Get Ampt Patient Registration Form

Completing the AMPT Patient Registration Form online is an important step in ensuring that you receive the appropriate care. This guide provides clear instructions on how to accurately fill out each section of the form, making the process as smooth as possible.

Follow the steps to complete the AMPT Patient Registration Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your editor.
2. Fill in the registration information by providing your date of birth, gender, social security number, and full name. Ensure all fields are accurately filled out to prevent any delays in processing.
3. Enter your home address, including street address, apartment number (if applicable), city, state, and zip code. Provide both home and cell phone numbers.
4. Choose your preferred method for receiving appointment reminders. Indicate whether you prefer text messages or email for communication, and specify your service provider for text messaging.
5. In the personal information section, indicate your occupation and employer's address. If applicable, include your work phone number.
6. Select your marital status from the available options and provide an emergency contact's information, including their relation to you and contact numbers.
7. If you are completing the form for a minor or someone requiring a legal guardian, fill in their guardian's details and date of birth.
8. Provide insurance information by filling out the details for your primary, secondary, and tertiary providers, including group and policy numbers along with contact numbers.
9. State your reason for consultation and indicate if you are being treated for a work-related injury. Additionally, answer questions about any previous physical therapy or home health services you may have received this calendar year.
10. Read and consent to the physical therapy evaluation and treatment by acknowledging the conditions outlined in the consent section. Ensure that you or your guardian signs and dates the form.
11. Once you have filled in all the required fields, save your changes. You can then download, print, or share the completed form as needed.

Start completing your AMPT Patient Registration Form online today for a straightforward registration experience.