Motor Vehicle Accident Intake Form

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1 2100 SE Lake Rd Ste 1 Milwaukie OR Motor Vehicle Accident Intake Form Today's Date: About You Name: Gender: Male Female Address: City: State: Zip: Home Number: Work Number: Other Number: Address: Date of Birth(MM/DD/YYYY) Age: Marital Status: Single Married Other If married please provide spouses name: If Patient Is a Minor, Name of Parent(s): Primary Care Physician: Emergency Contact Name: Relationship to Patient: Contact Number: Insurance Information Auto Insurance Company: Insurance Co. Phone #: Claim #: Claims Adjuster: Insurance Co. Address: Have you retained an attorney? Yes No Attorney Name: Attorney Phone #: How Did You Hear About Us? (please check all that apply) Google Yelp Bing CitySearch Facebook Chamber of Commerce Walk/drive by Chicks Connect Referred by: Insurance Website: Local Event: Other:

2 2100 SE Lake Rd Ste 1 Milwaukie OR Patient Name: Today' Date: Automobile Accident History Date of accident: Time: AM PM Driver of vehicle: Where were you seated? Vehicle s owner: Year and model of vehicle you were in: Year and model of the other vehicle(s) in collision: Number of vehicles in collision: Other: Number of people in your vehicle: Where did the accident occur? Visibility at the time of the accident: Poor Fair Good Road Conditions at the time of the accident: Icy Rainy Wet Clear Dark Other: Your vehicle: Hit another vehicle -or- Was hit in the: Right side Left side Rear Front Type of accident: Head-on collision Broad-side collision Rear-end collision Single vehicle collision Front-impact, rear-ended vehicle in front Other (explain): Were the internal vehicle parts broken? Yes No If yes, what: Windshield Right passenger window Left passenger window Steering wheel Front seat back Rear view mirror Other: Impact / Seat Belt/ Head Rest / Head / Body Position Describe in your own words what happened to you upon impact: Yes No Did you see the accident coming? Yes No Did you brace for impact? Yes No Did you have your hands on the steering wheel at impact? Head/Body position at the time of impact: Head: Straight Turned right Turned left Body: Straight Turned right Turned left At the time of the accident, what parts of your head/body hit what parts of the inside of the vehicle: Yes No Were you wearing glasses, a hat, or dentures? Where were they after the accident? Yes No Were seat belts worn? Yes No Were shoulder harnesses worn? Yes No Does your vehicle have air bags? One Two Other Yes No Did your airbags release? One Both Other Yes No Does your vehicle have headrests? If yes, what was its position compared to your head before the crash? Top of headrest even with: Middle of neck Top of head Bottom of head Yes No Was your vehicle moving at the time of the accident? Slowing down Speeding up Constant What was the speed limit on the road you were traveling? Mph Ability to Move Body Where were you in the vehicle prior to the accident? After the accident? As a result of the accident, were you: Rendered unconscious Dazed, situation vague Shaken up but could function Yes No Could you move all parts of your body? If no, what parts and why not? Yes No Were you able to get out of the vehicle? If no, why not?

3 2100 SE Lake Rd Ste 1 Milwaukie OR Patient Name: Today' Date: Symptoms from Accident Yes No Did you receive any bruises from the seat belts? If so, where? Yes No Did you receive any other bleeding cuts or bruises? If cut, where? If bruises, where? Please describe how you felt. PLEASE BE SPECIFIC Immediately after the accident: Later that Day Night: The next day(s): General Systems Update Check symptoms that have become apparent since the accident/injury: Nervousness Face flushed Shortness of breath Cold feet Fainting Neck pain/stiffness Ringing/buzzing ears Head seems too heavy Chest pain Anxiety Midback pain Loss of balance Irritability Constipation Seizures Low back pain Loss of smell Depression Diarrhea Visual disturbances Eyes sensitive to light Loss of taste Sleeping trouble Fatigue Forgetfulness Pain behind eyes Loss of memory Toe numbness Tension Blurred vision Dizziness Pins & needles - arms Finger numbness Fever Double vision Cold sweats Pins & needles - legs Cold hands Headache Confused/Disoriented Other: First Doctor/Hospital/Clinic Yes No Did you seek medical help immediately after the accident? If yes, how did you get there? Someone else drove me Drove own vehicle Police Ambulance Doctor/Hospital/Clinic: Date of first visit: Yes No Were you examined? Yes No Were x-rays taken? What diagnosis did the doctor give you?: Yes No Were you given treatment? If so, what type? What benefits did you receive from treatment? Date of last treatment: Yes No Did the doctor refer you to another health professional? If yes, to who and for what? Yes No Did you follow the recommendation? If no, why not? Second Doctor/Clinic Doctor/Clinic: Date of first visit: Yes No Were you examined? Yes No Were x-rays taken? Yes No Were you given treatment? If yes, what type? What benefits did you receive from treatment? Date of last treatment:

4 2100 SE Lake Rd Ste 1 Milwaukie OR Patient Name: Today' Date: Work Status History Occupation: Employer: Yes No Have you missed time from work? If no, who told you to return?: If yes, Off work full-time Dates: Off work part-time Dates: Unable to return to work since the accident. What type of physical activity is required at work: Yes No Is there alternative work available? Prior Similar Symptoms Yes No Did you have any physical complications just before the accident? If yes, please describe in detail: Yes No Prior to this accident, have you had any similar symptoms? If yes, please explain (falls, injuries, etc.): Yes No Have you been in accidents prior to this one? If yes, when Where? How was it treated? Result of being treated: Yes No Are you now being treated? Yes No Do you have any congenital (birth) factors that relate to this problem? If yes, please describe:

