Methuen Online Registration

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421 Merrimack St., #102, Methuen, MA 01844  (978) 689-4500

Methuen Online Registration

Contact Information

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 on the Next Page.

*Complete this section ONLY if this injury is the result of a Motor Vehicle Accident. Otherwise, click on the 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.