LOCATIONS MENU Home / Patient Forms Patient Forms Adult Outpatient Forms To expedite the registration process, we suggest you print out the following forms, complete them prior to your arrival and bring them with you on the day of your first outpatient therapy appointment. To view and print our standard forms you will need a PDF reader, such as Apple Preview, Microsoft Edge, or Adobe Reader. Outpatient Therapy Medical History Questionnaire Outpatient Therapy Medical History Questionnaire (Spanish) Patient Registration Form (English) Patient Registration Form (Spanish) Pelvic Floor Medical History Questionnaire* *only to be completed for Women’s/Men’s Health Appointments Pediatric Forms Northeast Rehab’s Outpatient Pediatric Rehabilitation Program provides therapeutic outpatient services to infants, children, and adolescents with a wide range of orthopedic and neurological diagnoses. We provide comprehensive and coordinated Physical, Occupational and Speech Therapy services. Your child’s rehab team will provide experienced pediatric assessment, education, therapeutic intervention and transition/discharge planning to ensure a fruitful life at home, in school, and within the community. To expedite your child’s registration process, we suggest you print out the following forms, complete them prior to your arrival and bring them with you on the day of their first appointment. To view and print our standard forms you will need a PDF reader, such as Apple Preview, Microsoft Edge, or Adobe Reader. Pediatric Registration Information Pediatric Medical History Form Pediatric Medical History Form (Spanish) Outpatient Minor Policy Statement and Information Outpatient Minor Policy Statement and Information (Spanish) Visit our Facebook page Visit our Twitter page Visit our Youtube page NORTHEAST REHABILITATION HOSPITAL GET IN TOUCH 603-893-2900 Inpatient admissions@northeastrehab.com Facebook Messenger (Requires Facebook) Outpatient CentralScheduling@northeastrehab.com Facebook Messenger (Requires Facebook) CAREERS LOCATIONS MAKE A REFERRAL HOW CAN WE HELP YOU? HEALTH INFORMATION MANAGEMENT NONDISCRIMINATION HOSPITAL ACCREDITATIONS WEAR A MASK ALSO OF INTERESTMedicare Advantage Denials ProcessWill my insurance cover therapy?Women and Men’s Health Forms