Home arrow Contact Us arrow Patient Registration
Patient Registration
Click and download a PDF version to print and fax to the location where you wish to have physical therapy.  For Boston and Medford, please fax to 617-636-5176 and for Wellesley, please fax to 781-235-5276.  Please provide a return contact number on the fax and an OSPT or AST staff member will contact you within one business day after receiving your faxed patient information sheet to schedule your appointment.

 or

You can fill out the patient registration form below.

Please fill in the information below and click "Send Form."

 

Choose a the location you will visit. required field
Please check if applicable: Motor Vehicle Accident Workers Compensation

Patient Information
Name: required fieldEmail Address: required field
DOB: required fieldHome Address: required field
City: required fieldState: required field Zip Code: required field
Phone: required field Type:

Employer Information
Employer/Company Name:
Address:
City: State: Zip Code:

Insurance Information
Primary Health Insurance: required field
Policy Number: (please include all letter prefixes and number suffixes) required field
Address:
City: State: Zip Code:
Customer Service Phone:
Policy Holder's Name: required field
SS#: Relationship To Insured: required field
Do you have a secondary insurance coverage? If yes, please complete the information below.
Secondary Health Insurance:
Policy Number: (please include all letter prefixes and number suffixes)
Address:
City: State: Zip Code:
Customer Service Phone:
Policy Holder's Name:
SS#: Relationship To Insured:
workers compensation and motor vehicle patients only
Contact Name:
Phone: Ext: Fax:
Health Insurance:
Policy/Claim Number

Physician Information

Primary Care Physician (full name): required field
Address: Phone: required field
Referring Physician (full name): required field
Address: Phone: required field
Injury/Diagnosis: required field
Date of Injury:
required field = Required