Pediatric Forms | Family Health Source

Pediatric Forms

Becoming a Patient

All Family Health Source locations are accepting new patients and accept Medicaid, Medicare, the West Volusia Hospital Authority Health Card and many private insurances. Please call the office location nearest you to see if we can accept your health coverage. If you are currently uninsured, we can still assist your needs and offer a sliding fee scale option to help make your visit an affordable one.

Although visits are by appointment only, our office will make every attempt to accommodate the very sick by working them into the schedule if at all possible.

Please click here to review our HIPAA Policy.

For New Patients

We encourage you to complete your New Patient Packet prior to your first appointment. You can download it below or pick it up at any of our locations.

New Patient Registration Form

Please transfer your previous medical records to our offices - especially if you are taking a maintenance drug that requires refilling.

For the Uninsured

We offer a sliding fee scale based on income and household size. Please bring proof of four weeks income or your most recent tax return.

Sliding Fee Application

West Volusia Hospital Authority
(WVHA) Health Card Program

Uninsured patients who reside in West Volusia
county may apply for the WVHA Health
Card Program. A WVHA Health Card holder
pays these co-pays:

    • Clinic doctor visit $4.00
    • Referred specialist visit $6.00
    • Prescription medicine $1.00
    • Hospital - Emergency Room Visit $10.00




All Patients

  • Arrive 15 minutes before your scheduled appointment
  • Please call us if you can’t make your appointment
  • Please call your pharmacy for medication refills
  • Please bring your insurance card and picture ID to each visit
  • Please bring medications to all visits


Patient Survey