Have you been in an auto accident?Fill out the form below to get on our MVA waitlist Name * First Name Last Name Email * Phone number * Cellphone if you would like text communication and updates. (###) ### #### What is the date of accident causing your injury? * MM DD YYYY What company is your auto insurance through? * Has your insurance adjuster advised that you will need a preauthorization or referral? * Yes No I am not sure What is the severity of injury and urgency for treatment? * Severe - in need of urgent treatment Moderate - can wait 2-4 weeks for treatment Mild - can wait 4-6 weeks for treatment Additional information (optional) Please include any additional relevant information about your accident and injury Thank you you for submitting your information! Your are now on our MVA waitlist, please check your email and phone for updates from us in the next 3-7 business days. For more information or further questions please feel free to call or text us at (541) 425-6254. Best,Functional Flexion
