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Chiropractic Accidental Injury Form Mobile App

This Chiropractic Accidental Injury Form Mobile App is for patients to fill out when they have been in a accident, such as an automobile accident or an on-the-job accident. Use this chiropractic treatment app to best treat a patient who has been in a car accident resulting in personal injury resulting in chronic pain or temporary pain, such as neck pain from whiplash. As chiropractors working with an insurance company for personal injury cases, use this app for a patient to fill out pertinent information and details about chronic pain caused by an auto accident or an on-the-job accident.

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Take a peek inside the Chiropractic Accidental Injury Form Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Name

  • Ico date

    Date

  • Ico date

    Date of Accident

  • Ico time

    Time of Accident

  • Ico multiline

    Location of Accident

  • Ico dropdown

    Have you lost any days of work?

  • Ico date

    Date Started Missing Work

  • Ico date

    Date Returned to Work

  • Ico dropdown

    Were You

  • Ico dropdown

    Were you struck from

  • Ico dropdown

    Did your car strike the others involved

  • Ico dropdown

    As a result of the Accident, were traffic citations issued to you?

  • Ico multiline

    How did the injury occur?

  • Ico dropdown

    Did you report the injury to your foreman or employer

  • Ico multiline

    Employer

  • Ico textbox

    Employer Phone

  • Ico checkbox

    Employer Address

  • Ico multiline

    Describe the circumstances of the accident (Be Specific)

  • Ico multiline

    Write symptoms you have noticed since the accident

  • Ico dropdown

    Did you require post-accident hospitalization?

  • Ico textbox

    Your Insurance Company

  • Ico multiline

    Insurance Company Address

  • Ico textbox

    Insurance Company Phone

  • Ico multiline

    Secondary Insurance Company

  • Ico multiline

    Secondary Insurance Address

  • Ico textbox

    Secondary Insurance Phone

  • Ico multiline

    Auto Insurance Company

  • Ico multiline

    Auto Insurance Address

  • ...and More!

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