SHCC:: CENTERS FOR NEUROLOGY AND PAIN MANAGEMENT
Follow Up Form
General Information
Your Name* :   Home phone number * :
Cell Phone :   Your e-mail address * :
             
Section 1
Were you involved in an auto accident? * : Yes    No
Were you the driver? : Yes    No
Was anyone else in the vehicle? : Yes    No
What was the date of the accident? :
Please provide a detailed description of accident? :
Did the police come to the accident scene? : Yes    No
Was there a citation issued? : Yes    No
    If Yes Who received the citation?
Were there any witnesses? : Yes    No
    If Yes Where did you get their name?
Were you injured? : Yes    No
Were you treated at the scene by paramedics? : Yes    No
Were you transported to a hospital? : Yes    No
    If yes what procedures were performed?
Were you admitted to the hospital? : Yes    No
Was your vehicle damaged? : Yes    No
What is the estimated cost of repairs to your vehicle? :
Do you have automobile insurance? : Yes    No
What is the name of your insurance carrier? :
Did the other party have automobile insurance? : Yes    No
What is the name of their insurance company? :
     
Section 2
Were you injured in a slip and fall or other type of accident? : Yes    No
What happened? :
Where did it happen? :
Was it due to a defective product? : Yes    No
Were you treated at the scene by paramedics? : Yes    No
Were you transported to a hospital? : Yes    No
    If yes what procedures were performed?
Were you admitted to the hospital? : Yes    No
Enter value*    5+3 = :
      


 
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