CA - Slip and Fall Accident History

SLIP AND FALL ACCIDENT HISTORY
Patient Name:*

First NameLast Name
Email:*
example@example.com
Phone Number:*
Format: (000) 000-0000.
Accident Information
Date of accident:*

MonthDayYear
Date
Time of accident (approximately):*

Hour Minutes

AM/PM Option
Location of accident:*
Description of injury:*
YesNo
How did you get to the medical facility?*
Name of hospital/facility*
YesNo
What body parts did they X-ray/MRI/CT?*
YesNo
Date admitted:*

MonthDayYear
Date
Date discharged:*

MonthDayYear
Date
Describe the accident in your own words:*
What were the conditions that caused your accident? (objects, weather, ice/water, etc.)*
What caused the obstacle or condition (a water leak, broken bottle, raised cement, etc.)?*
Were you carrying anything in your hands at the time of your fall?*
How did you land?*
Did anything fall on you?*
YesNo
YesNo
Where are the cuts/bruises?*
YesNo
How long did you lose consciousness?*
YesNo
Explain your physical complaints BEFORE this accident:*
YesNo
What congenital (from birth) factors are related to this problem?*
YesNo
Explain what activity restrictions were caused by this accident:*
Ankle/foot painBruises/cuts/scrapesChest painCold feetCold handsCold SweatsConstipationDepressionDiarrheaDigestive issuesDizziness/balance offEars buzzingEars ringingElbow painFace flushedFaintingFatigueFeverHead seems too heavyHeadachesHeartburnIrritabilityLight sensitivityLoss of smellLoss of tasteLow back painNeck painNervousnessNumbness in fingersNumbness in toesPins/needles in armsPins/needles in legsScarsShortness of breathShoulder painStiff neckStomach upsetTensionUpper back painWrist/Hand pain
Current Complaints
Circle the areas where you have pain:
Constant 100%Frequent 75%Intermittent 50%Occasional 25%
What makes symptoms worse?*
What gives relief of symptoms?*
SharpDullAcheBurnThrobNumbOther
Describe type of pain:*
YesNo
What type of doctor(s) have you seen?*
YesNo
List medications you are currently taking:*
YesNo
AutoWorkSlip and FallLeisureSportsOther
Describe prior accident/injury/slip and fall:*
When was the prior accident/injury/slip and fall?*

MonthDayYear
Date
Insurance Information

Please provide your health insurance information below. We will also need to make a copy of the front and back of your insurance card, even if you are going through an attorney.
Insurance Company (Aetna, Anthem, etc):
Subscriber/Member ID Number:
Provider phone number from back of card:
YesNo
Name of Company:
Adjuster Name:
Phone Number:
Format: (000) 000-0000.
Claim Number:
YesNo
Attorney Name:
Attorney Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attorney Phone Number:
Format: (000) 000-0000.
Notice of Doctor’s Lien
Patient Name*

First NameLast Name
Date of Accident*

MonthDayYear
Date
I do hereby authorize Elite Sports Medicine to furnish you, my attorney, with a full report of examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was recently involved.

I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as may be due and owing him for the medical service rendered me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect and fully compensate said doctor. And I hereby further give a Lien on my case to said doctor against any and all proceeds of my settlement, judgment, or verdict which may be paid to you, my attorney, or myself; as the result of the injuries for which I have been treated or injuries in connection therewith.

I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered me and that this agreement is made solely for said doctor’s additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment, or verdict by which I may eventually recover said fee.

This lien supersedes any type of pre-paid health insurance plan, which we may contract with. The balance due after payments from your insurance company must be paid from sums collected from any settlement, judgment, or verdict, which may be paid to you.

A holder of this medical debt contract is prohibited by section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding a debt to a consumer credit reporting agency, the debt shall be void and unenforceable.

A photocopy of this lien will be considered as valid as the original. This lien is irrevocable and binding to any subsequent Attorney retained by the patient.
Date*

MonthDayYear
Date
Patient’s or Guardian’s Signature*
Please note: According to California law, it is unlawful to knowingly make a false or fraudulent claim. *Por favor note: de acuerdo con la ley de California, es illegal hacer reclamo falso o fraudulento.

The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict, as may be necessary to adequately protect and fully compensate said doctor above-named.
Dated _______________________________

Attorney Signature __________________________________________________
Please verify that you are human*
Should be Empty:

SLIP AND FALL ACCIDENT HISTORY

Accident Information

Current Complaints

Insurance Information

Notice of Doctor’s Lien