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Hello! What's your name? *

What approximate month and year you were injured? *

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Did you miss any time from work for your injuries? *

Are you still receiving medical care for the injuries? *

Please tell us a little bit about what happened, where it happened, and what injuries occurred. *

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Do you have any questions for us? (We will probably either email you our answers or discuss them with you when we get in touch over the phone)

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