Vehicle Accident Report
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- Jeffery Simmons
- 5 years ago
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1 Vehicle Accident Report Date of Injury / / Claim # First NameMI Last Name Sex M F Address City State Zip_ Home Phone Cell Phone Best contact Cell Home Date of Birth Age Marital Status (Circle) M S D W Social Security Number_ Address Occupation Employer Work Address_ City, State Zip Spouse s Name_ # Children_ Drivers License No. State: Have you ever had Chiropractic before All Charges are due when services are rendered Method of payment ( ) Check ( ) Cash ( ) Credit Card ( ) Care Credit Are you or do you think that you might be pregnant? 1) Yes 2) No 3) Not Sure Cause of complaint: (circle) 1) Auto Accident 2) Work Injury 3) Other Accident 4) Illness 5) Congenital 6) Unknown Please Mark an X on the diagram where your problems are List your major complaints in order of severity I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. I authorize payment from my insurance carrier directly to this office with the understanding that all monies be credited to my account upon receipt. I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I understand that if I suspend or terminate my care and treatment, all fees for professional services rendered me will be immediately due and payable. In the event of my default, I promise to pay legal interest on the indebtedness together with such collection costs and reasonable attorney fees as may be required to effect collection. Patient Signature_Date Guardian or spouse s authorizing care
2 Patient Complaints Name: Date Please check any of the symptoms you have recently experienced GENERAL HEAD ARMS Anxiety Headaches Upper Arm pain Concentration Jaw Pain Pins & Needles Nervousness Jaw tension Numbness Irritability Pain in ears Weakness Fatigue Ringing in ears Elbow pain Depression Ear discharge Forearm pain Memory Loss Hearing loss Loss of sleep Eye pain HANDS Tension Decreased acuity Wrist pain Fainting spells Light sensitivity Hand pain Dizzy spells Floating lights Pins & Needles PMS Nose bleeds Numbness- Hand Nasal obstruction Thumb pain NECK Index finger pain Neck pain SHOULDERS Middle finger pain Pain radiates Pain with motion Ring finger pain Stiffness Pain at rest Little finger pain Grinding sounds Muscle spasm Numbness- Fingers Popping sounds Limited motion Muscle weakness Hoarseness Muscle Weakness PELVIS MIDBACK THIGH Hip joint pain Pain Pain Sacroiliac pain Muscle spasm Pain radiates Buttock pain Numbness Groin pain LOWBACK Pins & needles Tail bone pain Pain Knee pain Stiffness Swollen knee CALVES Muscle spasm Muscle weakness Calf pain Pain radiates Pain radiates CHEST Numbness URINARY TRACT Deep chest pain Pins & needles Painful urination Pain around ribs Cramps Frequent urination Pain with exertion Muscle weakness Unable to urinate Shortness of breath Leakage of urine Difficult breathing ANKLES Blood in urine Irregular heartbeat Pain Bed wetting Rapid heartbeat Swelling Night sweats Chronic cough
3 FEET DIGESTIVE TRACT WOMEN ONLY Pain Stomach pain Painful menstruation Numbness Indigestion Excess menstruation Pins & Needles Nausea Missed periods Swelling Gas Irregular periods Cramps Clay colored stool Big toe pain Black tarry stool 2 nd toe pain Hemorrhoids Mid toe pain Abnormal weight loss 4 th toe pain Diarrhea Small toe pain Constipation Any other new symptoms since the accident that are not listed above Which is your most serious complaint? Which is your next most serious complaint? Approximate date of onset (if known): / / Onset was: Sudden Gradual Are the complaints? Improving Getting worse About the same Comes & Goes When are the complaints most noticeable? Morning Afternoon Evening Night What aggravates the complaint(s)? Standing Walking Sitting Bending Lying Lifting Twisting Coughing What relieves the complaint(s)? Rest Sitting Lying Bending Stretching Exercise Lying knees bent
