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Car Accident
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Date of Accident
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Claim Number
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Struck on the
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Driver/Passenger
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Air bags deployed?
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Looking
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Unconscious?
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What did patient strike in car
• • •
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Where did patient go?
• • •
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Seatbelts?
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Additional Treatment
• • •
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Immed. Pain
• • •
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Getting better/worse
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Imaging and treatment?
• • •
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Lien
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Attorney Name
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Attorney Phone
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Attorney Fax
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Attorney Address
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Auto Insurance Medical Coverage
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Third Party Coverage
|
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Company Name
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Insurance Adjuster
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Insurance Phone
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Insurance Fax
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