Auto Accident Information
How did you hear about us?
Street Address Line 2
State / Province
Postal / Zip Code
Your Motor Vehicle Insurance Information
Your Car Insurance Company
3rd Party Car Insurance Company (other person-if any)
Automobile Accident Details
Date of Accident/Injury
Date Picker Icon
Street Address Line 2
District of Columbia
Police report number (if any)
Describe the Road conditions (dry, wet, icy, etc.)
Describe the Visibility? (clear, overcast, dark, etc.)
Describe your position inside the vehicle (Driver, front seat passenger, backseat passenger, etc.)
Describe the Vehicle you were in (Make, coupe, sedan, truck, minivan, van, SUV, etc.)
Describe the vehicle you were struck by (Make, coupe, sedan, truck, minivan, SUV etc.)
Describe what happened to your Vehicle was (rear ended, hit head on collision, sideswiped, hit from the side impact, etc.)
Position of your vehicle at the time of the accident (stopped at the intersection, driving posted speed, slowing to a stop, etc.)
Approximate Speed of your vehicle at the time of the accident (0 mph, 10 mph, 50 mph, etc.)
Approximate Speed of the other vehicle at the time of the accident (0 mph, 10 mph, 50 mph, etc.)
Did the airbags deploy?
Damage to your vehicle
Damage to the other vehicle
Position of headrest
Was your seatbelt on?
Describe Your position inside the vehicle at the time of the accident (sitting straight, turned to the right, turned to the left, etc.)
Did any part of your body strike anything inside the vehicle? (Head hit steering wheel, elbow hit the door, etc.)
If Yes to above, please list the hospital and/or all doctors you have seen for this condition
Were you treated for this condition at the hospital or by another doctor?
Was your vehicle drivable after the accident?
How did you leave the scene of the accident? (driven by self, driven by a family member, Uber, taxi cab, etc?)
HISTORY OF PRESENT ILLNESS
Has your condition
Remained the same
My condition interferes with
My daily routine
Tell Us About Your Pain
Use the corresponding numbers on the diagram to indicate where your pain is. Use the sliders to rate the severity of your pain on a scale of 1-10 with 10 being the most severe.
2 (right shoulder pain)
3 (left shoulder pain)
4 (right elbow pain)
5 (left elbow pain)
6 (right wrist pain)
7 (left wrist pain)
8 (right hip pain)
9 (left hip pain)
10 (right knee pain)
11 (left knee pain)
12 (right ankle pain)
13 (left ankle pain)
14 (right foot pain)
15 (left foot pain)
16 (neck pain)
17 (shooting pain into left arm)
18 (shooting pain into right arm
19 (mid back pain
20 (low back pain)
21 (shooting pain into left leg)
22 (shooting pain into right leg)
Past Medical History
Please select all that you have or have had in the past.
Please check all that you have or have had in the past.
High Blood Pressure
Irregular Heart Beat
Loss of Memory
Loss of Balance
Shortness of Breath
Foot / Ankle Pain
Numbness & Tingling
Anorexia / Bulemia
Ringing in Ears
Please tell us about any surgeries you have had in the past. Please include dates with each procedure.
Please list all medications that you are currently taking
Please list any medical allergies you have.
Rate your daily level of stress on a scale of 0 - 10.
Activities of Daily Living
How does this condition interfere with your life and ability to function.
Rising out of chair
Getting in and out of a car
Driving a car
INFORMED CONSENT TO CHIROPRACTIC CARE AND TREATMENT: I hereby consent to the performance of the chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy, massage therapy and diagnostic x-rays, on me (or on the patient named below, for whom I am legally responsible) by the Doctor of Chiropractic and/ or other licensed Doctor of Chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for the Doctor of Chiropractic at Britton Chiropractic, including those working at the clinic or office listed below or any other officer or clinic. I have had an opportunity to discuss with the Doctor of Chiropractic and with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures.I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to, fractures, disc injuries, strokes, dislocations, and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and wish to rely on the doctor to exercise judgment during the course of the procedure which to doctor feels at the time. Based upon the facts then known, is in my best interests.I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Patient Signature
HIPPA COMPLIANCE LAW: I am aware of the(HIPPA Compliance Law) which is a federal law protecting the privacy of the patient-specific health care information and providing the patient with control over how this information is used and distributed. I AGREE TO ABOVE Patient Signature
FINANCIAL AGREEMENT, ASSIGNMENT OF BENEFITS, AUTHORIZATION TO RELEASE INFORMATION :FINANCIAL AGREEMENT: Financial Responsibility All professional services rendered are charged to the patient and are due at the time of service, unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments. ASSIGNMENT OF BENEFITS: I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health/medical plan, to issue payment check(s) directly to BRITTON CHIROPRACTIC for services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance. AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize BRITTON CHIROPRACTIC to: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of lifetime. This order will remain in effect until revoked by me in writing. I have requested medical services from BRITTON CHIROPRACTIC on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized. I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original. I AGREE TO ABOVE Patient Signature
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