options)
Insurance and paperwork guidance
Not sure, help me figure it out
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Anything you want us to know?
Example: symptoms started later, already saw a doctor, preferred language, best time to reach you.
Preferred contact method
Text me
Call me
Either is fine
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I agree to be contacted by phone or text about my request. Message and data rates may apply.
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