SERVICES
Family Care
Pediatric Services
Women's Health
(Female doctor in NH)
Cardiology Care
Dermatology Services
Diabetes Healthcare of NH
at Derry Medical
Diagnostic Imaging
(CT Scan, MRI, Mammo, etc.)
Laboratory
Minor Surgery
Nutrition/Dietitian
Weight Sense

FOR PATIENTS
Patient Access
Patient Survey
Cancel an Appointment
Saturday Appointments
Patient Education

LOCATIONS
Overlook Medical Park
6 Tsienneto Rd - Derry, NH
Orchard View Drive
Professional Building
6 Buttrick Rd - Londonderry, NH

HOURS OF OPERATION
Monday - Thursday | 8am - 8pm
Friday | 8am - 5pm
Saturday | 8am - 12pm

CALL CENTER HOURS
Monday - Friday | 7:30am - 6pm
Saturday | 8am - 12pm

Prescription Refills - Londonderry Patients

Date:

Doctor:

Patient Name:

Patient Date of Birth:

Home Telephone Number:

Work Telephone Number:

Email Address:

	Medication	Dosage	Quantity
Sample
1.
2.
3.
4.
5.

Additional Comments and Instructions:

Pharmacy Name:

Pharmacy Address:

Pharmacy Telephone Number:

Additional Pharmacy
Information if Needed:

Please allow 24 to 48 hours (excluding weekends), for your refill to be processed.

Please print this completed form, prior to submitting, for your records.

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