Virtual Jennifer
Practice manager for Dr. Chughtai
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I am Virtual Assistant to
Dr Chughtai
and here to collect basic information about the accident. Please indicate if you agree to share the information.
Data Privacy Policy, can be viewed
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Summary Report
Type of the Accident
Circumstances of the Accident
Description of the Accident
Action Taken Soon After the Accident
Impact on Work
Impact on Home Routine
Impact on Social Life
Any Prior Accidents
Any Accidents After the Index Accident
Known Medical Conditions
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