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Fakhoury Medical & Chiropractic Center

Ocala Chiropractor

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Car Accident? Pain?

Call us

Auto Accident Intake Form

Auto Accident Intake Form

Step 1 of 11

9%
  • MM slash DD slash YYYY
  • Enter your emergency contact with phone number
  • Please list other activities that aggravate your condition
  • Select all that apply
    On a scale 0 (No change) to 10 (Unable to work at all)
    On a scale 0 (No change) to 10 (Need help with care)
    On a scale 0 (No change) to 10 (Only to see doctors)
    On a scale 0 (No change) to 10 (Cannot sit/stand at all)
    On a scale 0 (No change) to 10 (Cannot do at all)
    On a scale 0 (No change) to 10 (Cannot do at all)
    On a scale 0 (No change) to 10 (Cannot walk/run at all)
    On a scale 0 (No change) to 10 (Lost all income)
    On a scale 0 (No change) to 10 (On pain medication throughout the day)
    On a scale 0 (No change) to 10 (See doctors weekly)
    On a scale 0 (No change) to 10 (Never see them)
    On a scale 0 (No change) to 10 (Total interference)
    On a scale 0 (No change) to 10 (Need help all the time)
    On a scale 0 (No change) to 10 (Severe depression/tension)
    On a scale 0 (No change) to 10 (Severe Problems)
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Florida PIP Law Notification

    Please remember that you have 14 days from the time of your accident to file a claim if you want PIP benefits. Contact your insurance company so they are aware you will be receiving treatment.
  • Drop files here or
    Accepted file types: pdf, jpg, png, Max. file size: 100 MB, Max. files: 3.
    • Signature Requirement

    • MM slash DD slash YYYY
    • Clear Signature

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    Find Us!

    Hours of Operation

    Our Office Hours Are As Follows:

    • Monday 7:30 to 6:00
    • Tuesday 7:30 to 6:00
    • Wednesday 7:30 to noon
    • Thursday 7:30 to 6:00
    • Friday 7:30 to 6:00

    Contact Us

    Phone: (352) 351-3413
    Fax: (352) 629-6667
    Address:1009 SW 16th Lane

    Ocala, FL 34471

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    • About
      • Conditions
      • Services
      • Staff
      • Testimonials
      • History
    • Appointments
    • Auto Accident Intake Form
    • Auto-Accident Paper Work
    • Blog
    • Conditions
    • Health Insurance or Self Pay Forms
    • Hours Of Operation
    • Intervention Medicine Paperwork
    • Leave A Review
    • Medical Intake Form
    • Medical Release Form
    • New Medical Paperwork
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    • Non Auto Accident Paperwork
    • Ocala Car Accident Doctor
    • Ocala Chiropractor
    • Ocala Chiropractor V1
    • Online Auto Accident Paperwork
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    • Print Auto Accident Paperwork
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    • Chiropractic
    • Massage Therapy
    • Headaches
    • Low Back Pain
    • Mid & Upper Back Pain
    • Neck Pain
    • Shoulder & Arm Pain