17411 Irvine Blvd STE H
Tustin, CA 92780
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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