Motor Vehicle Accident Intake – Active Rehab Center

Motor

Have you received treatment for this injury?
YesNo

INSURANCE INFORMATION

ACCIDENT INFORMATION

Road Condition:
WetDrySnowIce

Did you hit your head?YesNo

Did you lose consciousness during or after the impact?YesNo

Were you able to get out/walk around unassisted?YesNo

Were your passengers during this accident affected?YesNo

Have you had any prior accidents?YesNo

HEALTH CONDITIONS

Before CollisionImmediately FollowingCurrently Experience

Are you currently receiving treatment from another health care professional?YesNo

AGREEMENT

By agreeing, you confirm that:
I acknowledge that any treatment that is not covered by MVA will be my responsibility.
AgreeDisagree

Just get in touch with us with your preferred method! We will try our best to help you with any and all questions.