Auto Accident / Personal Injury Form

(Last, First, MI)
Referral
Relationship

Please allow us to photocopy your insurance card.

Financial
Relation to Insured
Is The Complaint
What Makes It Better?
What Makes It Worse?
Who Else Have You Seen For This?
Diagnostic Tests
Does anyone in your IMMEDIATE family have a history of
If yes, who
If yes, who
If yes, who
Past Health History
(List and reactions)
(List all and frequency)
Are you CURRENTLY experiencing any of these symptoms?
General
Musculoskeletal
Neurological
Cardiovascular & Heart
Eyes and Vision
Ears, Nose and Throat
Mind/Stress
Gastrointestinal
Endocrine, Hematologic, and Lymphatic
Respiratory
Genitourinary
(Check all that apply)
List even if it was 20 years ago...
Women Only
Auto Accident Questionnaire
(First MI Last)
Accident Information
(if not you)
Where was your vehicle impacted?
Medical Information
If no, when?
If yes, when did you go?
Office Policies for Personal Injury Patients

This office will accept you as a new patient based on our clinical examination and belief that chiropractic care will be effective for the treatment of your injuries. To extend you credit while you are under treatment, you must provide the appropriate financial information so that payment for services can be received. Patients must bring the following information by the third office visit or pay for their treatment.

  1. Copy of police report and/or a copy of the exchange slip.
  2. Name of individual and insurance company of party that is liable.
  3. Copy of personal automobile policy.

  4. Name and telephone number of attorney, if one has been retained.

Following the completion of your treatment in this office, your bill will be forwarded to the responsible party. Please note that this account is still your responsibility and will be subject to monthly interest charges of 1.5% effective 30 days following your initial visit.

I have answered these questions to the best of my knowledge and certify them to be true and correct.

I have read the above information and certify it to be true and correct to the best of my knowledge and hereby authorize this office to provide me with chiropractic care, diagnostic testing, and/or therapeutic services, in accordance with this state’s statutes. I choose to decline receipt of my clinical summary after every visit.

Sign above
A copy of the full Health Information Privacy Policy for our office can be requested at the front desk. In brief, it states that we will not give any information about you except as consented above. The only people we give information to are your parents/guardians if you are a minor or whomever is responsible for your bill (i.e. insurance company, third party, or attorney if you have one).