{"id":1507,"date":"2025-05-14T09:52:07","date_gmt":"2025-05-14T09:52:07","guid":{"rendered":"https:\/\/softwavetherapycanada.com\/arc\/?page_id=1507"},"modified":"2025-05-14T10:19:33","modified_gmt":"2025-05-14T10:19:33","slug":"motor-vehicle-accident-intake","status":"publish","type":"page","link":"https:\/\/softwavetherapycanada.com\/arc\/motor-vehicle-accident-intake\/","title":{"rendered":"Motor Vehicle Accident Intake"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1507\" class=\"elementor elementor-1507\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-216ba9c e-flex e-con-boxed e-con e-parent\" data-id=\"216ba9c\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-25a8cc4 elementor-widget elementor-widget-heading\" data-id=\"25a8cc4\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Motor<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7102e55 elementor-widget elementor-widget-heading\" data-id=\"7102e55\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Vehicle Accident Intake<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-1087c0c e-flex e-con-boxed e-con e-parent\" data-id=\"1087c0c\" data-element_type=\"container\" id=\"intake-form\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-aae8723 intakeform e-flex e-con-boxed e-con e-child\" data-id=\"aae8723\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-37beb41 elementor-widget elementor-widget-heading\" data-id=\"37beb41\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">New<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b612de3 elementor-widget elementor-widget-heading\" data-id=\"b612de3\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Patient Intake<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b0aaf56 contact-form elementor-widget elementor-widget-shortcode\" data-id=\"b0aaf56\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1509-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"1509\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/arc\/wp-json\/wp\/v2\/pages\/1507#wpcf7-f1509-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1509\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1509-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"row\">\n  <div class=\"col-md-6\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span>\n  <\/div>\n  <div class=\"col-md-6\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n  <\/div>\n\n  <div class=\"col-md-6\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"date-of-loss\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of Loss\" value=\"\" type=\"date\" name=\"date-of-loss\" \/><\/span>\n  <\/div>\n <div class=\"col-md-6\">\n  <label>Have you received treatment for this injury?<\/label><br>\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"radio-965\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-965\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-965\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n\n<div class=\"col-md-6\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"If yes, where?\" value=\"\" type=\"text\" name=\"treatment-location\" \/><\/span>\n<\/div>\n\n  <div class=\"col-md-12\"><strong>INSURANCE INFORMATION<\/strong><\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-company\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name of MVA Insurance Company\" value=\"\" type=\"text\" name=\"insurance-company\" \/><\/span>\n  <\/div>\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-country\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"insurance-country\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Canada\">Canada<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n  <\/div>\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-address1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address Line 1\" value=\"\" type=\"text\" name=\"insurance-address1\" \/><\/span>\n  <\/div>\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-address2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Address Line 2\" value=\"\" type=\"text\" name=\"insurance-address2\" \/><\/span>\n  <\/div>\n  <div class=\"col-md-4\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"insurance-city\" \/><\/span>\n  <\/div>\n  <div class=\"col-md-4\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-province\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Province\" value=\"\" type=\"text\" name=\"insurance-province\" \/><\/span>\n  <\/div>\n  <div class=\"col-md-4\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-postal\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Postal Code\" value=\"\" type=\"text\" name=\"insurance-postal\" \/><\/span>\n  <\/div>\n\n  <div class=\"col-md-6\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"adjuster-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Adjuster First Name\" value=\"\" type=\"text\" name=\"adjuster-first-name\" \/><\/span>\n  <\/div>\n  <div class=\"col-md-6\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"adjuster-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Adjuster Last Name\" value=\"\" type=\"text\" name=\"adjuster-last-name\" \/><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"adjuster-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Phone\" value=\"\" type=\"text\" name=\"adjuster-phone\" \/><\/span>\n  <\/div>\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"adjuster-fax\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Fax\" value=\"\" type=\"text\" name=\"adjuster-fax\" \/><\/span>\n  <\/div>\n\n  <div class=\"col-md-6\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"policy-holder-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Policy Holder First Name\" value=\"\" type=\"text\" name=\"policy-holder-first-name\" \/><\/span>\n  <\/div>\n  <div class=\"col-md-6\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"policy-holder-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Policy Holder Last Name\" value=\"\" type=\"text\" name=\"policy-holder-last-name\" \/><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"relationship-to-policy-holder\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Relationship to Policy Holder\" value=\"\" type=\"text\" name=\"relationship-to-policy-holder\" \/><\/span>\n  <\/div>\n\n  <div class=\"col-md-6\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"policy-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Policy No.\" value=\"\" type=\"text\" name=\"policy-number\" \/><\/span>\n  <\/div>\n  <div class=\"col-md-6\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"claim-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Claim No.