Oberg & Larsen Chiropractors - Pasco, Richland, Kennewick, Washington

Accident Information

Accident Report

First Name:
Last Name:
Middle Name:
Date:
My auto/workers insurance is:
Claim No:
My personal insurance is:
Do you have an attorney that has advised you in this claim:
Attorney's Name:
Address:
Phone:

Accident Information:

Date of accident:
Hour:
AM
PM
Accident location:
How did the accident happen:

If auto accident:

Driver's name of other vehicle, if applicable:
Name of their insurance company:
How many people were in the auto:
Were you the:Driver
Passenger (Front Seat)
Pedistrian
Passenger (Back Seat)
Was the car struck from:Behind
Left Side
Front
Right Side
Did your car strike the other(s) involved:Yes
No
Undetermined
OR
Did the other car strike yours:Yes
No
Undetermined

Injury Information:

What happened to you at the time of the accident:
What did you feel immeadiately after the accident:
When did you first notice symptoms from the accident? What did you feel?
Where you taken somewhere after the accident:
What was done for you there:
Did you require post-accident hospitalization:
List all seen doctors and type of treatment since the accident:
Have you lost any days from work?:Yes
No
If yes, what kind of work and when?
Did you return to work:Yes
No
If yes, on what date?

Patient Initials: Date:

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