DMC New Patient Registration Form: WRIGHT & ASSOCIATES

To establish care as a DMC Patient:

(1) Complete and submit this secure registration form. (2) Complete and submit a Release of Medical Records Form (click on Med Release on our hompage or here: https://www.dmcprimarycare.com/new-patient-reg/. (3) Change your PCP to a DMC provider with your insurance IN THEIR SYSTEM if your plan requires it. (3) Make an appointment to see a DMC provider.

Main Telephone Number: 603-537-1300

Patient First Name

Patient Last Name

Patient Date of Birth

Patient Street Address

Patient City

Patient Zip Code

Patient/Guardian Cell Phone Number

Patient/Guardian Email Address

Patient/Guardian Home Phone Number

Best Time of Day to Reach You at the Phone Number Above Please select all that apply

Mornings

Lunch Time (11:30 am to 2:00 pm)

Afternoons

Early Evenings (5:00 pm - 8:00 pm)

Patient's Previous Provider's Name

Approx Date of Last Visit With Provider (Month/Year)

Insurance Member ID Number

IF ESTABLISHING CARE FOR A MINOR: Parent/Guardian Name (First and Last)

IF ESTABLISHING CARE FOR A MINOR: What is your relationship to the minor?

(Mother, father, legal guardian, etc)

What is your race and ethnicity?

You may decline answering this question

What is your preferred language (if not English)?

You may decline answering this question

Is there anything else you would like our Patient Service Team to know?

Please Click the Submit Button When Finished. Thank You!

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