\" value=\"\" type=\"text\" name=\"claim-number\" \/><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\"><strong>ACCIDENT INFORMATION<\/strong><\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"accident-description\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Please provide a brief description of how the accident occurred.\" name=\"accident-description\"><\/textarea><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    You were:<br>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"vehicle-type\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"vehicle-type[]\" value=\"Driver\" \/><span class=\"wpcf7-list-item-label\">Driver<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"vehicle-type[]\" value=\"Passenger\" \/><span class=\"wpcf7-list-item-label\">Passenger<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"vehicle-type[]\" value=\"Motorcyclist\" \/><span class=\"wpcf7-list-item-label\">Motorcyclist<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"vehicle-type[]\" value=\"Cyclist\" \/><span class=\"wpcf7-list-item-label\">Cyclist<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"vehicle-type[]\" value=\"Pedestrian\" \/><span class=\"wpcf7-list-item-label\">Pedestrian<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    Your vehicle was:<br>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"vehicle-impacts\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"vehicle-impacts[]\" value=\"Front Impact\" \/><span class=\"wpcf7-list-item-label\">Front Impact<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"vehicle-impacts[]\" value=\"Rear Impact\" \/><span class=\"wpcf7-list-item-label\">Rear Impact<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"vehicle-impacts[]\" value=\"Side Impact\" \/><span class=\"wpcf7-list-item-label\">Side Impact<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"vehicle-impacts[]\" value=\"Rollover\" \/><span class=\"wpcf7-list-item-label\">Rollover<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"vehicle-impacts[]\" value=\"Multiple\" \/><span class=\"wpcf7-list-item-label\">Multiple<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    Road Condition:<br>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"road-condition\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"road-condition[]\" value=\"Wet\" \/><span class=\"wpcf7-list-item-label\">Wet<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"road-condition[]\" value=\"Dry\" \/><span class=\"wpcf7-list-item-label\">Dry<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"road-condition[]\" value=\"Snow\" \/><span class=\"wpcf7-list-item-label\">Snow<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"road-condition[]\" value=\"Ice\" \/><span class=\"wpcf7-list-item-label\">Ice<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"had-head-impact\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"had-head-impact\" value=\"Did you hit your head?\" \/><span class=\"wpcf7-list-item-label\">Did you hit your head?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"had-head-impact\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"had-head-impact\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"head-impact-before-after\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"head-impact-before-after\" value=\"Did you lose consciousness during or after the impact?\" \/><span class=\"wpcf7-list-item-label\">Did you lose consciousness during or after the impact?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"head-impact-before-after\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"head-impact-before-after\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"seatbelt-used\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"seatbelt-used\" value=\"Were you able to get out\/walk around unassisted?\" \/><span class=\"wpcf7-list-item-label\">Were you able to get out\/walk around unassisted?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"seatbelt-used\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"seatbelt-used\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"passengers-hurt\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"passengers-hurt\" value=\"Were your passengers during this accident affected?\" \/><span class=\"wpcf7-list-item-label\">Were your passengers during this accident affected?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"passengers-hurt\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"passengers-hurt\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"previous-accidents\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"previous-accidents\" value=\"Have you had any prior accidents?\" \/><span class=\"wpcf7-list-item-label\">Have you had any prior accidents?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"previous-accidents\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"previous-accidents\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"if-yes-prior-accident\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"If yes, please list the details\" value=\"\" type=\"text\" name=\"if-yes-prior-accident\" \/><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\"><strong>HEALTH CONDITIONS<\/strong><\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"health-conditions\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Neck pain\/stiffness\" \/><span class=\"wpcf7-list-item-label\">Neck pain\/stiffness<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Shoulder pain\" \/><span class=\"wpcf7-list-item-label\">Shoulder pain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Arm\/hand weakness\" \/><span class=\"wpcf7-list-item-label\">Arm\/hand weakness<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Upper back pain\" \/><span class=\"wpcf7-list-item-label\">Upper back pain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Mid back pain\" \/><span class=\"wpcf7-list-item-label\">Mid back pain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Lower back pain\" \/><span class=\"wpcf7-list-item-label\">Lower back pain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Hip\/groin pain\" \/><span class=\"wpcf7-list-item-label\">Hip\/groin pain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Headaches\" \/><span class=\"wpcf7-list-item-label\">Headaches<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Jaw pain\" \/><span class=\"wpcf7-list-item-label\">Jaw