This packet is required for every new patient and annually for all established patients. It covers all the necessary information for our offices to provide your child's care to the best of our ability. 

633 Dunlawton AVe.

Port Orange, FL 32127

P: 386-424-1414  F:386-424-9130

We are always accepting new patients here at Volusia Pediatrics
For new patients from out of state, our office will need to have all previous medical records

and immunization information before scheduling an appointment for your child

For your first appointment:

  • Arrive 15 minutes early to check in. 
  • Provide your co-pay or co-insurance. They are due at the time of visit
  • All new patients must be accompanied by their responsible party
  • Provide a current State or Federal Identification Card (This is required at EVERY Appointment)
  • All responsible parties must have each new patients insurance cards (This is required at EVERY Appointment)

Below is a list of accepted insurances within our practice*  

New Patients

  • EBS-RMSCO
  • ​​FIRST COAST ADVANTAGE
  • FLORIDA HEALTH CARE
  • FLORIDA HOSPITAL HEALTHCARE 
  • FLORIDA TRUE HEALTH
  • FMH BENEFIT SERVICES
  • GOLDEN RULE
  • HEALTH SMART
  • HUMANA​

  • MEDSAVE
  • MULTI-PLAN
  • PLUMBERS & PIPEFITTERS UNION
  • OXFORD
  • TRICARE - SOUTH
  • UMR
  • UNITED BENEFITS
  • UNITED HEALTHCARE - Commercial
  • VOLUSIA HEALTH NETWORK

This form is to be used to request any records from previous physicians, specialists or hospitals to be released to our office for your child's care. It must be signed by a Parent, Guardian or verified person on the child's permission to be involved portion of the new patient packet. 

IF WE DO NOT HAVE PREVIOUS RECORDS PRIOR TO APPOINTMENTS - ALL SERVICES MIGHT NOT BE AVAILABLE

​*Not all insurances are accepted at both locations. This list is subject to change without notice. Please check with the office directly to ensure coverage. 

Please be aware that we are not accepting new patients with Medicaid Insurance Policies at this time.

  • AETNA
  • AMERIGROUP
  • ASSURANT HEALTH
  • AVMED (part of Multi-Plan)
  • BEECH STREET
  • BCBS
  • CENTURY HEALTH CARE (BEECH STREET CO)
  • CHAMP VA
  • CIGNA​
  • CONCERT HEALTH PLAN

317 S. Dixie Freeway

New Smyrna Beach, FL 32169

P: 386-424-1414  F:386-424-9130

Per Federal HIPPA Guidelines no medical information can be sent through email.

All requests for records must have a release signed. All requests for complete medical history are subject to fees.

Please contact our office for specific information. 

To make your child's transition to our practice as smooth as possible, we have provided the documents that you will need prior to your first appointment.

Please read over and then download all appropriate forms to fill out and fax or bring to our offices. Any questions or concerns that you may have can be answered by our caring staff.

Just call or email us through our contact page and we will be happy to help you through the process.

