top of page

CAR ACCIDENT
INTAKE FORM

BACKGROUND INFO

Address
Date of birth
Month
Day
Year
Time of the accident
Time
HoursMinutes
Working at the time?
Yes
No
If yes, making a comp claim?
Yes
No
Single choice
Driver
Passenger
Pedestrian

TREATMENT

Ambulance?
Yes
No
Emergency room?
Yes
No

INJURIES

FOLLOW UP TREATMENT



to

Losing time from work?
Yes
No

VEHICLE YOU WERE IN

Are you a licensed driver?
Yes
No
Do you have auto insurance?
Yes
No

OTHER VEHICLE

Do you have information on other car involved?
Yes
No

Describe property damage:

Photos of your vehicle?
Yes
No
Is your car drivable?
Yes
No
bottom of page