Creative Wellness Chiropractic
Personal Injury/Auto Accident Intake

Personal Injury/Auto Accident Intake

Auto Accident Intake Form

This form is to be filled out in completion if you were in an accident or had a personal injury claim.

Personal Injury/Auto Accident Intake

Name(Required)
Address(Required)

Medical History

Please indicate any significant condition that you have experienced.(Required)

Accident Description

Time of Accident(Required)
:
Were you the:(Required)
Any Bruises?(Required)
Did the airbag deploy?(Required)
Did any part of your body strike part of the vehicle?(Required)
Explain your symptoms/complaints
At the time of impact were you:(Required)
Was a police report filed?

After the accident

Were you hospitalized?(Required)
If yes, what type?
List any medications you are currently taking.(Required)
If none, put N/A.
If none, put N/A.
If none, put N/A.
Have you had any of the following previously? Mark all that apply.(Required)

Vehicle Information

Patient's Auto Insurance Info:

Other Vehicle's Auto Insurance

Patient's Health Insurance

Attorney's Info

Acknowledgment and Agreement(Required)
Name (Print & Sign)(Required)