• SUPPLEMENTAL HISTORY: AUTO ACCIDENT

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  • Were you the:
  • Were you wearing a seat belt?
  • How many vehicles were involved in the accident?
  • How many people were in your vehicle?
  • What direction were you headed?
  • Type of accident:
  • Speed: Was your vehicle:
  • Speed: Was the other vehicle:
  • Visibility at the time of the accident:
  • Were you aware the accident was going to happen before impact?
  • Did you brace yourself before impact?
  • Head position at the time of impact?
  • Body position at the time of impact?
  • Could you move all your body parts after the accident?
  • As a result of the accident were you:
  • Have you suffered from memory loss since the accident?
  • Were you hospitalized?
  • Have you been treated by a physician?
  • Are you still being treated?

  • Describe how you felt:

  • Rows
  • Before the accident did you have any of your present complaints?
  • Have you lost time from work as a result of this accident?

  • Insurance companies involved:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have Med-Pay coverage?
  • Format: (000) 000-0000.
  • Have you retained an attorney?
  • Format: (000) 000-0000.

  • Assignment Of Benefits

    By signing this form you authorize your insurance company to make payments directly to this clinic; however, you are ultimately responsible for payment. If your insurance company sends checks to you, you are legally obligated to bring them to us.

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  • Should be Empty: