Personal Injury Protection
Name of Company responsible for payment.
Date of Accident
Name of Claims Manager
Who is the referring doctor?
Do you still have availability on your PIP?
Have you recieved massage using this PIP claim previous to your first massage at Reflex Massage?
Are you using an attorney?
Law firm representing you?
Name of Attorney
Attorney Phone Number
Review & Agree
Personal Injury Protection Guarantee
You need to review and accept this before submitting