IF YOU WOULD BE A NEW PATIENT AND:

1. Are over 12 years of age and were NOT involved
   in a work or auto accident, please fill out this form
    
2. Were involved in a WORK-RELATED INJURY,
   please fill out this form
    
3. Were involved in an AUTO ACCIDENT,
   please fill out this form
    
4. Are UNDER 12 YEARS OF AGE, please fill out this form