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Accident Recovery Pain Relief Injury Rehabilitation Same-Day Illness & Injury Ongoing & Preventive Care

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Location & Contact

Motor Vehicle Accident Form in Fresno

Tell us about the collision before you arrive

Collision details, coverage information and the parties involved. Send it before you come in and your accident visit moves faster.

Patient details

1

Patient details

First name*

Last name*

Date of birth*

Phone*

Email*

The collision

2

The collision

Date of accident*

Approximate time

Where did it happen?*

You were the*

DriverPassengerPedestrianCyclistMotorcyclist

Police report number (if any)

Type of collision

Coverage & legal

3

Coverage & legal

Bring your cards to the visit if you have them.

Your auto carrier

Your claim or policy number

Other party's auto carrier

Other party's claim number

Attorney name (if represented)

Attorney phone

Would you like to be treated on a lien?

YesNoNot sure, please explain it to me

Your injuries

4

Your injuries

Areas of pain or injury

HeadNeckShouldersUpper backLower backArms or handsHipsLegs or knees

Describe your symptoms since the accident*

Have you been treated elsewhere for this accident?

NoEmergency roomAnother clinicUrgent care

Signature and consent

Signature & consent

Type your full name as your signature*

Date*

I confirm these accident details are accurate to the best of my knowledge and authorize First Health Medical Center to use them to coordinate my treatment and billing.

Having trouble? Print the PDF version instead, or call (559) 227-2273 and our front desk will take your details by phone.

A family-founded walk-in medical center serving Fresno, Clovis and the Central Valley since 1989. Urgent care, accident and injury treatment, chiropractic care and primary care under one roof.

7161 N Howard St #100, Fresno, CA 93720
(559) 227-2273
Monday – Friday, 8:00am – 6:00pm

Services

Women's Health
Urgent Care
Accident & Injury Treatment
Chiropractic Care & Rehabilitation
Primary Care

Treatments

Accident Recovery
Pain Relief
Injury Rehabilitation
Same-Day Illness & Injury
Ongoing & Preventive Care

About

Our Story
Clinic Tour
Patient Stories
Careers

Resources

Telemedicine
Patient Forms
Health & Recovery Tips
Referrals

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