VEHICLE ACCIDENT INFORMATION

PATIENT INFORMATION

Patient:

Date:

Address:

City:

State:

Zip:

Phone:

Email address

Date of Birth:

Employer:

How were you referred:

Do you have an attorney:

Yes No

Name:

Phone:

Date of Accident:

Claim Number:

Who's at Fault:

Name of Insurance Company:

Name of Adjuster:

Phone Number of Adjuster:

Fax Number of Adjuster:

I hereby instruct

Insurance Co. to pay by check made out to and mailed to:
Center of Gravity
Chiropractic & Rehabilitation Clinic
607 Park Grove, Ste B
Katy, TX 77450

If my current policy prohibits direct payment to doctor, then I also hereby instruct and direct you to make out the check and mail it to the doctor as follows:
Center of Gravity
Chiropractic & Rehabilitation Clinic
607 Park Grove, Ste B
Katy, TX 77450

For the medical expense benefits allowable under my health or PIP, and otherwise payable to me under my current insurance policy as payment toward the total charges for all services rendered. This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance for all service charges over and above this insurance payment.

A PHOTOCOPY OF THIS ASSIGNMENT SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL.

I also authorize the release of any information pertinent to my case to you as the insurance company and /or attorney.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Date:

Signature of Policyholder

Signature of Claimant, if other than policyholder

VEHICLE ACCIDENT INFORMATION

PATIENT INFORMATION

Patient:

Date:

Date of Accident:

Time of Accident:

Please describe the accident in your own words:

Where were you in the car before the accident occurred?

How many people were in your vehicle?

ACCIDENT INFORMATION

Road/Street Name:

City:

State:

Nearest intersection with road/street:

Driving conditions:

Dry Wet Icy Other

If other, specify:

Which direction were you headed?

Speed you were traveling:

m.p.h.

VEHICLE

Make & model of vehicle you were in:

Were you wearing a seatbelt

Yes No

Lap

Shoulder

Was vehicle equipped with airbags?

Yes No

Did they properly inflate?

Yes No

Did your seat have a headrest?

Yes No

What position?

Low Mid-position High

IMPACT

Did your car impact another vehicle?

Yes No

Or a structure

Yes No

If yes, please explain:

Did any part of your body strike anything in the vehicle?

Yes No

If yes, please explain:

Was impact from:

Front

Rear

Left

Right

Other

Were both hands on the steering wheel?

Yes No

If no, which hand?

Left Right

Was your foot on the brake?

Yes No

If yes, which foot was on the brake?

Left Right

Were you:

Surpirsed by impact Braced for impact

POLICE

Did the police come to the accident site

Yes No

Were there any witnesses?

Yes No

Was a police report filed?

Yes No

Was a traffic violation issued?

Yes No

If yes, to whom?

PATIENT CONDITION

Were you unconscious immediately after the accident?

Yes No

If yes, for how long?

Describe how you felt immediately after the accident:

Did you go to the hospital?

Yes No

Name of hospital:

Name of doctor:

Diagnosis:

Treatment received:

X-rays taken:

SYMPTOMS / INJURIES

Have you been able to work since this injury?

Yes No

How many work days have you missed?

Prior to the injury were you able to work on an equal basis with others your age?

Yes No

Is this condition getting progressively worse?

Yes No Unknown

Please indicate as precisely as possible where you continue to experience pain, numbness, or tingling:

Add new row

If other, specify:

How often do you have this pain?

Is it constant or does it come and go?

Does it interfere with your:

Work

Sleep

Daily Routine

Recreation

Movements that are painful to perform:

Sitting

Bending

Standing

Lying down

Walking

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient, Parent, Guardian or Personal Representative

Date:

Please Print Name of Patient, Parent, Guardian or Personal Representative

Informed Consent

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable. I will be responsible for any costs of collection, attorney's fees or court costs required to collect my bill.

I hereby authorize physicians and staff at CENTER OF GRAVITY to treat my condition as deemed appropriate. It is understood and agreed the amount paid the doctor for X-rays, is for examination only and the X-ray negatives will remain the property of this office, being on file where they may be seen at any time. The doctor will not be held responsible for any pre-existing medically diagnosed conditions.

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any staff member of CENTER OF GRAVITY Chiropractic office responsible for any errors or omissions that I may have made in the completion ofthis form.

Chiropractic, as well as many other types of health care, is associated with potential risks in the delivery of treatment. Therefore it is necessary to inform the patient of such risks prior to initiating care.While chiropractic treatment is remarkably safe,you need to be informed about the potential risks related to your care to allow you to be fully informed before consenting to treatment.

Chiropractic is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition or disease as a result of treatment in this office. An attempt to provide you with the very best care is our goal and if the results are not acceptable, we will refer you to another provider who we feel can further assist you.

Specific Risk Possibilities Associated with Chiropractic Care.
Soreness- Chiropractic adjustments and physical therapy procedures are sometimes accompanied by post treatment soreness. This is a normal and acceptable accompanying response to chiropractic care and physical therapy. While it is not generally dangerous, please advise your doctor if you experience soreness or discomfort.

Soft Tissue Injury- Occasionally chiropractic treatment may aggravate a disc injury, or cause other minor joint, ligament, tendon or other soft tissue injury.

Rib Injury- Manual adjustments to the thoracic spine, in rare cases, may cause rib injury or fracture. Precautions such as pre-adjustment xrays are taken for cases considered at risk. Treatment is performed carefully to minimize such risk.

Physical Therapy Burns- Heat generated by physical therapy modalities may cause minor burns to the skin. These are rare, but if it occurs you should report it to your doctor, or a staff member at.

Stroke- Stroke is the most serious complication of chiropractic treatment. The most recent studies (Journal of the CAA, Vol. 37 No. 2, June, 1993) estimate that the incidence of this type of stroke is 1 in every 3 million upper cervical adjustments.

Other Problems- There are occasionally other types of side effects associated with chiropractic care care. While these are rare, they should be reported to your doctor promptly.

If you have any questions concerning this form or the above statements, please ask your doctor.

Having carefully read the above, I hereby give my informed consent to have chiropractic treatment administered.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date:

Parent/Legal Guardian Signature:

Date:

Your information will be encrypted.