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Patient Forms

Impact MD Accident Care > Patient Forms

Click below for our HIPAA Notice of Privacy Practices form

Click below to fill out your Motor Vehicle Accident Assessment Form

Click below to download your Personal Injury (Non MVA) Assessment Form

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Fields Marked With An ”*” Are Required

Disclaimer : By providing my phone number to Impact MD Accident Care I agree and acknowledge that Impact MD Accident Care may send text messages to my wireless phone number for any purpose. Message and data rates may apply. Message frequency will vary, and you will be able to opt out by replying “STOP”. For more information on how your data will be handled, please see our privacy policy.
Privacy Policy : No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.
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