4 VEHICLE ACCIDENT REPORT Name Date of Accident / / Time of Accident : (AM /PM) Were you at work when the accident occurred? Have you been unable to work since injury? Yes No If yes, you were off work partially or completely Please list date off work: _ to _. Are you working now? ( ) Yes, part time ( ) Yes, full time ( ) No Were you: ( ) Driver ( ) Passenger (Front) ( ) Passenger (Rear) ( ) Pedestrian Were you wearing seatbelts? ( ) Yes ( ) No Was your vehicle moving? ( ) Yes ( ) No Other vehicle moving? ( ) Yes ( ) No Type of Vehicle: ( ) Auto ( ) Light Truck ( ) Truck ( ) Van ( ) Bus ( ) Motorcycle ( ) Motor Scooter ( ) Motor-home ( ) Bicycle Other vehicle: ( ) Auto ( ) Light Truck ( ) Truck ( ) Van ( ) Bus ( ) Motorcycle ( ) Motor Scooter ( ) Motor-home ( ) Bicycle How accident occurred: ( ) Struck by another vehicle ( ) Struck another vehicle ( ) Struck a stationary object ( ) Other Where was your vehicle hit? ( ) Front ( ) Rear ( ) Rt. Side ( ) Lft. Side ( ) Rt. Front ( ) Lft. Front ( ) Rt. Rear ( ) Lft. Rear Where was other vehicle hit? ( ) Front ( ) Rear ( ) Rt. Side ( ) Lft. Side ( ) Rt. Front ( ) Lft. Front ( ) Rt. Rear ( ) Lft. Rear What occurred at the moment of impact? (Circle as many as apply) Tensed body for impact Neck whipped forward & back Spine torque and twisted Thrown over seat Thrown from vehicle Pinned in vehicle Thrown from side to side Cut and Bruised Did you strike your: (Circle as many as apply) Head Against the: Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Shoulder (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Arm (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Upper Arm (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Forearm Arm (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Elbow (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Wrist (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Hip (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Knee (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Ankle (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Ribcage (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Thigh (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Shin (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Foot (Lft. /Rt.) Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Low back Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Upper back Dashboard Windshield Steering Wheel Rt. Door Lft. Door Seat Frame Unknown object Were you rendered unconscious? (Y/N) Did you receive medical attention at the scene of the accident? (Y/N) Where did you go immediately following the accident? ( ) Hospital ( ) Home ( ) Personal Doctor ( ) To this office ( ) Resumed activities
5 Hospital Name Hospital City/State How did you get there? ( ) Ambulance ( ) Drove myself ( ) Someone drove me ( ) Walked When did your symptoms develop? Immediately Hours later The next day Over the first few days During first week Over next few weeks Over the next few months Were you: (Circle as any as apply) Shaken Disoriented Nauseous Dizzy Did you have any physical complaints before the accident? (Y/N) If YES please describe: In your own words, please describe accident: How did you feel immediately after the accident? If you were treated by another Doctor or Therapist for this condition, answer the following questions: Name: ( ) CA ( ) DC ( ) DDS ( ) DS ( ) DPM( ) MD ( ) OD ( ) PT Tests Performed: ( ) Examination ( ) X-Ray ( ) CAT scan ( ) EMG ( ) Thermography ( ) MRI ( ) EEG ( ) Lab ( ) Psychological Prescription given: ( ) Pain Killers ( ) Muscle relaxants ( ) Antibiotics ( ) Sedatives ( ) Anti-inflammatory ( ) Other Treatment given: ( ) Daily ( ) 1x/week ( ) 2x/week ( ) 3x/week ( ) 4x/week ( ) 1x/month ( ) 2x/month Treatment duration: ( ) Days ( ) Weeks ( ) Months Date first appointment: / / Date last appointment: / / Did the treatment help? ( ) No, Aggravated the condition ( ) No ( ) Yes, a little ( ) Yes, a lot ( ) Cured the condition Patient Signature Date Important: This form may be used in the determination of insurance benefits and/ or litigation for compensation. It is imperative that this from be filled out completely to protect your rights of compensation.
