Ribley Family Chiropractic
2453 Towne Lake Parkway
Woodstock, GA 30189
Automobile Accident History
Date of Accident
Time Accident Occurred
Were you taken to the hospital?
Did you stay in the hospital as a patient?
Name of the doctor who treated you after the accident?
If X-rays were taken, which ones?
The following questions pertain to you, the patient, and the vehicle you were in.
Were you unable to work/attend school due to your injuries? (Please enter the date range)
Have you retained an attorney?
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