_________________________PLEASE COMPLETE INFORMATION BELOW______________________
** Injury Due to: (please circle) School Sports: Yes / No Recreational Sport:
Yes / No Altercation: Yes / No Work-comp: Yes / No Automobile: Yes / No State
of Auto Accident: ________
Injury due to something other than listed above: ________________________________________________________________
Please fill out Other Party information completely especially if a Third Party
Insurance will be involved.
Patient Name: ______________________________ DOB:________________ Doctor: _____________________
Current Address: ______________________________________________________________________________________
Current Home Phone: ____________________________ Current Work Phone: _________________________
** Date of Injury: ________________________________ Time of Injury: ______________________________
Address Where Injury Happened: _______________________________________________________________________
How Did the Injury Happen: ___________________________________________________________________________
What was Injured: ____________________________________________________________________________________
Chief Complaint: _____________________________________________________________________________________
Was a Police Report Filed Yes / No Do you plan on filing charges Yes / No
Police Case Number: _______________________________
Did you go to the ER?: Yes / No Are there Films: Yes / No Are there Medical
Records: Yes / No
Does the patient have personal health insurance: Yes / No Please Present Card
to Receptionist
Insurance Company Name: ________________________________ Phone Number: ____________________________
Policy Number: __________________________________________ Claim Number: ____________________________
Mail Bills To (If other than yourself): ____________________________________________________________________
____________________________________________________________________
If you are here due to a WORK-COMP injury please fill out Employer and Other
Party information completely.
Patients Employer At Time of Injury_________________________________________________________________________________
Phone:___________________________________________
Employer's Address: _____________________________________________________________________________________________
Contact Name: ___________________________________________ Work comp claim #
__________________________
Other Party Information: (Home Owners Ins., Third Party Auto Ins., Business
Ins., Work CompIns., ETC)
Name: ____________________________________________ Phone: _____________________________
Address: __________________________________________ City: __________________
St: ______ Zip: __________
Company Name: ____________________________________ Phone: _____________________________
Agent's Name: ______________________________________ Case Number: _______________________
Address: __________________________________________ City: __________________
St: ______ Zip: __________
Claim Adjuster: _____________________________________ Adj. Phone Number: ________________________
I UNDERSTAND THAT IF THE INSURANCE COMPANY HAS NOT PAID WITHIN 90 DAYS,
IT IS MY RESPONSIBILITY TO MAKE PAYMENT ARRANGEMENTS.
PATIENT/GUARDIAN SIGNATURE ____________________________________ DATE: ______________________
Required Required
To be completed by office personnel only: Checked by _____ and _____ Copy of
Ins on file: Yes / No