• AUTOMOBILE ACCIDENT HISTORY

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  • Your Vehicle Information

  • Other Vehicle Information

  • Road Conditions

  • Head restraints, Seat backs

  • Seat belts and Air bags

  • Head and Body position

  • Accident Diagram

  • Accident description

  • During the crash

  • After the crash

  • Hospital

  • Current Complaints

    Please list, in detail, all current symptoms / complaints in order of severity.
    • Symptom #1  
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    • COLLAPSE STOPPER  
    • Symptom #2  
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    • COLLAPSE STOPPER  
    • Symptom #3  
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    • COLLAPSE STOPPER  
    • Symptom #4  
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    • COLLAPSE STOPPER  
    • Symptom #5  
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    • COLLAPSE STOPPER  
    • Current Accident

      Please list all previous treatments for conditions related to this auto accident including all doctors visits, MRIs, X-rays, etc.
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    • Treating Doctor #1  
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    • COLLAPSE STOPPER  
    • Treating Doctor #2  
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    • COLLAPSE STOPPER  
    • Treating Doctor #3  
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    • COLLAPSE STOPPER  
    • Treating Doctor #4  
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    • COLLAPSE STOPPER  
    • Treating Doctor #5  
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    • COLLAPSE STOPPER  
    • Treating Doctor #6  
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    • COLLAPSE STOPPER  
    • Previous Accidents

      List all treatments for conditions related to previous auto accidents including all hospital stays, doctors visits, MRIs, X-rays, etc.
    • Most Recent Previous Accident  
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    • COLLAPSE STOPPER  
    • Previous Accident  
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    • COLLAPSE STOPPER  
    • Personal Injury Insurance Information

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    • Your Auto Insurance Info

    • Other Party's Insurance Info

    • Health Insurance (info required to collect from Med Pay)

    • Clear
    • Notice of Doctor’s Lien

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    • I do hereby authorize Elite Sports Medicine to furnish you, my attorney, with a full report of examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was recently involved.

      I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as may be due and owing him for the medical service rendered me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect and fully compensate said doctor. And I hereby further give a Lien on my case to said doctor against any and all proceeds of my settlement, judgment, or verdict which may be paid to you, my attorney, or myself; as the result of the injuries for which I have been treated or injuries in connection therewith.

      I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered me and that this agreement is made solely for said doctor’s additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee.

      This lien supersedes any type of pre-paid health insurance plan, which we may contract with. The balance due after payments from your insurance company must be paid from sums collected from any settlement, judgment or verdict, which may be paid to you.

      A photocopy of this lien will be considered as valid as the original. This lien is irrevocable and binding to any subsequent Attorney retained by the patient.

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    • Clear
    • Please note: According to California law, it is unlawful to knowingly make a false or fraudulent claim. *Por favor note: de acuerdo con la ley de California, es illegal hacer reclamo falso o fraudulento.

      The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict, as may be necessary to adequately protect and fully compensate said doctor above-named.

    • Dated _______________________________

       

      Attorney Signature __________________________________________________

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