Your Information

Today's Date *

Patient Full Name *

Date of Birth *

Age

Sex

Marital Status

Street Address *

City *

State

ZIP

Cell Phone *

Work Phone

Email Address

Employer / Company

Occupation / Job Title

Emergency Contact Name

2

Accident Details

Date of Accident *

Approximate Time

Where did the accident happen? *

Type of Accident *

Rear-end (hit from behind) Front-end (head-on) Side impact (T-bone) Sideswipe Rollover Multi-vehicle pile-up Pedestrian struck Other

Briefly describe how the accident happened

Number of vehicles involved

Your position in the vehicle

What was your vehicle doing at the moment of impact?

Stopped / parked Decelerating / braking Moving at speed Accelerating Turning Changing lanes

Was a police report filed?

Yes No

Who was at fault?

Were there any passengers in your vehicle?

Yes No

3

Vehicle & Impact Details

Your Vehicle Year

Make

Model

Estimated speed of your vehicle at impact

Estimated speed of other vehicle at impact

Vehicle damage — describe the damage to your vehicle

Where were you looking at the moment of impact?

Straight ahead Rear-view mirror Left Right Down (phone / radio) Up

Head / neck position at moment of impact

Straight / neutral Turned left Turned right Looking down Looking up Tilted sideways

Were you bracing for the impact?

Yes No Partially

Symptoms at the Scene / Shortly After

Did you have any symptoms immediately at the accident scene?

Yes No

When did your symptoms first appear?

Did you leave the scene on your own, or were you transported?

Left on own (drove) Left on own (passenger) Ambulance to ER Ambulance refused Family member transported me

4

Medical Care Received

Have you been to the ER or urgent care since the accident?

Yes No

Studies performed at ER / urgent care (check all that apply)

X-ray MRI CT scan Ultrasound Blood work None performed

ER / urgent care diagnosis or findings (if told anything)

Have you seen any other doctors, chiropractors, or physical therapists since the accident?

Yes No

Are you currently taking any prescription or OTC medications for pain / injuries?

Yes No

Have you received any prior chiropractic care (not related to this accident)?

Yes No

Do you have any known drug allergies?

5

Your Current Symptoms

Where are you experiencing pain or symptoms? (check all that apply)

Head Face / jaw (TMJ) Neck Upper back Mid back Lower back / lumbar Left shoulder Right shoulder Left arm Right arm Left hand / wrist Right hand / wrist Chest / ribs Abdomen Left hip Right hip Left leg / thigh Right leg / thigh Left knee Right knee Left ankle / foot Right ankle / foot

Describe the quality of your pain (check all that apply)

Sharp Dull / aching Burning Throbbing Shooting / radiating Numbness Tingling / pins & needles Stiffness / tightness Muscle spasm Weakness

Current pain intensity: 5 / 10

0 — No pain 5 — Moderate 10 — Worst possible

What makes your pain worse? (check all that apply)

Morning (upon waking) End of day Driving Sitting Standing Walking Bending forward Bending backward Turning head Lifting anything Physical activity Rest / inactivity

Have you missed any work since the accident?

Yes No

Have your daily activities been limited?

Yes No

Anything else you want Dr. Jensen to know about your symptoms?

6

Medical History

Have you had prior back or neck injuries or pain (before this accident)?

Yes No

Have you been in any prior vehicle accidents or had other significant injuries?

Yes No

Have you had any surgeries?

Yes No

Current or past health conditions (check all that apply)

Arthritis / joint disease Osteoporosis Herniated disc (prior) Spinal stenosis Diabetes Heart disease High blood pressure Cancer (type below) Fibromyalgia / chronic pain Anxiety / depression PTSD Headache / migraine disorder TMJ disorder Autoimmune condition Asthma / lung disease Thyroid disorder Stroke / neurological condition Other (describe below)

For Female Patients (skip if not applicable)

Currently pregnant?

Yes No

Last menstrual period (approx.)

Primary Care Physician

PCP Phone

How did you hear about Mansfield Spinal Care?

7

Insurance & Attorney

Not sure about your coverage? That's okay — fill in what you know. Our staff will verify benefits and explain your payment options at your first visit. See our Legal Resources page for information about PIP and Letter of Protection (LOP).

