Georgetown Online Registration

                                                                 64 East Main St., Georgetown, MA 01833  (978) 352-5510

Georgetown Online Registration

Contact Information

YES, please e-mail me the Partners In Rehab, PT Quarterly Newsletter.

Provide your health insurance and referral information.

If patient is NOT the policy holder, complete subscriber information:

*Complete this section only if this is a work related injury. Otherwise, click Next Page.

*Complete this section only if this injury is the result of a motor vehicle accident. Otherwise,  click Next Page.

Medical Information

*Medical Information Release Authorization

This authorization or photocopy thereof, will authorize you to furnish all information you may have regarding my condition while under your observation or treatment, including the history obtained, X-ray and physical findings, diagnosis or prognosis. You are authorized to provide this information in accordance with the personal injury protection benefits law.