Auto Accident

Patient First Name

Please complete this field.

Patient Last Name

Please complete this field.

Location of the Auto Accident:

Please select an option.

Name of Examiner / Contact:

Please complete this field.

Examiner's Telephone Number:

Please complete this field.

Examiner's Extension

Please complete this field.

Name of Lawyer:

Please complete this field.

Is this a litigation case?

Please select an option.

Address:

Please complete this field.

Lawyer's Telephone Number:

Please complete this field.

Lawyer's Fax Number:

Please complete this field.

The Following Information is Very Important:

Name of your Physician

Please complete this field.

Physician's Address:

Please complete this field.

Physician Telephone Number

Please complete this field.

Did your physician refer you?

Please select an option.

If your physician referred you, how long ago was it?

Please complete this field.

If your physician did not refer you, who referred you?

Please complete this field.

Are they former patient's of this office?

Please complete this field.

If so, what is their name?

Please complete this field.

Address:

Please complete this field.

Allergies:

Please complete this field.

I HEREBY AUTHORIZE DR. STUART I. SPRINGER TO RELEASE ANY INFORMATION ACQUIRED IN COURSE OF MY EXAMINATION AND TREATMENT TO MY INSURANCE COMPANY

I ALSO AUTHORIZE PAYMENT TO DR. STUART I. SPRINGER FOR THE SURGICAL AND / OR MEDICAL BENEFITS DUE UNDER THE ARMS OF MY INSURANCE POLICY.

I AM AWARE THAT MY INSURANCE COMPANY MAY OR MAY NOT PAY FOR DURABLE GOODS I.E. (SLINGS, ACE BANDAGES, CRUTCHES, ETC.)

Full Name:

Please complete this field.

Date:

Please complete this field.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Subscribe to updates from Dr. Stuart Springer