A Fine Spine Chiropractic
2812 Santa Monica Blvd Suite 208
Santa Monica, CA 90404
(310) 844-5502
afinespine@gmail.com
Automobile Accident History
First Name
Last Name
Address
Birthdate
Date of Accident
Time Accident Occurred
Were you taken to the hospital?
Did you stay in the hospital as a patient?
Name of the doctor who treated you after the accident?
If X-rays were taken, which ones?
The following questions pertain to you, the patient, and the vehicle you were in.
Were you unable to work/attend school due to your injuries? (Please enter the date range)
Have you retained an attorney?