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 *
Last Name *
Date of Accident *
MM
/
DD
/
YYYY
Time of Accident *
Time
:
Vehicle Make *
Vehicle Model *
Vehicle Year *
Street/Location *
# of Persons in Your Vehicle *
Were you the *
Were you *
Speed of your vehicle *
Speed of their vehicle *
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:
When did you go to the hospital?
Clear selection
How did you get to the hospital?
Clear selection
Was the Doctor a?
Clear selection
Were any X-rays taken?
Clear selection
Medication prescribed? *
Were you rendered unconscious? *
If Yes, How Long?
Traffic violation issued? *
If Yes, To Whom? *
Retained an attorney? *
If Yes, Name & Phone#
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
Describe the accident? *
How did you feel right after? *
Names of all persons in this accident: *
Have you contacted Your auto insurance company? *
Claim # for Medical Care (your insurance) *
Your Insurance Contact Person *
Insurance Phone *
Have you contacted The Other Driver's auto insurance company? *
Claim # (liable party) *
Insurance Contact Person *
Insurance Phone *
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