6 Office Policies Personal Injury cases are accepted in our office. All personal injury cases, whether car or home accidents, must provide necessary information regarding your personal car insurance, the at fault insurance, your commercial health insurance, as well as the accident report, and attorney name and contact information if one has been retained. The personal car insurance is needed because most individuals have medical benefits (usually called Medpay or PIP ) included in their automobile policies and some do not even realize it. If these benefits are available on your policy, our office requires that you use them in the event that your injuries are as a result of an automobile accident. The following outlines why we require Medpay or PIP be filed: 1. Medpay and PIP are exactly like health insurance using either form of coverage does not cause your rates to go up. However, if your rates are increased it is not because of the medpay was filed. It is most likely because: (a) the accident was determined by the insurance company to be your fault, (b) you received a police citation or ticket, and (c) you have been involved in numerous reported auto accidents within a brief period of time and are therefore considered high risk. 2. Filing your Medpay or PIP does not relieve the at Fault party from having to pay in full for your loss. Filing Medpay or PIP does not relieve the other party from being held responsible for payment. If the at fault driver s liability insurance refuses to make payment on your medical bills for whatever reason, filing your Medpay/PIP will help ensure that you are not left to pay these expenses out of pocket. 3. We do not charge for filing your Medpay or PIP. As long as Lark Chiropractic is filing my Medpay/PIP and, the insurance company is continuing to cover the charges accrued, collection of payment at time of service will be waived. If overpayment on my account is made, Lark Chiropractic will refund the difference. I clearly understand and agree that all services rendered to me are charged directly to me, thus, I am personally responsible for payment in full. Signature below of patient/guardian indicates that you have read and accept above provisions. Signature of Patient or Guardian Date Printed Name
7 Contractual Lien I hereby authorize and direct you, the insurance company, and/or my attorney, to pay directly to Lark Chiropractic such sums that may be due and owing this office for services rendered to me, both by reason of accident, of illness and by reason of any other bills that are due this office, and to withhold such sums from any disability benefits, medical payment benefits, liability benefits, health and accident benefits, workmens compensation benefits, or any other insurance benefits obligated reimburse me or from any settlement, judgment or verdict on my behalf as may be necessary to adequately protect said office. I hereby further give a lien to said office against any and all insurance named herein, and any and all proceeds of any settlement, judgment or verdict that may be paid to me as a result of the injuries or illness for which I have been treated by said office. This is to act as an assignment of my rights and benefits to the extent of the office s services provided. I understand that I remain personally responsible for the total amounts due the office for their services. I further understand and agree that this assignment, lien and authorization does not contribute any consideration for the office to await payments and they may demand payment from me upon rendering services at their option. I authorize this office to release any information pertinent to my case to any insurance company or attorney to facilitate collection under this assignment, lien and authorization. I agree that the above mentioned office be given power of attorney to endorse my name on any and all checks for payment of my doctor bill. I further understand and agree, that if this office must take any action to collect an outstanding balance on my account, I will be responsible for payment of and reimburse this office for all costs of such collection efforts including but not limited to all court costs and attorney fees. I have been advised that if my attorney does not wish to cooperate in protecting the doctor s interest, the doctor will not await payment, but will require me to make payments on my current balance. By signing below, I acknowledge I have read, understand and agree to the above provisions. Patient Name (please print): Patient Signature: Date: Name of custodial parent or Legal Guardian (please print): Parent/Guardian Signature:
8 Contact Information Please print all information. Patient Name (please print): At Fault Insurance Information Insurance Company Name: Claim #: Adjuster Name: Phone Number: Your Auto Insurance Information Insurance Company Name: Claim #: Adjuster Name: Phone Number: Attorney Information Firm Name: Attorney Name: Phone Number: Health Insurance Information Need copy of your insurance card. Insurance Company Name: Insured s Name: Insured s Date of Birth: Accident Report Need copy of Accident Report. Reports are typically released 48 hours after accident.
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Christos Vasakiris, D.C.,D.A.C.A.N. 350 West Montauk Highway Lindenhurst, N.Y, 11757 PLEASE PRINT Patient Name SS# Address City State Zip Code Birth Date / / Age Circle one: Marital Status: S/M/D/W/P How
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE We realize that this is your first visit to our office, and our past experience has shown us that new patients have many unanswered questions on their minds. Our staff will attempt
City: State: Zip: Home Cell Work Alternate Phone: Address: Home Cell Work Sex: Male Female Marital Status: Single Married Other:
Denton Sanger Aubrey Patient Information Patient Registration Information Name: (First) (MI) (Last) Social Security #: Date of Birth: Address: Phone: City: State: Zip: Home Cell Work Alternate Phone: Email
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided.
