Intake Form
General Information:
Intake Date
/
Month
/
Day
Year
Date
Name
Date of Birth
/
Month
/
Day
Year
Date
Address
Address (at time of accident)
Telephone Number
Format: (000) 000-0000.
Email Address
example@example.com
Social Security Number
Driver’s License Number
Accident Information:
Date of Accident
/
Month
/
Day
Year
Date
Location of Accident
Location of Accident
Type of Accident MVA, Pedestrian, etc
Did EMS Transport You to the Hospital?
Description of Accident:
Driver of Vehicle
Owner of Vehicle
Passengers in Vehicle
Police Report Number
Police Department
Other Information
Insurance Information:
Automobile Insurance Carrier
Auto Insurance Policy Holder
Policy #
Claim #
Adjuster Information
If no auto insurance, resident relative information
Prior Motor Vehicle Accidents
Prior Auto Claims
Health Insurance Carrier
Policy #
Group #
Medical Information:
Injuries:
Treatment Received Thus Far:
Physical Limitations:
Household Services/Attendant Care?
Hospitals
Current Treating Facilities
Treating Doctors
Primary Care Physician
Prior Medical Problems
Prior Treating Hospitals
Employment Information:
Place of Employment (at time of accident)
Employer’s Address
Dates Employed
/
Month
/
Day
Year
Date
Rate of Pay
Title and Duties
Dates Off Work Due to Accident Related Injuries
/
Month
/
Day
Year
Date
Did a Doctor Advise To Stay Home?
Other Information:
Other Information
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