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
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Email *
First Name *
Last Name *
Date of Accident *
MM
/
DD
/
YYYY
Time of Accident *
Time
:
What did your vehicle impact? *
Were you the *
Vehicle Make *
Vehicle Model *
Vehicle Year *
Street/Location *
# of Persons in Your Vehicle *
Were you *
Speed of your vehicle *
Speed of their vehicle *
Impact to your vehicle came from? *
How was visibility at the time of the collision? *
What were the road conditions? *
Did you *
Were you wearing a seat belt? *
Did you have any bruising from the seat belt? *
Were you *
What was your hand position during the crash? *
In relation to the base of your skull, where was the headrest? *
The direction you were facing  *
Were you rendered unconscious? *
If Yes, How Long?
Did the vehicle have airbags? *
Did the airbags inflate? *
Did any part of your seat break? *
Did your body strike anything in the vehicle? *
Have you worked since this injury? *
Are your work activities restricted? *
Were there any witnesses? *
Visited a Hospital or Doctor? *
Name of hospital:
When did you go to the hospital?
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How did you get to the hospital?
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Was the Doctor a?
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Were any X-rays taken? *
Medication prescribed? *
Please Choose ALL Treatment You have done since your Accident. *
Required
Did the police arrive? *
Police report filed? *
Traffic violation issued? *
If Yes, To Whom? *
Vehicle was
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Retained an attorney? *
If Yes, Name & Phone#
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 *
Other Vehicle Make/Model *
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