Patient Forms
Wentworth Health Partners
Primary Care
New Patient Registration Packet - Adults
New Patient Registration Packet - Minors
Patient Registration Form - Annual Update
This registration form is required annually to ensure that your demographic information is current in our system. Please use this version if you are an existing patient at our practice.
DownloadProtected Health Information Release Form
This form is required to give us permission to obtain or release protected health information.
DownloadPermission to Discuss My Healthcare
This form is completed and signed by patients who would like to authorize another individual the ability to discuss the patient’s healthcare needs with our staff or providers. This form is optional and needs to be renewed every 12 months.
DownloadAdult Health Questionnaire
This form is used to gather important health information from adults.
DownloadYouth Health Questionnaire
This form is used to gather important health information from youth.
DownloadAuthorization for Minor to Attend Provider Visits without a Parent (NEW HAMPSHIRE)
Please choose this version if you are visiting a primary care practice located in New Hampshire.
DownloadAuthorization for Minor to Attend Provider Visits without a Parent (MAINE)
Please choose this version if you are visiting a primary care practice located in Maine.
DownloadContact Us
Wentworth-Douglass Hospital
789 Central Avenue
Dover, New Hampshire 03820
Phone: (603) 742-5252
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