Patient Forms & Info

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

Useful Forms

Release of Information for Current Patients

  • Medical patients: Fill out entire form
  • Dental patients: Initial only the second item on the list in middle of the page.

Income Info & Sliding Fee Scale Application

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

Health Info Privacy Practices

Annual Renewal Forms

  • 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

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

  • Download a PDF in your language:
    Espanol | Portuguese | 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

Regardless of which option you choose:

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. 

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We will have a delayed opening at 9:15am on Wednesday 9/14/22

Banner Example

We will be closing at 3pm on Wed. 11/23/22, and will remain closed on Thurs. 11/24/22. Happy Thanksgiving!