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Motor Vehicle Accident Intake Form

3 pages•12 fields•HIPAA-ready
Ready to useHIPAA compliantCustomize in minutes
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Motor Vehicle Accident Intake Form

Page 1 of 3

Patient Full Name
Jane Martinez
Date of Birth
03/15/1985
Date of Accident
03/15/1985
Accident Location
Were You the Driver or Passenger
Option A
Option B
Option C
Were You Wearing a Seatbelt
Option A
Option B
Option C
Did Airbags Deploy
Option A
Option B
Option C
Describe How the Accident Occurred
Enter details here...
Current Symptoms
Fatigue
Pain
Nausea
Dizziness
Shortness of breath
Pain Level (1-10)
None (0)
Mild (1-3)
Moderate (4-6)
Severe (7-10)
Auto Insurance Company
Blue Cross Blue Shield
Patient Signature
Sign here
Submit
Use this template

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The Motor Vehicle Accident Intake Form captures all critical details of a motor vehicle collision and the resulting injuries. It documents the accident circumstances including date, location, speed, point of impact, seatbelt and airbag usage, and whether the patient was the driver or passenger. This thorough accident reconstruction information is essential for clinical correlation and supports personal injury documentation requirements.

The form includes comprehensive symptom assessment fields covering common MVA injuries such as neck pain, headaches, back pain, numbness, dizziness, and cognitive symptoms. It captures auto insurance details, attorney information if applicable, and whether a police report was filed. Pre-existing conditions and prior accidents are documented to establish baseline health status, which is critical for personal injury cases.

Widely used by chiropractic offices, physical therapy clinics, orthopedic practices, pain management centers, and emergency departments. This form serves as the foundation for personal injury documentation and helps providers create thorough medical-legal records that support the patient's treatment plan and any associated insurance or legal proceedings.

What's included

  • Detailed accident circumstances and vehicle information
  • Safety device usage (seatbelt, airbag, headrest)
  • Comprehensive symptom checklist for common MVA injuries
  • Pain scale and body location documentation
  • Auto insurance and attorney information
  • Police report and emergency room visit documentation
  • E-signature capture

Who uses this template

  • Chiropractic initial evaluation after auto accidents
  • Physical therapy intake for MVA-related injuries
  • Orthopedic assessment of collision-related musculoskeletal injuries
  • Pain management evaluation for post-accident chronic pain

All form fields

12 fields across 3 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Date of AccidentDate
Accident LocationText
Were You the Driver or PassengerMultiple Choice
Were You Wearing a SeatbeltMultiple Choice
Did Airbags DeployMultiple Choice
Describe How the Accident OccurredLong Text
Current SymptomsCheckbox
Pain Level (1-10)Multiple Choice
Auto Insurance CompanyText
Patient SignatureE-Signature

How to use the Motor Vehicle Accident Intake Form

Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Motor Vehicle Accident Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.

Setup steps

  1. 1Choose the template. Find the Motor Vehicle Accident Intake Form in the template library and click “Use this template” to add it to your account.
  2. 2Customize fields. Add, remove, or reorder any of the 12 fields. Set fields as required or optional based on your practice needs.
  3. 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
  4. 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
  5. 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.

Frequently asked questions

Is the Motor Vehicle Accident Intake Form HIPAA compliant?

Yes. All Formisoft templates, including the Motor Vehicle Accident Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.

Can I customize the fields in this template?

Absolutely. You can add, remove, reorder, or modify any of the 12 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

How do patients fill out this form?

Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.

Can I send this form automatically before appointments?

Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.

Does this template work on mobile devices?

Yes. The Motor Vehicle Accident Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.

8 min saved per patient98% patient satisfaction3x faster than paper

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