Personal Injury Protection
Personal Info
First Name
Last Name
General Information
Name of Company responsible for payment.
Date of Accident
Claims Manager
Claim Number
Name of Claims Manager
Who is the referring doctor?
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?
Name of Attorney
Attorney Phone Number
Review & Agree
Personal Injury Protection Guarantee
(Review Required)
You need to review and accept this before submitting
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