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided. Last Name: First Name: Primary Care Physician: Referring
EMERGENCY CONTACT Name of relative/friend not living with you. Home Phone Cell INSURANCE
DATE PATIENT INFORMATION Name Date of Birth Home# Work# Cell# Do you receive text messages? Address City State Zip SS# email Sex Marital Status Employer If Student, what school? Spouse s Name Who may we
Personal Insurance Intake Form
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: - - Address: Street City State Zip Email Address: Home Phone: Cell Phone: Gender: Height: Weight: lbs Marital Status:
SOUTH TEXAS BONE & JOINT
SOUTH TEXAS BONE & JOINT NEW PATIENT INFORMATION (PLEASE PRINT) DATE: PATIENT S NAME EMAIL DATE OF BIRTH AGE M/ F SOCIAL SECURITY # MAILING ADDRESS PERMANENT OR TEMPORARY CITY, STATE, ZIP CODE (AREA CODE)
221 Madison Ave Morristown, New Jersey (973) Fax (973) PATIENT INFORMATION. Mailing Address: City: State: Zip: Birth Date:
221 Madison Ave Morristown, New Jersey 07960 (973) 538 4444 Fax (973) 538 0420 PATIENT INFORMATION Marc A. Cohen, MD, FAAOS, FACS Diplomate American Board of Spinal Surgery Fellow American College of Spinal
Greater Austin Allergy, Asthma & Immunology
Greater Austin Allergy, Asthma & Immunology phone: (512) 732-2774 fax: (512) 329-6871 PATIENT INFORMATION Patient Name DOB Age SSN Today s Date Sex Single Married Widowed Divorced Present Address City,
Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip
PATIENT INFORMATION Marital Status Patient s Last Name First Initial Date of Birth S M D W Home Phone Work Phone Mobile Phone E-Mail Address City State Zip Occupation Employer Employer Phone Employer Address
STATE ZIP SPOUSE OR GUARDIAN INFORMATION
REFERRED BY FAMILY DOCTOR DARRELL C. BRETT, M.D., P.C. BRET GENE BALL, LLC 10,000 SE MAIN, SUITE 360 PORTLAND, OREGON 97216 NEUROLOGICAL SURGERY PATIENT INFORMATION (PLEASE PRINT) DATE PATIENT S LAST NAME
Patient Registration. D. INSURANCE (if applicable)
Patient Registration A. PATIENT Account #: Address: City: State Zip: Preferred Contact Method: Home Phone Work Phone Cell Phone DOB: SSN #: Gender: Male Female E-MAIL: Check here to receive Electronic
Name: Date of Birth: Sex: Office: Date:
Patient Information Name: Date of Birth: Sex: Office: Date: Address: City: State: Zip: Social Security Number: Home Phone: Cell Phone: Email: May we leave a message? Email? Martial Status Emergency Contact
Palmer Chiropractic. Your health is our concern. Name Address Preferred: Cell / Hm # / Wk # Address City Zip Code. Home Ph Work Ph Cell Ph
Palmer Chiropractic Your health is our concern Name Email Address Preferred: Cell / Hm # / Wk # Address City Zip Code Home Ph Work Ph Cell Ph Date of Birth Age Sex M F Marital Status S M D W Social Security
Name Married Single (last) (first) (middle) Address City State Zip. Cell Phone Home Phone
Mission Statement: To improve the health potential of the people around us by providing excellent quality service and care utilizing education, love & chiropractic. Date Social Security No. Name Married
CHIROPRACTIC 1 ST NEW PATIENT INFORMATION PATIENT INFORMATION
PATIENT INFORMATION INSURANCE INFORMATION Patient Name: : Address: Birthdate: Responsible for this account: Relationship to Patient: Insurance Co.: Group #: ID #: SS Number: Sex: M F Age: Employer/School:
I acknowledge that upon my request I will be provided with a copy of
THE CENTRAL ORTHOPEDIC GROUP, LLP DOCTOR LOCATION: PLV / RVC / MASS DATE: PATIENT NAME: ACCOUNT # CONSENT TO TREAT: CONSENT INFORMATION The information I have given to the Central Orthopedic Group is complete
4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB):
PATIENT CASE HISTORY
Family Chiropractic Center of Santa Fe 2019 Galisteo St. Suite M6 Santa Fe, NM 87505 505-984-0006 www.spchiro.net PATIENT CASE HISTORY Name: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell
MICHAEL K. BLOCK, DPM, LLC PATIENT FINANCIAL POLICY
MICHAEL K. BLOCK, DPM, LLC PATIENT FINANCIAL POLICY Dear Patient, Thank you for choosing Michael K. Block, DPM, LLC for your podiatric needs. We value our relationship with you and would like to tell you
