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Autocase Injury
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WHAT TO EXPECT
SERVICES
FAQ
CONTACT US
Auto Case Injury
Patient Information
Patient’s Last Name
Patient’s First Name
Date
Address
City
Postal Code
Home Phone
Cell Phone
Email
*
Social Security No
Employer Name
Job Title
Work Phone No
Date of Birth Patient
Age
Gender
Handedness?
Weight
Height
Marital Status
Spouse’s Name
Spouse’s Date of Birth
Person responsible for this account
Health Insurance Information
Health Insurance Company
Phone number
*
Policy/Member ID No
Group No
Company Address
Company City
Zip Code
Car Company Adjuster
Phone #
Name of the insurance card holder
Social Security # of card holder
Name of their employer
Employer Phone No
Children names and ages
Car Insurance Information
Car Insurance Company
Adjuster...
Phone no:
Agent
Agent Phone
Policy
Claim No
Drivers License No
Name of Insured on your Car Policy
Date of Loss/Accident?
Medical Coverage?
Uninsured Motorist Coverage?
Underinsured Motorist Coverage?
Personal Injury Protection (PIP)
Medical expenses to date as a result of the accident?
Lost wages since accident
What is the repair amount of your car?
Lawyer/ Law Firm
Phone Num..
In case of emergency, whom should we contact?
Family physician
Phone number..
Date you first saw any Doctor after accident
Is this Workman’s Compensation?
Is this Personal Injury?
Have you received any medical treatment since your accident?
Hospital
Hospital Cost
Medical Doctor
Medical Doctor Cost
Chiropractor_
Chiropractor Cost
Other Cost
ACCIDENT QUESTIONNAIRE
Accident Patient’s Name
Date of incident
Today’s Date
DESCRIBE YOUR VEHICLE
Vehicle Type
Make
Year
Model
Estimated Speed:
Actions of patient’s vehicle
Vehicle Size
How was the patient’s vehicle hit
Damage to patient’s vehicle
Describe the second vehicle
Damage to the other vehicle?
Weather Conditions
Road Conditions
DESCRIBE THE MOMENT OF IMPACT
Body position at time of impact
Direction body was thrown
Head position at impact
Direction head was thrown
Type of restraint
Place patient was seated in the vehicle
Did Airbags deploy
Were you seen at a Medical Facility following your accident
SYMPTOMS
CIRCLE ALL YOU COMPLIANTS
DO YOU HAVE LACERATIONS, CUTS OR BRUISING?
HEAD INJURIES: (now or at the time of the accident)
JAW PROBLEMS
NECK INJURIES
SHOULDER INJURIES
HAND PAIN CONDITION
MID BACK PAIN OR UPPER BACK PAIN
LOW BACK PAIN
PELVIC OR SACRAL PAIN
HIP PAIN CONDITION
UPPER LEG PAIN CONDITION
KNEE PAIN CONDITION
ANKLE PAIN CONDITION
FOOT PAIN
CHEST PAIN
STOMACH PAIN
OTHER SYMPTOMS
Ready to Begin Your Healing Journey?
Start with a consultation and get the answers your brain and body need.
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