5 Doctor s Lien and Assignment of Right to Recovery 2100 SE Lake Rd Ste 1 Milwaukie OR I do hereby authorize Milwaukie Spine and Sport, LLC to furnish you, my attorney and/or insurance carrier, with information regarding the accident in which I was involved. I understand that I am directly responsible to Milwaukie Spine and Sport, LLC for any and all bills submitted for services. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. In consideration of not having to immediately pay debt, I hereby assign and convey to Milwaukie Spine and Sport, LLC a legal and equitable interest in any and all causes of action of rights of recovery. I also understand that a nine percent interest charge will be accrued to any balance held over ninety days until my balance is zero. I hereby authorize my attorney, and insurance company to pay directly to Milwaukie Spine and Sport, LLC, that which is owing for professional services as a result of this accident and by reason of any other bills that are due to Milwaukie Spine and Sport, LLC including attorney fees. These are to be withheld from any settlement or judgment I hereby further give a lien on my case to Milwaukie Spine and Sport, LLC against any and all proceeds of my settlement, judgment or verdict which may be paid to you as result of the injuries for which I have been treated. I further instruct a separate check to be issued to Milwaukie Spine and Sport, LLC for services rendered. I have read this document, I understand it, and I voluntarily agree to be bound by it. I am directing my attorney to protect Milwaukie Spine and Sport, LLC interest as provided herein. Patient Name (PRINT) Patient Signature Date 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 adequately to protect the said doctor named above. Attorney Name (PRINT) Attorney Signature Date

6 Patient Privacy Notice 2100 SE Lake Rd Ste 1 Milwaukie OR HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION We are required by law to have your written consent before we use or disclose to others your medical information for purposes of providing or arranging for your health care, the payment for or reimbursement of the care that we provide to you and, the related administrative activities supporting your treatment. We may be required or permitted by certain laws to use and disclose your medical information for other purposes without your consent or authorization. As our patient, you have important rights relating to inspecting and copying your medical information that we maintain; amending or correcting that information. We have available a detailed Notice of Privacy Practices handout at the front desk if you would like further details. I hereby authorize Milwaukie Spine and Sport, LLC to make use and disclosure of my protected health information (information in my medical and/or financial records) as indicated below. Patient's Name: Date: Signature of Patient or Guardian: RECORDS RELEASE I hereby give consent to Milwaukie Spine and Sport, LLC to access information concerning my selected records. Financial/ Insurance Medical Other (specify) Signature of Patient: Date: Group Practice Privacy Notice Milwaukie Spine and Sport, LLC is a multi-practitioner office, and on occasion, your treatment may be provided by another doctor due to illness, vacation, time conflict, etc. In order to provide the best care to patients, it may be necessary to discuss health information in a private setting (away from other patients) in order to update other practitioners in the office of a patient's status. By signing this form you acknowledge that you have been made aware and accept that your health information may be discussed among the practitioners. PATIENT SIGNATURE: DATE: SIGNATURE OF PARENT OR GUARDIAN:

7 Consent for Treatment 2100 SE Lake Rd Ste 1 Milwaukie OR I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy, on me (or on the client named below, for whom I am legally responsible) by the doctors of chiropractic and at Milwaukie Spine and Sport, LLC and/or other licensed doctors of chiropractic who now, or in the future, treat me while employed by, working or associated with or serving as back-up for the chiropractic physicians of Milwaukie Spine and Sport, LLC. I have had an opportunity to discuss with the doctor of chiropractic, and/or with other office or clinic personnel at Milwaukei Spine and Sport, LLC the nature and purpose of chiropractic adjustments and procedures. I understand and am informed that, as with all healthcare treatments, results are not guaranteed. I further understand and I am informed that, as is with all healthcare treatments, in the practice of chiropractic there are some risks to treatment, including but not limited to, muscle spasms for short periods of time, aggravating and/or temporary increase in symptoms, lack of improvement in symptoms, 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 I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctors feels at the time, based upon the facts then known, is in my best interest. 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's Name: Date: Signature of Patient or Guardian: Consent for Treatment of a Minor I (we) being the parent or guardian of,a minor, the age of do hereby consent, authorize and request Dr. to administer such treatment deemed advisable, necessary or requested on the above minor. Guardian s Signature: Date:

8 Financial Policy 2100 SE Lake Rd Ste 1 Milwaukie OR Responsibility for Payment: We consider the patient to be responsible for payment of services. In cases where the patient is a minor, the parent that the child is living with is responsible for payment. 2. Insurance Billing: As a courtesy to you, we will bill your primary insurance company provided that the pertinent identification numbers are provided. It is the patient s responsibility to inform our office of ANY insurance changes. 3. Auto Insurance: If patient is involved in an automobile accident, the responsible party is the insured automobile the patient was in at the time of the accident. The patient is required by this office to fill out and sign all lien agreements. 4. Major Medical Insurance: Please see the following regarding major medical insurance: If your annual insurance deductible has not yet been met, payment is expected at the time of service. Insurance is considered to be a private contract between the patient and insurance company: it is the patient s responsibility to resolve any difficulties with claims processing directly with the insurance company. We will call for benefits, but there is NO GUARANTEE OF BENEFITS. 5. Workers Compensation: If an injured worker has completed the appropriate forms in our office, we will bill his/her industrial accident insurance. 6. All Insurance Claims: Any amount not covered by major medical insurance, auto insurance, workers compensation insurance is the FULL RESPONSIBILITY of the patient or patient s guardian. 7. Supplements, supports, etc: All supplements and other supplies must be paid for at the time they are received. I,, have read this financial policy and understand its content. Signature of Patient/Guardian: Date:

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