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
Laser Hair Removal
Minor Surgery
Nutrition/Dietitian
Weight Sense
Patient Access

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

HOURS
Monday - Thursday | 8am - 8pm
Friday | 8am - 5pm
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, Location & Telephone Number:

Pharmacy Information if Other:

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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