Accident or Injury Form

Patient name       _______________________________________

Date of birth        _______/_______/______

Date of injury     _______/________/________

Where did the accident or injury occur?

How did the accident or injury occur?

Was  this a motor vehicle accident?            NO         YES

Did the injury involve another party?       NO         YES

Did this injury occur on the job?                   NO          YES

Did you or will you be filing a worker's

compensation claim for this injury?           NO           YES

At this time, do you think that another

party (other than your insurance plan,

worker's compensation, or Medicare

will be responsible for the medical

expenses related to this injury?                    NO          YES

________________________________________                                 ________/________/__________

Signature of patient or guardian                                                             DATE

_______________________________________

Patient name