Forms & Info for Patients

Our staff would be happy to answer any questions or to provide you with a hard copy of any document.

Annual Renewal Forms

Below are choices of ways to find the paperwork that we ask all patients to complete annually. 

  • Download a PDF
  • Print it out and fill it in
  • Mail it to your health center or drop it off:
    – Families First, 8 Greenleaf Woods Drive, Portsmouth, NH, 03801
    – Goodwin Community Health, 311 Route 108, Somersworth, NH 03878
    – Lilac City Pediatrics, 180 Farmington Road, Rochester, NH  03867

One of the forms asks you to acknowledge that you have been given access to the following documents. Please click the links below to read them. 

Use this form to ask us to send you a renewal packet in the mail. 

One of the forms asks you to acknowledge that you have been given access to the following documents. Please click the links below to read them. 

  • Download a PDF in your language:
     Espanol | Indonesia | Tiếng Việt | Người Bồ Đào Nha
  • Print it out and fill it in.
  • Mail it to your health center or drop it off:
    – Families First, 8 Greenleaf Woods Drive, Portsmouth, NH, 03801
    – Goodwin Community Health, 311 Route 108, Somersworth, NH 03878
    – Lilac City Pediatrics, 180 Farmington Road, Rochester, NH  03867

One of the forms asks you to acknowledge that you have access to these documents, which you may read by clicking these links:

Other Forms

Income Info & Sliding Fee Scale Application 

Release of Medical Information for new patients (online) (PDF)

Release of Medical/Dental Information for existing patients (online) (PDF)
(For Dental, initial only the second item on the list in middle of the page.)

Health Info Privacy Practices (PDF) (online)

Behavioral Health Informed Consent, Notice of Privacy Practices and Mental Health Bill of Rights