Go2Dr™ Patient Appointment Request Form

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 603-669-9200.)

User Information

I am the

Patient Patient's representative / family member

Please fill the representative name and relationship to patient fields below

Other

Representative / family member name

Relationship to patient

Patient Information

First name

Last name

Date of Birth

Gender

Male Female

Language

This field is optional

Phone number for contact

Best time for you to call me

My preferred appointment time(s)

Address

City

Zip

Insurance and HMO authorization if required

Primary Care Provider (PCP)

Preferred provider name

Optional, leave this field empty for first available provider

Medical Information

Symptoms/Complaint

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