pain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Ringing in ears\" \/><span class=\"wpcf7-list-item-label\">Ringing in ears<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Loss of balance\" \/><span class=\"wpcf7-list-item-label\">Loss of balance<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Loss of vision\" \/><span class=\"wpcf7-list-item-label\">Loss of vision<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Vision affected\" \/><span class=\"wpcf7-list-item-label\">Vision affected<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Difficulty swallowing\" \/><span class=\"wpcf7-list-item-label\">Difficulty swallowing<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Nausea\" \/><span class=\"wpcf7-list-item-label\">Nausea<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Tingling\" \/><span class=\"wpcf7-list-item-label\">Tingling<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Sleep changes\" \/><span class=\"wpcf7-list-item-label\">Sleep changes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"health-conditions[]\" value=\"Mood changes\" \/><span class=\"wpcf7-list-item-label\">Mood changes<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"other-symptoms\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Other symptoms\" value=\"\" type=\"text\" name=\"other-symptoms\" \/><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"pain-timing\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"pain-timing[]\" value=\"Before Collision\" \/><span class=\"wpcf7-list-item-label\">Before Collision<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"pain-timing[]\" value=\"Immediately Following\" \/><span class=\"wpcf7-list-item-label\">Immediately Following<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"pain-timing[]\" value=\"Currently Experience\" \/><span class=\"wpcf7-list-item-label\">Currently Experience<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"major-injuries\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Major Injuries or Surgeries (and Timeframe)\" value=\"\" type=\"text\" name=\"major-injuries\" \/><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Current Medications\" name=\"current-medications\"><\/textarea><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"under-treatment\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"under-treatment\" value=\"Are you currently receiving treatment from another health care professional?\" \/><span class=\"wpcf7-list-item-label\">Are you currently receiving treatment from another health care professional?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"under-treatment\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"under-treatment\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"what-treatment\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"If yes, what treatment are you receiving?\" value=\"\" type=\"text\" name=\"what-treatment\" \/><\/span>\n  <\/div>\n\n  <div class=\"col-md-12\"><strong>AGREEMENT<\/strong><\/div>\n\n  <div class=\"col-md-12\">\n    By agreeing, you confirm that:<br>\n    I acknowledge that any treatment that is not covered by MVA will be my responsibility.<br>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"agreement-consent\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"agreement-consent\" value=\"Agree\" \/><span class=\"wpcf7-list-item-label\">Agree<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"agreement-consent\" value=\"Disagree\" \/><span class=\"wpcf7-list-item-label\">Disagree<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"btn-fomr mb-3\">\n    <input class=\"wpcf7-form-control wpcf7-submit has-spinner btn btn-default\" type=\"submit\" value=\"Submit\" \/>\n  <\/div>\n<\/div><input type='hidden' class='wpcf7-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-a490b6d e-con-full e-flex e-con e-parent\" data-id=\"a490b6d\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0eb2cfc elementor-widget elementor-widget-html\" data-id=\"0eb2cfc\" data-element_type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<iframe src=\"https:\/\/www.google.com\/maps\/embed?pb=!1m18!1m12!1m3!1d2528.2634840022547!2d-79.27715062381674!3d43.77555807109661!2m3!1f0!2f0!3f0!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x89d4d19bebda1ddd%3A0xc1c4cca0249bf38e!2s2240%20Midland%20Ave%2C%20Scarborough%2C%20ON%20M1P%204R9%2C%20Canada!5e1!3m2!1sen!2s!4v1747122853705!5m2!1sen!2s\" width=\"600\" height=\"450\" style=\"border:0;\" allowfullscreen=\"\" loading=\"lazy\" referrerpolicy=\"no-referrer-when-downgrade\"><\/iframe>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-51cb397 e-flex e-con-boxed e-con e-parent\" data-id=\"51cb397\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-9afec90 e-con-full e-flex e-con e-child\" data-id=\"9afec90\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b5dc4a3 elementor-widget elementor-widget-heading\" data-id=\"b5dc4a3\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Didn\u2019t find the answers you were looking for?<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9698f7b elementor-widget elementor-widget-heading\" data-id=\"9698f7b\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"elementor-heading-title elementor-size-default\">Just get in touch with us with your preferred method! We will try our best to help you with any and all questions.<\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-1ada86d e-con-full e-flex e-con e-child\" data-id=\"1ada86d\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3edc205 elementor-align-center btn-default wow fadeInUp elementor-widget elementor-widget-button\" data-id=\"3edc205\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"#\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Contact Us<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Motor Vehicle Accident Intake New Patient Intake Didn\u2019t find the answers you were looking for? Just get in touch with us with your preferred method! We will try our best to help you with any and all questions. Contact Us<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-1507","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/pages\/1507","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/comments?post=1507"}],"version-history":[{"count":0,"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/pages\/1507\/revisions"}],"wp:attachment":[{"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/media?parent=1507"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}