Call Us!  Derry, NH: (603) 437-3338 | East Hampstead, NH: (603) 382-0019 | Salem, NH: (603) 898-9947

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Patient Registration Forms

Sports and Rehab acknowledges that every patient’s time is valuable.  We have provided all of our patient forms online for you to fill out.  Please fill out the Registration Form and the Medical History Form.

The Cancellation Form can be printed out.  Please sign it and bring it with you on your first visit.

 

Thank you,  The Staff at Sports and Rehab.

Download Patient Registration Form

Derry Online Patient Registration

Salem Online Patient Registration

Hampstead Online Patient Registration

 

Parental Permission Form

Consent for care and treatment provided by Sports and Rehab and The Safe Sports Network.

 

Auto Claims

You must provide your auto insurance policy/claim number as we will bill your auto insurance, who in turn collects from the person's insurance who hit you. Please be aware that there is a med-pay limit on your policy. Since there is a limit, we ask for back up insurance, either your health insurance or a lien from an attorney. This way there will be no surprise bills should the med-pay exhaust. We do not bill the insurance of the person who hit you (3rd party billing) as they will not pay us.

 

Worker's Compensation

Please let us know who your health insurance is as a back up should your worker's comp claim be denied.