Patient Forms & Info

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

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
    – Lilac City Pediatrics, 180 Farmington Road, Rochester, NH 03867

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

  • 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

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. 

Other Forms

Release of Medical/Dental Information for Current Patients

(For Dental, 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

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

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

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