All forms required of new patients and established patients are accessible via our secure Patient Portal and can be submitted quickly and easily as fillable forms. If you are a new patient, please enroll in the secure Patient Portal via the link below to access the forms. If you have enrolled and have an existing Patient Portal account, you may access it below. Select the “Forms” tab to access and submit your forms electronically.
Check-In is required within 48 hours and no later than 24 hours before each scheduled appointment and is best completed via the secure portal. Answers to Check-In questions below may be called in if you are unable to access the secure portal. Voicemail is available 24/7 at 603-718-8328.
Your Check-In serves as a pre-visit health screening and helps us to provide you with complete care during your visit. You may incur an additional charge for assistance with Check-In and your visit may be cancelled or rescheduled if Check-In is unable to be completed.
1. NAME OF PATIENT
2. DATE AND TIME OF MY APPOINTMENT
3. What would like your provider to address during your visit?
4. Have you had any other symptoms or concerns in the last week, or are there any recent events that may be affecting your health?
5. Any recent medical visits, new lab test results, procedures, diagnoses, medications, or supplements since your last visit?
6. Any new sensitivities or allergies to foods, drugs, or environmental factors since your last visit?
7. Do you need refills on anything prescribed from this office?
8. If “no” applies, please answer “no” or “no to all”. Do not answer N/A. If “yes” applies to any question below, please provide details:
a. Have you had a fever or any flu-like symptoms within the past week?
b. Have you been exposed to anyone with any flu-like symptoms in the past week?
c. Within the past week, did you travel to any place that is currently experiencing any type of infectious disease outbreak, or have you been in close contact with anyone who has recently traveled as such?
9. Have you received COVID-19 vaccination or booster(s)? Please provide date of most recent vaccination, or let us know it is “on file” if you have previously provided it.
Are you waitlisted for an earlier appointment?
Patients who have completed and submitted the paperwork and who are waitlisted for an earlier appointment will be given priority for earlier appointments that become available. Completing and submitting your paperwork ahead of time is evidence of investment in your own health and serves you best by allowing us adequate time for thorough review before your visit. Please enroll in or access your secure patient portal and submit your forms as soon as you can, and no later than 24 hours before your appointment.
We look forward to seeing you soon!