DMC Telehealth Appointment Request

If you have an urgent medical need and wish to be seen in person today, please call 603-537-1300 instead of filling out this form.

Important Note: Due to revised federal and commercial insurance regulations following the COVID-19 Pandemic, patients are required to physically be located in the state of NH at the time of their telehealth appointment. If you are not able to be in NH during your televisit, please be sure to call 603-537-1300 at least 24-hours prior to your scheduled appointment to reschedule.

If you have questions regarding telehealth coverage or out of pocket costs (such as co-pays), please contact your insurance provider.

Are you a new patient?

Yes No

First Name

Last Name

Date of Birth

Ex: 01/01/1965

Preferred Email

Appointment information and confirmations will be sent to this email address.

Parent or Guardian Name

Phone Number (Mobile Preferred)

Brief Reason for Telehealth Appointment Request

Name of Insurance Provider

(Ex: Anthem, Harvard Pilgrim, United Health Care)

Insurance Policy Number

Group Number

Your information will be encrypted.