Direction to Pay

At painPRO we understand that after a motor vehicle accident, you maybe unable to work. Treatment cost can add-up quickly. To reduce your financial burden, we offer a recovery support option. Please contact us for more information.
PATIENT INFORMATION
Patient’s Legal First and Last Name*
First Last
Phone*
Email*
Patient DOB*
MM slash DD slash YYYY
Date of MVA*
MM slash DD slash YYYY
LAWYER INFORMATION
Law Firm*
Lawyer Name*
Lawyer Contact Name*
Lawyer Contact Phone & Email*
Law Firm Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
ICBC INFORMATION
Type of Treatment*
- Chiro
- Physio
- RMT
- Active Rehab
ICBC Claim #*
ICBC Adjuster Name*
ICBC Adjuster Phone Number*
Dr.Note - request a copy*
- Yes
- No
Preferred Location for Treatment*