Personal Injury Protection
Required Field
Personal Info
First Name
Last Name
General Information
Name of Company responsible for payment.
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Date of Accident
Claims Manager
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Claim Number
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Name of Claims Manager
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Who is the referring doctor?
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Do you still have availability on your PIP?
Yes
No
Have you recieved massage using this PIP claim previous to your first massage at Reflex Massage?
Yes
No
Are you using an attorney?
Yes
No
Law firm representing you?
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Name of Attorney
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Attorney Phone Number
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Personal Injury Protection Guarantee
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