Patient Information Request Form

Getting Started

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.

Please note: As of Summer 2023, we are accepting new pediatric and prenatal patients at all locations. We are scheduling new adult primary-care patients in our Somersworth location, but first available appointments for new patients are about six months out. We are not currently scheduling new adult patients in our Portsmouth location.

"*" indicates required fields

Choose a Location (Somersworth or Portsmouth)*

How can we help you?*

I need paperwork FOR NEW PATIENTS sent to me by mail.

I have a question about becoming a new patient.

Name*

First Last

Email Address

Please check to make sure you typed it correctly!

Phone number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How many packets do you need mailed to you? (One per patient)*

How many of the new patients are under age 19?

Questions or Comments*

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.

Name

This field is for validation purposes and should be left unchanged.

Helpful Links

How Are We Doing?

Goodwin Community Health:
Families First Health & Support Center:
Parents Connect group:

Greater Seacoast Community Health:

The services described here are supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) with an award totaling $3,960,707 in 2023 with 82% financed with non-HHS sources. This content does not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the U.S. Government. This organization has federal Public Health Service-deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals. More information ….

Greater Seacoast Community Health receives support from the City of Portsmouth and U.S. Housing and Urban Development Community Development Block Grant Program.

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