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Our Locations
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Resources
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Franchise Opportunities
Services
Chiropractic Care
Medical Care
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Contact
Home
About Us
Our Locations
About Dr. Samad
Resources
Join Our Team
Franchise Opportunities
Services
Chiropractic Care
Medical Care
Physio – Therapy Modalities
Attorney Referrals
Contact
SCHEDULE TODAY
Home
About Us
Our Locations
About Dr. Samad
Resources
Franchise Opportunities
Services
Chiropractic Care
Medical Care
Physiotherapy Modalities
Attorney Referrals
Locations
Contact Us
SCHEDULE TODAY
Home
About Us
Our Locations
About Dr. Samad
Resources
Franchise Opportunities
Services
Chiropractic Care
Medical Care
Physiotherapy Modalities
Attorney Referrals
Locations
Contact Us
SCHEDULE TODAY
PATIENT INFORMATION
Location
Atlanta
Morrow
Lithia Springs
Decatur
Macon
Full Name
Date
Home Address
City
State
ZIP
Birth date
Social Security Number
Select
Male
Female
Nearest relative
Phone
Nearest friend
Phone
Employer
Work phone
Email
HEALTH INSURANCE INFORMATION
Do you have health insurance?
Yes
No
Carrier
Policy #
Group #
Insured's name
AUTO INSURANCE INFORMATION
Your auto insurance carrier
Policy #
MedPay
Yes
No
MedPay limit
Claim #
Policy holder's name
Time of accident
Car year / make / model
Date of accident
Driver
List all passengers in your car
CLAIM INFORMATION
Driver's name
Auto insurance carrier
Policy #
Policy holder's name
Claim #
Adjuster's name
Adjuster's number
Accident Information
Case #
Precinct
Date of accident
Were you a:
Driver
Passenger
Pedestrian
How many cars?
Location of accident
Country
Were police on the scene?
Yes
No
Report filed?
Yes
No
Citation (ticket) issued?
Yes
No
Citation issued for
Your car
The other car
Were you taken to the ER in an ambulance?
Yes
No
Did you go to the emergency room?
Yes
No
Date
Hospital
Did the ER take x-rays?
Yes
No
Any other treatment?
Yes
No
Have you seen another doctor?
Yes
No
Who?
Medical Injuries
Describe the accident
Describe the damage to your car
What was the position of your head?
Left
Right
Straight
Were you braced for impact?
Yes
No
What were the road conditions?
Clear
Dry
Raining
Please check symptoms you have experienced since the accident
Neck pain
Neck tightness
Back pain
Pack stiffness
Chest pain
Knee pain
Pins & needles in arms
Pins & needles in legs
Numbness in fingers / hand
Numbness in toes / feet
Wrist pain
Ankle pain
Shoulder pain
Dizziness
Headaches
Loss of memory
Loss of balance
Blurry vision
Bullets
Frequent / painful urination
Loss of appetite
Chest pains
Nausea
Constipation / painful elimination
Other
Have you had any surgeries?
Yes
No
Please describe
Have you missed time from work / school due to these injuries?
Yes
No
Do you need a medical excuse note for work or school?
Yes
No
Do you consume any of the following?
Smoke
Alcohol
Recreational drugs
Medical History
Do you presently have or have you had any of the following in the past 6 months?
Diabetes
Cancer
Asthma
Heart disease
Lung disease
COPD
Hypertension
Stroke
Arteriosclerosis
Liver disease
Spine curvatures
Kidney infection or disease
Other
Attorney Information
Do you have an attorney?
Yes
No
Attorney name
Address
City
State
ZIP
I authorize, request and assign the insurance company to pay directly to the medical provider Chiro-Time Clinics, Inc or Atlanta Injury and Wellness center, Inc for insurance benefits otherwise payable to me. I understand that I am financially responsible for all charges for treatment that are not paid by insurance. However, I also understand that if the insurance company denies my claim or does not accept liability of my case, I will not be charged by this facility. I hereby authorize the doctor to release all information necessary, including the diagnosis, and records of any exam or treatment rendered to me, in order to secure payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions.
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