Phone:  770-368-0333
3949 Holcomb Bridge Rd, Suite 201
Norcross, GA 30092
Rick Neal, DC
Peachtree Corners Chiropractic Clinic
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bronze figure in Dr. Neal's officeVehicle Accident Information
Please answer all questions completely and then consult your chiropractor!

We provide our Accident form in two formats for your convenience. Choose the one you prefer:
  • Download (here), to print and fill out by hand, or
  • Use your computer to fill out and print the form below.

To protect your confidentiality online, we do not support E-mailing this information. After you complete the form, use your browser to print it, and mail or bring it with you to our office. Thank you!

Patient Information
Number: [ office use ] Date:  
Patient: Home Phone:  
Gender: Male   Female Marital Status:  
Date of Birth: Occupation:  
Address: City:  
State: Zip:  
Referred By: Social Security #:  
Company: Business Phone:  

Accident Information
Please explain in detail how your accident happened:
Other vehicle (if any) insurance:
Driver: Insurance Company:  
Phone: Address:  
Policy No: Claim No:  
Insurance for vehicle you were in:
Driver: Insurance Company:  
Phone: Address:  
Policy No: Claim No:  
Name of person who has made contact with you:
Have you retained an attorney? Yes   No   Not Yet
If so, please provide their information: Attorney Name:  
Phone: Address:  
About the accident:
Time: AM or PM?   AM   PM
Date: Police Notified?   Yes   No
Heading? N   S   E   W On (name of road):  
Number of people traveling in vehicle you were in:
Other vehicle:
Heading? N   S   E   W On (name of road):  
Number of people traveling in other vehicle:
Your injury:
Did head strike windshield or object? Yes   No
Were you knocked unconscious? Yes   No
If so, for how long?
You were struck from: Behind   Front   Left Side   Right Side
Where were you sitting? Front Seat   Back Seat
Were you the driver or a passenger? Driver   Passenger
Were you wearing your seat belt? Yes   No
Other protective devices (e.g., air bags)? Yes   No
Did you feel pain immediately? Yes   Later that day   Next day
If none of above, when did the pain begin?
If immediately, where did you feel pain?
Treatment given:
Where were you taken after the accident?
Was any doctor consulted after the accident? Yes   No
If so, give doctor's name:
What type of doctor is he/she? DC   MD   OD   DDS
What was the doctor's diagnosis?
What treatment was given?
How often did you see the doctor?
How long did you see the doctor?
Complaint history:
Have you ever had any complaints in the involved area before? Yes   No
If so, what were the complaints?
Before the injury, could you work equal to others your age? Yes   No
Are your work activities restricted as a result of this accident? Yes   No
Since the injury, are your symptoms: Improving?   Getting worse?   The same?

   
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Dr. Neal is a member in good standing of the American Chiropractic Association (ACA), Acupuncture Society of American (ASA), Council on Extremity Adjusting (CEA) and the Georgia Chiropractic Association (GCA). American Chiropractic Association (ACA) Acupuncture Society of America (ASA) Council on Extremity Adjusting (CEA) Georgia Chiropractic Association (GCA)