You can now submit your clinical history online.

It will take approximately 10-20 minutes to complete the online clinical history form, depending on your medical history.

For privacy reasons, you will NOT be able to save your form to work on it later and if you leave your computer idle for more than 20 minutes, your form will not be saved. You will have to begin again. Please be sure you have enough time to complete the entire form before you begin.

Before you begin, be sure you have all of the items listed below on hand.

• The name of your doctor who is admitting you to the facility
• The date of your scheduled procedure
• A short description of the procedure
• The name of the person driving you home
• The name of the person that will care for you after the procedure
• The name and dosage of ALL of your medications
• The dates and descriptions of past surgeries

To register, enter the date of your scheduled procedure below and then click "Start."

If you would prefer not to submit your clinical history online, please call the facility at 603-433-0941 for a telephone interview.

If you have any questions regarding your clinical history or the above procedures, please call us between 8 a.m. - 4:30 p.m., Monday thru Friday, at 603-433-0941. We look forward to serving you as our patient!