Lilac Natural Medicine - Dr. Michelle Haff - (603) 707-4433
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Forms

New Patient Forms
New Patients: Please complete all new patient questionnaires through the patient portal. When you scheduled your initial appointment, you should have received an email inviting you to create an account on the portal. Do not print and complete these forms unless you cannot complete them through the portal.
Adult Intake
File Size: 243 kb
File Type: pdf
Download File

Pediatric Intake
File Size: 229 kb
File Type: pdf
Download File

Acupuncture Intake / Informed Consent
File Size: 89 kb
File Type: pdf
Download File

Informed Consents
File Size: 84 kb
File Type: pdf
Download File

Policies and Financial Agreement
File Size: 119 kb
File Type: pdf
Download File

Card on File Authorization
File Size: 76 kb
File Type: pdf
Download File

Notice of Privacy Practices
File Size: 267 kb
File Type: pdf
Download File

Other Forms
Records Release
File Size: 51 kb
File Type: pdf
Download File

Card on File instructions for ChARM patient portal
File Size: 190 kb
File Type: pdf
Download File

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​​Lilac Natural Medicine
170 S. River Road, Ste. 102
Bedford, NH 03110
Phone: 603-707-4433
​Fax: 888-652-3587

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©COPYRIGHT 2025
​LILAC NATURAL MEDICINE, LLC
​​​ALL RIGHTS RESERVED.
PRIVACY NOTICE

  • Home
  • About Dr. Haff
  • Naturopathic Medicine
  • What We Treat
    • Pediatric Health
    • Women's Medicine
    • GI Health
    • Mental Health
    • Endocrine Health
    • Fertility Services
  • Services & Therapies
    • Naturopathic Care
    • Acupuncture
    • Fertility Services
    • Telemedicine
  • For Patients
    • Schedule an Appointment
    • What to Expect
    • Insurance and Fees
    • Forms
    • Testimonials
  • Contact Us
    • Schedule an Appointment
    • Patient Portal
  • Order Supplements
  • Social & More
    • Blog
    • Events
    • Privacy Notice