Appointment Request

* Required field. Please note: you will need to fill in all required fields in order to submit your request to us.

* Are you a new patient?

Yes No

* Patient Name

* Date of Birth

* Preferred Email

Parent or Guardian

* Preferred Phone Number

Brief Reason for Appointment

* Preferred Time Frame

* Preferred Location

* Preferred Day

* Preferred Time

* Preferred Day

* Preferred Time

* Preferred Provider

* Second Choice

* Which is most important?

* Insurance Provider and Policy#

Thank you for your request.

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Disclosure

If you are experiencing a Life Threatening Medical Emergency, please dial 911 for immediate assistance.

(This online form is NOT for medically urgent appointments. If you have immediate medical needs that are urgent but not life threatening, do NOT use this form. Please visit a DMC Walk-in Clinic in either Bedford or Londonderry or call our main number at 603-537-1300 to request a same day visit.)

Our practice will confirm the appointment date and time and notify you by email. We will make every effort to respond to you as quickly as possible. If you did not enter your insurance provider and policy number, and if we are unable to fulfill your request, we may call or email you for more information. Please note that the more flexible you are with times or providers, the easier it will be to schedule. If you need to change the appointment, please call us at 603-537-1300 noting that you need to reschedule. Our phones and online appointment requests are answered live from 7:30 a.m. to 7:30 p.m. Mon-Thurs, 7:30 a.m. to 5:00 p.m. Friday, and from 8:00 a.m. until 2:30 p.m. on Saturday.

Request Primary Care Appointment

Appointment Request

Thank you for your request.

Disclosure