Auto Accident
Welcome to Corrective Chiropractic. Thank you for taking a moment to fill in our Auto Accident Form. Please fill this form completely and to the best of your knowledge. When complete you will submit this HIPAA compliant form. Let us know if you have any questions. 252-758-7583
Email address *
First Name *
Your answer
Last Name *
Your answer
Date of Accident *
MM
/
DD
/
YYYY
Time of Accident *
Time
:
Vehicle Make *
Your answer
Vehicle Model *
Your answer
Vehicle Year *
Your answer
Street/Location *
Your answer
# of Persons in Your Vehicle *
Your answer
Were you the *
Were you *
Speed of your vehicle *
Your answer
Speed of their vehicle *
Your answer
Were you wearing a seat belt? *
Have you worked since this injury? *
Are your work activities restricted? *
Were there any witnesses? *
Did the vehicle have airbags? *
Did the airbags inflate? *
Did the police arrive? *
Police report filed? *
Visited a Hospital or Doctor? *
Name of hospital:
Your answer
When did you go to the hospital?
How did you get to the hospital?
Was the Doctor a?
Were any X-rays taken?
Medication prescribed? *
Were you rendered unconscious? *
If Yes, How Long?
Your answer
Traffic violation issued? *
If Yes, To Whom?
Your answer
Retained an attorney? *
If Yes, Name & Phone#
Your answer
In relation to the base of your skull, where was the headrest? *
Impact to your vehicle came from? *
The direction you were heading? *
The direction they were heading? *
The direction you were facing? *
What did your vehicle impact? *
Strike anything in the vehicle? *
If Yes, Please Explain
Your answer
Describe the accident? *
Your answer
How did you feel right after? *
Your answer
Names of all persons in this accident: *
Your answer
Have you contacted Your auto insurance company? *
Have you contacted The Other Driver's auto insurance company? *
Claim # *
Your answer
Insurance Contact Person *
Your answer
Insurance Phone *
Your answer
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