Accident Form - align Orthodontics

Edmonton
Sherwood Park
Spruce Grove

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Edmonton
Sherwood Park
Spruce Grove

Accident Form

"*" indicates required fields

Your Information

Name*

First Name * Last Name *

Email Address*

HISTORY OF ACCIDENT

1. Date of accident

Date of accident

DD dash MM dash YYYY

2. Address/location of accident

Address/location of accident

3. Were you...

Were you...

A passenger in a vehicle?

The driver of a vehicle?

A pedestrian?

At work?

Other

Please specify...

4. What type/model of vehicle?

What type/model of vehicle?

5. Estimated damage

Estimated damage

Please enter a number greater than or equal to 0.

6. Were you wearing a seatbelt?

Were you wearing a seatbelt?

Yes

No

7. Where was the vehicle hit?

Where was the vehicle hit?

Front end

Rear end

Front right area

Front left area

Rear right area

Rear left area

Head on

On driver's side

On passenger's side

Other

Please enter where the vehicle was hit

8. Was there any direct trauma?

Was there any direct trauma?

Yes

No

Did your...

Did your...

Forehead

Face

Chin

Side of head

Back of head

Top of head

Teeth Jaw

Other

Please specify

forcibly strike...

forcibly strike...

Steering wheel

Windshield

Passenger's side window

Driver's side window

Headrest

Seat

Roof

Interior of car

Other

Please specify

9. Were any areas of your body painful shortly after the accident/incident?

Were any areas of your body painful shortly after the accident/incident?

Head

Neck

Face

Jaw

Left shoulder

Right Shoulder

Left arm

Right arm

Lower back

Upper back

Other

Please specify

10. Briefly describe the history of symptoms, accident or incident

Briefly describe the history of symptoms, accident or incident

11. Did you go to the hospital?

Did you go to the hospital?

Yes

No

How did you get to the hospital?

How did you get to the hospital?

By car

By ambulance

Other

12. Has a doctor or dentist ever diagnosed a TMJ disorder prior to the accident?

Has a doctor or dentist ever diagnosed a TMJ disorder prior to the accident?

Yes

No

Please explain

13. What treatment have you received to date?

What treatment have you received to date?

Meds

Physio

Chiro

Patient Signature

Signature*

Parent/Guardian if patient is under 18

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Edmonton

#301, 2603 Hewes Way
Edmonton, AB T6L 6W6

Sherwood Park

#26, 171 Broadway Boulevard
Sherwood Park, AB T8H 2A8

Spruce Grove

96 Campsite Rd, Unit 32,
Spruce Grove, AB T7X 4J3

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