Language
English (US)
Spanish (Latin America)
LAPINE FAMILY CHIROPRACTIC CLINIC
Provide your details and injury information to help us assist you better.
Accident Help
We help auto injury patients get evaluated quickly, document injuries properly, and start treatment right away. We Bill your Auto Insurance company, In most cases there are not out of pocket expenses for treatments.
Full Name *
*
First Name
Last Name
Date of Auto Accident *
*
-
Month
-
Day
Year
Date
Do you have auto insurance? *
*
Yes
No
Has your claim been filed? *
*
Yes
No
Other
Is an Attorney Involved? If not we can help.
*
Yes
No
Considering One
Did you go directly to the emergency room or an urgent care clinic after the accident? *
*
Yes
No
Are you currently being treated for these injuries? *
*
Yes
No
Did your accident occur in the state of Florida? *
*
Yes
No
Were you a driver or passenger? *
*
Driver
Passenger
Do you currently have pain? *
*
Neck pain
Low Back pain
Headaches
Stiffness
Numbness or tingling
Shoulder
Thoracic (mid back)
Other
What type of accident was it? *
*
Rear End Collision
Side Impact (T-Bone)
Head On Collision
Other
ACCIDENT DETAILS *
*
If you are currently working with an attorney please provide their contact information.
When would you like to be seen? *
*
Today
Within 24 hours
This week
Preferred contact method *
*
Call
Text
Email
Email Address *
*
example@example.com
Phone Number *
*
-
Area Code
Phone Number
Submit
Should be Empty: