Car Accident Intake Form

Our mission is to serve our patients. We are committed to treating each patient promptly with integrity, honesty and compassion.

Car Accident Intake Form

Please submit each form from each tab. Our specialist will contact you within 24 hours. 

Your Auto Insurance Information
If you have your “policy declaration,” you may email us at info@injurymd.com and
skip the “Your Auto Insurance” section. We will ultimately need a copy of your policy
declaration in the future.

Other Driver’s Contact and Auto Insurance Information

What Happened After the Collision?

Please email us your Collision Report to info@injurymd.com

If you took pictures please email us to info@injurymd.com. If you did not take pictures, please take them

Email us pictures of any injuries you have sustained to info@injurymd.com

Your Health Insurance Information

More About You

You can email us a picture of yourself to help us remember your face and to put a face on your injury to remind the insurance companies that you are a human being. Please email us at info@injurymd.com