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ATTORNEY INFORMATION
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Last Name:
Phone Number:
Email:
Street Address:
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DESIRED PHYSICIAN TYPE
Specialty:
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Acupuncture
Aquatic Therapy
DC (Chiropractor)
Dentist
ENT (Ear, Nose & Throat)
General Surgery
Hand Surgeon
InfraRed Therapy
Internal Medicine
Massage Therapy
Maxillofacial Surgeon
MD (Medical Doctor)
Neurodiagnostic Testing
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Neurosurgeon
Nurse Practictioner
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Occupational Medicine
Ophthalmologist
Orthopedic Surgeon
Orthopedist
Osteopathy
Outpatient Surgery
Pain Management
Physical Medicine
Physical Therapist (PT)
Physiotherapy
Plastic Surgery
Podiatrist
Psychologist
QME (Medical Evaluator)
Spine Surgeon
Surgery Center
CLIENT INFORMATION
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Last Name:
Date of Birth:
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Date of Accident:
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Health Insurance Company:
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