Patient Information Request

  • Thank you for your interest in becoming a patient, or for being a patient already! You can use this form to request intake paperwork and/or ask a question. To get started, please choose the practice you are interested in (Families First in Portsmouth, Goodwin Community Health in Somersworth, or Lilac City Pediatrics in Rochester).
  • Please check to make sure you typed it correctly!
  • Please do NOT use this form for time-sensitive messages or for personal health information (medical information, medical questions, prescription refill requests, etc.). This email system cannot keep such information secure, and we cannot respond to medical questions via this website. Instead, established patients should use the secure Patient Portal found on our website, or call our phone number. After hours, you can always reach a nurse at that number.
  • This field is for validation purposes and should be left unchanged.