Elite Intake Portal
v1.08
List
New Patient
New Patient Intake Form
Patient Status
OPEN
CLOSED
PENDING
LITIGATION
1. General & Accident Information
Primary Claim # (Unique Index)
Patient Name
Intake Date
Accident Date
Injuries
Accident Report #
Police Dept
Address
Hospital
Ambulance
Date of Birth
Sex
Medical Provider
— Select Medical Provider —
ACE Pain Spine
Back Pain MD
Urgent Care MD
Happy Spine Chiropractic LLC
Gwinnett Medical Back & Neck Pain
Path PT
Mercy Laser Therapy
Dr. J Pain & Rehab Clinic
1st Choice Injury & Rehab Clinic
Lotus Spine Chiropractic LLC
Social Security
Household Ins
Previous Accident/Medical
Phone (H)
Phone (C)
Phone (W)
Relation to Car Owner
Bankruptcy? Y/N
Discharge Date
Email
Spouse
Medicare Y/N
Medicaid Y/N
Ins Type
Purpose of Trip
2. Vehicle Information
Reg. Owner
Year
Make
Model
Phone #
Location
Drivable?
Damage
Body Shop Info
PD Value
3. Insurance & Adjuster Contacts
Primary Insurance (Side A)
Insurance Name
Policy Holder
Policy #
Claim #
PD Adjuster
PD Phone
PD Fax
PD Email
BI Adjuster
BI Phone
BI Fax
BI Email
BI Address
Secondary Insurance (Side B)
Insurance Name
Policy Holder
Policy #
Claim #
PD Adjuster
PD Phone
PD Fax
PD Email
BI/MP Adjuster
BI/MP Phone
BI/MP Fax
BI/MP Email
BI/MP Address
Liability
Medpay Limit
Policy Limit
UM/UIM Limit
📎 Attach / Manage Documents
Document Type
Diagnosis
Prognosis
Miscellaneous
Select File to Upload
File will be uploaded and attached when you click "Save Record" below.
Save Record & Upload Files
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