Intake Form Intake What type of accident were you involved in?(Required) Car Accident 18-Wheeler Accident Other Who was involved?(Required) Drivers Passengers Pedestrians Other When did the accident happen?(Required) Where did the accident happen?(Required)(e.g., specific address, intersections, city, state)Who do you believe was at fault for the accident? Me The other driver Not sure How did the accident happen?(Required)(e.g., what were the sequence of events, were there any contributing factors like wether or road conditions?)Was a police report filed?(Required) Yes No Not sure Do you have auto insurance? Yes No Does the other driver have auto insurance? Yes No Not sure Was your vehicle damaged?(Required) Yes No Is your vehicle drivable? Yes No Were you injured in the accident?(Required) Yes No What injuries did you sustain?Did you receive medical treatment? Yes, taken to the ER by ambulance Yes, later I went to the ER Yes, I went to Urgent Care/Doctor Not yet What is your name?(Required) First Last How do you prefer to be contacted?(Required) Phone Email What is your phone number?What is your email address? Enter Email Confirm Email When is the best time to contact you?(Required) Mornings Afternoons Evenings Is there anything else you would like us to know?
