formisoft
Registration

Motor Vehicle Accident Intake Form

3 pages•12 fields•HIPAA-ready
Ready to useHIPAA compliantCustomize in minutes
Use this templateBrowse all templates

Form preview

formisoft.com/f/mva-intake

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

Sign up and start customizing in minutes.

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
8 min saved per patient98% patient satisfaction3x faster than paper

Start with this template

Sign up and start customizing the Motor Vehicle Accident Intake Form for your practice. Set up in minutes.

Use this templateBrowse all templates

Related templates

Advance Directive Form
Patient Full Name
Date of Birth
Healthcare Proxy Name
Proxy Phone Number
Proxy Relationship
Registration

Advance Directive Form

Document patient advance directive preferences including healthcare proxy designation, living will provisions, and end-of-life care wishes.

3 pages•12 fields
Appointment Request Form
Patient Full Name
Date of Birth
Phone Number
Email Address
New or Returning Patient
Registration

Appointment Request Form

Let patients request appointments online by specifying their preferred dates, times, providers, and reason for visit to streamline your scheduling workflow.

2 pages•10 fields
Clinical Trial Enrollment Form
Full Legal Name
Date of Birth
Phone Number
Email Address
Home Address
Registration

Clinical Trial Enrollment Form

Enroll patients in clinical research studies by collecting eligibility criteria, medical history, informed consent, and study-specific demographic data in a structured multi-page form.

3 pages•15 fields
Motor Vehicle Accident Intake FormUse this template