DMC Telehealth Appointment Request

Please correct the errors described below.

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.

For the best live video experience on your mobile device, DMC Patients should download
DMC | CONNECT, our FREE mobile telehealth app, from the Google Play (Android) or the iOS (Apple) app store prior to your telehealth appointment.

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

Ex: 01/01/1965
Appointment information and confirmations will be sent to this email address.
Please select one
(Ex: Anthem, Harvard Pilgrim, United Health Care)

Your information will be encrypted.