Referral Request

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

* Patient Name

* Date of Birth

* Preferred Email

* Preferred Phone Number

* Your DMC Provider's Name

* Your insurance company name

* Specialist name

* Reason for the referral

* Date of your appointment?

* Have you been seen by your PCP recently for this same medical reason?

Yes No

* Have you been seen for this same medical reson at the emergency room, urgent care, or another facility?

Yes No

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 call our main number at 603-537-1300.)

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 you for more information. If we are unable to fulfill your request we may call you to discuss additional options. Please note that the more flexible you are with times or providers, the easier it will be to schedule a same day appointment. 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 6:00 p.m. Friday, and from 8:00 a.m. until 2:30 p.m. on Saturday.

Thank you.

Your referral request was received.

Someone will call you once the referral is completed, before the scheduled appointment. If you need to reschedule for another time, please call 603-537-1300 or use our Make an Appointment Form.

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