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What Happend?
Where did it take place?
Brief description of injuries:
Brief description of medical care recieved to date:
What hostpital?
What doctors?
Brief description of medical treatment you will need in the future:
Amount of medical bills, if known:
Who is the injured person?
select... I am A loved one A loved friend Were the police involved and was there a police report or ticket issued?
select... Yes No Please tell us about any injuries that may have been a result of said case?
select... Yes No No No No No