New Patient Forms

 

These forms are part of the new patient registration process. Printing out the forms and completing them in advance can save you time at your first visit.

If you need help with any portion of these forms, our Patient Service Representatives are happy to help you.

 

All Forms for New Patients

This packet contains all the forms you may need to get set up as a patient. It also includes some forms which you may or may not need, such as the financial assistance form. Scroll down for more info on each form or to print them individually.

Download All New Patient Forms – English
Download All New Patient Forms – Spanish
Download All New Patient Forms – Portuguese

New Patient Intake Form

All patients must complete this form. It gives us basic information and consent to provide care.

Patient Intake Form – English
Patient Intake Form – Spanish
Patient Intake Form – Portuguese

Release to Obtain Records Form

This required form allows us to request records from your previous health care provider. If you do not have a prior health care provider, please let us when scheduling your first appointment.

Release to Obtain Records Form

Personal Representative Form

A personal representative is someone you authorize to be involved in your health care. Complete this form if you want to allow our staff to speak with a spouse or another individual regarding your health care. This includes conversations such as rescheduling appointments or questions on billing issues.

Personal Representative Form

Learning Assessment Form

Completing the “What’s your Learning Style” questionnaire helps ensure we provide educational material in the best manner possible.

Learning Assessment Form

Financial Assistance Application

If you are uninsured, you may qualify for our financial assistance program. Please complete this application to see if you are eligible. If you have questions, please ask to speak with a Certified Application Counselor.

Financial Assistance Application – English
Financial Assistance Application – Spanish
Financial Assistance Application – Portuguese

New Patient Information Booklet

When you come to the office for your first visit, you will receive our New Patient Information Booklet. This booklet contains helpful information on our practice and is updated annually. Below are the most recent editions available for download.

2019-20 New Patient Booklet – English
2019-20 New Patient Booklet – Spanish
2019-20 New Patient Booklet – Portuguese

Transfer Your Records to Us

You have a right to your medical records

To provide you with the best care possible, our providers need access to your past medical history.

If you have not requested to have your medical records transferred to us, complete this form. Return it to us, and our medical records department will work with your previous provider to transfer the records.

Release to Obtain Records Form

New Patient FAQs

What are your hours?

Our hours have changed as we respond to the COVID 19 pandemic. As of July 1, 2020, our hours are:

Nashua:
Monday – Friday: 8:00 am to 5:00 pm
Monday – Friday: 8:00 am to 10:00 am, dedicated to patients over 65 and those receiving prenatal care
Starting July 22, Wednesdays, 2:30-5:00 pm, Teen Clinic

Newmarket:
Monday – Friday: 8:00 am to 5:00 pm
Monday – Friday: 8:00 am to 10:00 am, dedicated to patients over 65 and those receiving prenatal care

Raymond:
Monday – Friday: 8:00 am to 5:00 pm
Monday – Friday: 8:00 am to 10:00 am, dedicated to patients over 65 and those receiving prenatal care

How do I get my prescriptions refilled?

The simplest way to request a refill is through the secure patient portal MY HEALTH. You can also request a refill by calling the health center and selecting option #2.

Allow one week for all refill requests.

Request new prescriptions through an appointment with your provider.

What if I don’t have health insurance?

All patients are welcome at Lamprey Health Care – whether you have health insurance or not.

You may be surprised to find that you qualify for reduced rate insurance or other coverage programs. Our Certified Application Counselors are available to review your situation and can help determine if you’re eligible for coverage.

We have a variety of options to make sure you get the health care you and your family need. This includes payment plans and a sliding fee discount program. Please visit the Financial Assistance section for more details.