Motor Vehicle Accident Summary (Online)

Complete your Motor Vehicle Accident Summary before your appointment. This comprehensive form helps Dr. Tejani understand your jaw, bite, TMJ, and overall health history.

Motor Vehicle Accident Summary

Patient Name:(Required)

First Last

Accident Report #:(Required)

ICBC Claim #:(Required)

ICBC Representative and/or Lawyer — Name and Phone Number(Required)

Name

Phone Number

Accident Date(Required)

Accident Time(Required)

Road Conditions:(Required)

Weather Conditions:(Required)

Vehicle Description:(Required)

Make / Model / Year

What happened?(Required)

Were you the:(Required)

Driver

Passenger

Pedestrian

Other

Where was the car hit?(Required)

Were you seat-belted?(Required)

Was there a head rest?(Required)

Did the airbags deploy?(Required)

Did you hit anything?(Required)

If yes, what?

Where were you hurt?(Required)

If yes, please specify.

Cost of damage to car?(Required)

Did you go to the hospital?(Required)

Which one?

How you got there? Ambulance?

Which Physician?

Other passengers?(Required)

If yes, please specify.

Who have you seen since the accident?(Required)

Do you have any symptoms now?(Required)

If yes, please specify.

Do you use or have you used any dental appliance?(Required)

If yes, please specify.

Have you seen a dentist for this issue?(Required)

If yes, please provide the dentist’s name.

And date of visit

Documentation: Medical or other reports?

Please upload any supporting documents below.

Max. file size: 32 MB.

Motor Vehicle Accident Summary (Online)

Motor Vehicle Accident Summary

Contact us today to start living a better life.

(604) 687-3740

1010 Mainland St, Vancouver, BC V6B 2T4

Office Hours