How do you plan to pay for care? (check all that apply)

Auto Insurance / PIP (Personal Injury Protection) — Texas minimum Health insurance (Blue Cross, Aetna, United, Cigna, etc.) Letter of Protection / Attorney Lien (no insurance — attorney advances cost) Workers' Compensation (if accident occurred during work) Self-pay / out-of-pocket

Auto Insurance (Your Policy)

Insurance Company

Policy Number

Claim Number

Adjuster Name

Adjuster Phone

PIP Coverage Amount (if known)

Other Driver's Insurance (if applicable)

Insurance Company

Claim / File Number

Adjuster Name

Adjuster Phone

Health Insurance (if applicable)

Insurance Company

Policy / Member ID

Group Number

Do you have a personal injury attorney?

Yes No — I'd like a referral No — not interested

Attorney Full Name

Law Firm

Attorney Phone

Attorney Email

Attorney Address

8

Agreements & Signature

Assignment of Benefits & Contractual Lien

ASSIGNMENT OF INSURANCE BENEFITS AND MEDICAL LIEN

I, the undersigned patient (or guardian), hereby irrevocably assign and transfer to Mansfield Spinal Care & Rehabilitation ("Practice"), all rights, privileges, and benefits payable under any automobile insurance policy, personal injury protection (PIP) coverage, MedPay, uninsured/underinsured motorist coverage, health insurance, or any other insurance or third-party benefit plan applicable to the treatment provided for injuries arising out of the motor vehicle accident described in this form.

Medical Lien (Texas Property Code § 55.001 et seq.): I grant the Practice a lien upon any recovery, settlement, judgment, or verdict I may obtain from any at-fault party, their insurance carrier, or any other source as a result of this accident, in an amount equal to the reasonable and customary charges for all medical services rendered by the Practice. This lien shall attach to any proceeds of any settlement, judgment, or verdict in my favor.

Authorization to Bill and Release Records: I authorize the Practice to submit claims on my behalf to any applicable insurance carrier and to release any medical records, reports, narratives, or billing statements necessary to support those claims or to comply with a subpoena, court order, or written request from my attorney.

Financial Responsibility: I understand that I am personally responsible for all charges incurred for my care at the Practice, regardless of whether my insurance carrier pays, whether my attorney obtains a recovery, or whether any claim is disputed or denied. This assignment does not release me from my personal obligation to pay for services rendered.

Letter of Protection (if applicable): If I am represented by an attorney who has agreed to guarantee payment from any settlement or judgment proceeds, I authorize my attorney to honor this lien and direct payment accordingly. I further authorize the Practice to communicate directly with my attorney regarding outstanding balances.

This assignment shall remain in effect until all charges are paid in full. A photocopy or electronic copy of this assignment shall be considered as valid as the original. By signing below, I acknowledge that I have read, understand, and voluntarily agree to the terms above.

I have read and agree to the Assignment of Benefits and Medical Lien terms above. * I understand I am financially responsible for all services regardless of insurance payment or attorney outcome. *

HIPAA Notice of Privacy Practices

Mansfield Spinal Care & Rehabilitation is required by law to maintain the privacy and security of your protected health information (PHI) and to notify you promptly of any breach.

Your health information may be used and disclosed for treatment, payment, and healthcare operations. For personal injury and auto accident cases, records may be shared with your attorney (with your written authorization), insurance adjusters, and courts as required by law.

Read our full HIPAA Notice of Privacy Practices →

I authorize the Practice to use and disclose my health information for:

(a) Treatment — to provide, coordinate, or manage healthcare and related services (b) Payment — to obtain payment for services, including auto insurance claims and personal injury billing (c) Healthcare Operations — for quality assurance and practice management (d) Legal / Attorney — to share records with my personal injury attorney

By typing your full name below and checking the required boxes, you certify that:

All information in this form is accurate and complete to the best of your knowledge.
You have read the Assignment of Benefits / Medical Lien and agree to its terms.
You have received the HIPAA Notice of Privacy Practices.
You understand this typed signature has the same legal effect as a handwritten signature.

Patient Full Name — Digital Signature *

Date *

Parent / Guardian Name (if patient is a minor)

Relationship to Patient

I have read and agree to all the above. I authorize the disclosures selected above and acknowledge the HIPAA Notice of Privacy Practices. *

Privacy note: This form is transmitted securely via HTTPS. Do not include credit card numbers or unrelated financial information. Questions before your visit? Call (817) 477-2907.

Fields marked * are required. Dr. Jensen will review this before your first appointment.

Accident Patient Intake Form

Your Information

Accident Details

Vehicle & Impact Details

Medical Care Received

Your Current Symptoms

Medical History

Insurance & Attorney

Agreements & Signature