Have You Been
Impacted by PA21?
We Want to Hear Your Story
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Name
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First
Last
Email
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Phone Number
Relationship to Patient
Self
Family/Friend
Care Provider
Other
When did the accident occur or (if you are a provider) when did you start serving patients?
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What was care like BEFORE auto no-fault reform was passed?
What is your care like now, AFTER auto no-fault reform has been applied?
May we contact you to learn more?
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