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Fakhoury Medical & Chiropractic Center

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Car Accident? Pain?

Auto Accident Intake Form

Auto Accident Intake Form

Step 1 of 11

9%
  • Date Format: 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)
  • Date Format: MM slash DD slash YYYY
  • Date Format: 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.
  • Signature Requirement

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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
  • Saturday 7:30 to noon

Contact Us

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

Ocala, FL 34471

Location 2
Phone: 352-633-9975
Address:11950 County Road 101 Suite 106, The Villages, Fl 32162
***Behind Bonefish Grill!

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