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Patient Information
Patients coming to us for the first time will receive a new patient packet by mail. Occasionally, the packet may be delayed in the mail, preventing it from getting to you in a timely fashion. For your convenience, electronic copies of our pre-visit questionnaires that can be filled out electronically or printed and brought to your first visit can be found below. It is not necessary to fill out both questionnaires. Most patients will receive the Medical/Mobility Questionnaire. Those patients only seeing Dr. Gourvitz for neuropsychological assessment will fill out the neuropsychological questionnaire.
Pre-visit Medical/Mobility Questionnaire
Pre-visit Neuropsychological Questionnaire
We grow by learning not only what we’re doing right, but also by what we could be doing better. Please let us know about your visit with us so we can continue to improve our services. Forms can be emailed to ldonnellan2@elliot-hs.org, sent by mail, or dropped off in our feedback box at the front desk.
To schedule, cancel, or reschedule an appointment, please call our office at 603-624-8652 or log into your MyChart account. If you do not have a MyChart account, please click here to sign up.
Insurance Card, including your policy number and/or Medicare/Medicaid card.
Co-payment is expected when you check in. For your convenience, we accept checks, cash, Visa, Mastercard, Discover, and American Express.
Prescription Medication(s) in their original bottles or a list of all medications, including over-the-counter medications, vitamins, and supplements, and the amounts you take.
To refill a prescription, please call our office at 603-624-8652 or log into your MyChart account. If you do not have a MyChart account, please click here to sign up.
Please allow 48 hours to refill medications.
To request a referral, please call our office at 603-624-8652 or log into your MyChart account. If you do not have a MyChart account, please click here to sign up.
Important Documents
If you would like a copy of your medical record, please download and complete the form below. Completed forms can be mailed, faxed, or brought back to our office.
Medicare covers an Annual Wellness Visit with your primary care provider. There are no co-pays or deductibles for this visit.
Your first Annual Wellness Visit will include, among other things, a medical history, health risk assessment, and an evaluation of physical condition and screening for cognitive impairment. In addition, your doctor will work with you to set a prevention plan, including appropriate health screenings.
Medicare is a federal health insurance program for people aged 65 or older and younger people receiving Social Security disability benefits.
Contact Us
Please contact us for questions about services available at Elliot Memory & Mobility Center.