City: State: Zip: Home ( ) Cell ( ) Work ( ) Who Referred You? Phone ( ) Address: City: State: Zip:
Today s : First Name: M.I. Last Name: Address: City: State: Zip: Apt Home ( ) Cell ( ) Work ( ) Email: of Birth: Marital Status: S M D W Sex: F / M Social Security # - - Who Referred You? Phone ( ) Address:
Patient Registration. D. INSURANCE (if applicable)
A. PATIENT Please Print Legibly Account #: Address: City: State: Zip: Preferred Contact Method: Home Phone Work Phone Cell Phone Patient Registration DOB: SSN #: Gender: Male Female E-MAIL: Check here
Phone: (512) Fax: (512)
Phone: (512) 732 2774 Fax: (512) 329 6871 NEW PATIENT INFORMATION Patient Name DOB Age SSN Today s Date Gender Single Married Widowed Divorced Address/City/State/Zip Email: Cell phone Occupation (if minor,
Welcome to Phillips Family Chiropractic
Welcome to Phillips Family Chiropractic Name: Age: DOB: / / SS# / / Address: City: State: Zip Code: Phone: ( ) - Employer: Occupation: Circle One: Single / Married Number of Children: Email: Spouse: Employer:
Joint Effort Rehab, LLC
Patient Information DEMOGRAPHICS Joint Effort Rehab, LLC New Patient Forms First Name: MI: Last Name: Sex: M F Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: *Email SSN#: of Birth: *By
Insured s Name: (Last) (First) (Init) Relation to patient: D.O.B.: Soc. Sec. #: Insurance Company: ID#:
Frank E. Kaden, D.C. Chiropractic, Inc. 1035 Aviation Blvd., Hermosa Beach, CA 90254 Office: (310) 937-2323 Facsimile: (310) 937-3399 www.kadenchiropractic.com PERSONAL INJURY / ACCIDENT MEDICAL HISTORY
Informed Consent for Physical Therapy Services
Informed Consent for Physical Therapy Services The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis, and intervention by use of rehabilitative
REASON FOR TODAYS VISIT Is this injury / condition related to your..
DATE: PATIENT INFORMATION Patient Name: First Middle Last Male Female Address: City: State: Zip: Home phone: Cell: Date of Birth: Marital Status: married single other Soc Sec #: Drivers Lic. # Email Address:
Corona-Temecula Orthopaedic Associates P H Y S I C A L T H E R A P Y A N D W E L L N E S S C E N T E R
PATIENT QUESTIONNAIRE Please fill out this form COMPLETELY using your LEGAL name. Do not leave any blanks. FAMILY PHYSICIAN (First Name, Last Name) PATIENT INFORMATION DATE TO SEE DOCTOR (Name) / / PATIENT
Address. City/State/Zip. Marital Status: S M D W Sex: M F Date of Birth / / Age. Primary Phone Secondary Phone. Employer PARENT/GUARDIAN
PATIENT INFORMATION First Name M.I Last Name Address City/State/Zip SSN.#_ Marital Status: S M D W Sex: M F of Birth / / Age Primary Phone Secondary Phone Employer Email PARENT/GUARDIAN Name of Birth /
Other Scan(s): List All Your Medical Diagnosis: Chemotherapy? YES NO If yes, please list treatment regimen:
Patient Name: Today s Date: Preferred Language: Date of Birth: Age: SSN: Race: Ethnicity: Home Phone: Cell Phone: Work Phone: Best contact phone number should we need to reach you about your treatment:
Name SS# Date of birth / / Gender Ethnicity. Mailing Address City/State ZIP. Marital Status Spouse Name. Phone# Cell# Work#
PATIENT INFORMATION (Please print clearly) Today s date / / Name SS# of birth / / Gender Ethnicity Mailing Address City/State ZIP Marital Status Spouse Name Phone# Cell# Work# EMERGENCY CONTACT PERSON
Orange County Doctors of Physical Therapy Inc Valley View Street Garden Grove, Ca Tel: (714) Fax: (714)
Orange County Doctors of Physical Therapy Inc. 12558 Valley View Street Garden Grove, Ca 92845 Tel: (714) 901-7800 Fax: (714) 901-2300 INFORMATION FOR CASE HISTORY FILE Patient s Name Last First M.I. Home
STEVENS FAMILY CHIROPRACTIC METROPOLIS AVE, SUITE 101 FT MYERS, FL (239) Patient Intake Form. Sex: Male Female.
Patient Intake Form : Name: Sex: Male Female Address: City: State: Zip: Home Phone: Cell Phone: Preferred Phone: Email Address: Social Security #: Of Birth: Occupation: Marital Status: Single Married Divorced
PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Last Name First Name Address City, State, Zip Email Address Home Phone Work Phone Cell Phone SS# Date of Birth Age Sex ( ) Male ( ) Female Marital Status (check one):