Following are forms you may need as a DMC Primary Care patient. If you have questions or are looking for information not listed here, please call us at 603.537.1300. Our Medical Records main fax number is 603.537-1355.
Release of Medical Records Form:
- Electronic Version [ADULT]: Authorization form for Use and Disclosure of Protected Health Information
- Electronic Version [MINOR]: Authorization Form for Use and Disclosure of Protected Health Information
COVID-19 Vaccination Questionnaire:
- Electronic Version: COVID-19 Pre-Vaccination Questionnaire & Consent Form
- Printable Version [PDF]: COVID-19 Pre-Vaccination Questionnaire & Consent Form
Other Forms for All Patients:
- Electronic Version: New Hampshire Immunization/Vaccination Registry OPT OUT FORM
- Printable Version: New Hampshire Immunization/Vaccination Registry OPT OUT FORM
- Electronic Version: Personal Information/Permission to Speak
- Printable Version: Personal Information/ Permission to Speak
- Notice of Patient Privacy Practices
- Testing Procedure Instructions for Mammogram, Ultrasound, Stress Testing (ETT) and Echocardiography
DMC Employee Forms:
Return to Work Questionnaire (Electronic Version)
Return to Work Questionnaire (PDF)