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On-Line Registration Code Request Form
Date of Birth
Please select the CHMG practice(s) you currently visit.
Concord Family Medicine
Epsom Family Medicine
Family Care of Concord
Family Health Centers
Family Physicians of Pembroke
Family Tree Health Care
Penacook Family Physicians
Pleasant Street Family Medicine
Breast Care Center
Center for Urologic Care
Concord Plastic Surgery
Concord Surgical Associates
International Travel Clinic
Wound Healing Center
Who was your provider at your last visit?
Please enter the year you last visited your CHMG practice(s).
Please provide the email address where you would like your Registration Code sent to.
Please re-enter your email address for verification.
By checking this box, I certify that I am the above stated patient and that I am electronically signing my application. I understand that an electronic signature has the same legal effect as a written signature.
Note to Concord Hospital Employees: It is our policy that you do not use your work email address for Patient Connect.
Please provide us with a phone number where we can reach you between 8:00am - 5:00pm Monday - Friday in the event we have any questions.
Your request will be processed within 24 hours Monday through Friday until 3pm (excluding holidays).
Please be sure to check your email spam/junk folder if you have not received a reply from us within 24 hours.
Please enter a custom answer