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.

To get started, please choose the practice you are interested in:

Families First – family medicine, Portsmouth
Goodwin Community Health – family medicine, Somersworth
Lilac City Pediatrics – pediatricians in Somersworth or Portsmouth

"*" indicates required fields

Choose a Practice*

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)*

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.

Comments

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

New Patients

Become a Patient

Current Patients

Insurance and Payment Options

Health Care

Family Services

Removing Barriers

Getting Started

Helpful Links

Become A Patient

Quick Links

Health Center Locations

Goodwin Community Health

Families First

Lilac City Pediatrics

How Are We Doing?

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