/* angular-svg-round-progressbar@0.3.8 2015-10-21 */ // shim layer with setTimeout fallback // credit Erik Möller and http://www.paulirish.com/2011/requestanimationframe-for-smart-animating/ 'use strict'; (function() { var lastTime = 0; var vendors = ['webkit', 'moz']; for(var x = 0; x < vendors.length="" &&="" !window.requestanimationframe;="" ++x)="" {="" window.requestanimationframe="window[vendors[x]+'RequestAnimationFrame'];" window.cancelanimationframe="window[vendors[x]+'CancelAnimationFrame']" ||="" window[vendors[x]+'cancelrequestanimationframe'];="" }="" if="" (!window.requestanimationframe){="" window.requestanimationframe="function(callback)" {="" var="" currtime="new" date().gettime();="" var="" timetocall="Math.max(0," 16="" -="" (currtime="" -="" lasttime));="" var="" id="window.setTimeout(function()" {="" callback(currtime="" +="" timetocall);="" },="" timetocall);="" lasttime="currTime" +="" timetocall;="" return="" id;="" };="" }="" if="" (!window.cancelanimationframe){="" window.cancelanimationframe="function(id)" {="" window.cleartimeout(id);="" };="" }="" }());="" angular.module('angular-svg-round-progress',="" []);="" 'use="" strict';="" angular.module('angular-svg-round-progress').constant('roundprogressconfig',="" {="" max:="" 50,="" semi:="" false,="" rounded:="" false,="" responsive:="" false,="" clockwise:="" true,="" radius:="" 100,="" color:="" "#45ccce",="" bgcolor:="" "#eaeaea",="" stroke:="" 15,="" duration:="" 800,="" animation:="" "easeoutcubic",="" offset:="" 0="" });="" 'use="" strict';="" angular.module('angular-svg-round-progress').service('roundprogressservice',="" [function(){="" var="" service="{};" var="" isnumber="angular.isNumber;" var="" base="document.head.querySelector('base');" fixes="" issues="" if="" the="" document="" has="" a=""> element service.resolveColor = base && base.href ? function(value){ var hashIndex = value.indexOf('#'); if(hashIndex > -1 && value.indexOf('url') > -1){ return value.slice(0, hashIndex) + window.location.href + value.slice(hashIndex); } return value; } : function(value){ return value; }; // credits to http://modernizr.com/ for the feature test service.isSupported = !!(document.createElementNS && document.createElementNS('http://www.w3.org/2000/svg', "svg").createSVGRect); // utility function var polarToCartesian = function(centerX, centerY, radius, angleInDegrees) { var angleInRadians = (angleInDegrees - 90) * Math.PI / 180.0; return { x: centerX + (radius * Math.cos(angleInRadians)), y: centerY + (radius * Math.sin(angleInRadians)) }; }; // deals with floats passed as strings service.toNumber = function(value){ return isNumber(value) ? value : parseFloat((value + '').replace(',', '.')); }; service.getOffset = function(element, options){ var value = +options.offset || 0; if(options.offset === 'inherit'){ var parent = element; var parentScope; while(!parent.hasClass('round-progress-wrapper')){ if(service.isDirective(parent)){ parentScope = parent.scope().$parent.getOptions(); value += ((+parentScope.offset || 0) + (+parentScope.stroke || 0)); } parent = parent.parent(); } } return value; }; // credit to http://stackoverflow.com/questions/5736398/how-to-calculate-the-svg-path-for-an-arc-of-a-circle service.updateState = function(val, total, R, ring, size, isSemicircle) { if(!size) return ring; var value = val > 0 ? Math.min(val, total) : 0; var type = isSemicircle ? 180 : 359.9999; var perc = total === 0 ? 0 : (value / total) * type; var x = size/2; var start = polarToCartesian(x, x, R, perc); // in this case x and y are the same var end = polarToCartesian(x, x, R, 0); var arcSweep = (perc <= 180="" "0"="" :="" "1");="" var="" d="[" "m",="" start.x,="" start.y,="" "a",="" r,="" r,="" 0,="" arcsweep,="" 0,="" end.x,="" end.y="" ].join("="" ");="" return="" ring.attr('d',="" d);="" };="" service.isdirective="function(el){" if(el="" &&="" el.length){="" return="" (typeof="" el.attr('round-progress')="" !="=" 'undefined'="" ||="" el[0].nodename.tolowercase()="==" 'round-progress');="" }="" return="" false;="" };="" easing="" functions="" by="" robert="" penner="" source:="" http://www.robertpenner.com/easing/="" license:="" http://www.robertpenner.com/easing_terms_of_use.html="" service.animations="{" t:="" is="" the="" current="" time="" (or="" position)="" of="" the="" tween.="" this="" can="" be="" seconds="" or="" frames,="" steps,="" seconds,="" ms,="" whatever="" –="" as="" long="" as="" the="" unit="" is="" the="" same="" as="" is="" used="" for="" the="" total="" time.="" b:="" is="" the="" beginning="" value="" of="" the="" property.="" c:="" is="" the="" change="" between="" the="" beginning="" and="" destination="" value="" of="" the="" property.="" d:="" is="" the="" total="" time="" of="" the="" tween.="" jshint="" eqeqeq:="" false,="" -w041:="" true="" linearease:="" function(t,="" b,="" c,="" d)="" {="" return="" c="" *="" t="" d="" +="" b;="" },="" easeinquad:="" function="" (t,="" b,="" c,="" d)="" {="" return="" c*(t/="d)*t" +="" b;="" },="" easeoutquad:="" function="" (t,="" b,="" c,="" d)="" {="" return="" -c="" *(t/="d)*(t-2)" +="" b;="" },="" easeinoutquad:="" function="" (t,="" b,="" c,="" d)="" {="" if="" ((t/="d/2)">< 1)="" return="" c/2*t*t="" +="" b;="" return="" -c/2="" *="" ((--t)*(t-2)="" -="" 1)="" +="" b;="" },="" easeincubic:="" function="" (t,="" b,="" c,="" d)="" {="" return="" c*(t/="d)*t*t" +="" b;="" },="" easeoutcubic:="" function="" (t,="" b,="" c,="" d)="" {="" return="" c*((t="t/d-1)*t*t" +="" 1)="" +="" b;="" },="" easeinoutcubic:="" function="" (t,="" b,="" c,="" d)="" {="" if="" ((t/="d/2)">< 1)="" return="" c/2*t*t*t="" +="" b;="" return="" c/2*((t-="2)*t*t" +="" 2)="" +="" b;="" },="" easeinquart:="" function="" (t,="" b,="" c,="" d)="" {="" return="" c*(t/="d)*t*t*t" +="" b;="" },="" easeoutquart:="" function="" (t,="" b,="" c,="" d)="" {="" return="" -c="" *="" ((t="t/d-1)*t*t*t" -="" 1)="" +="" b;="" },="" easeinoutquart:="" function="" (t,="" b,="" c,="" d)="" {="" if="" ((t/="d/2)">< 1)="" return="" c/2*t*t*t*t="" +="" b;="" return="" -c/2="" *="" ((t-="2)*t*t*t" -="" 2)="" +="" b;="" },="" easeinquint:="" function="" (t,="" b,="" c,="" d)="" {="" return="" c*(t/="d)*t*t*t*t" +="" b;="" },="" easeoutquint:="" function="" (t,="" b,="" c,="" d)="" {="" return="" c*((t="t/d-1)*t*t*t*t" +="" 1)="" +="" b;="" },="" easeinoutquint:="" function="" (t,="" b,="" c,="" d)="" {="" if="" ((t/="d/2)">< 1)="" return="" c/2*t*t*t*t*t="" +="" b;="" return="" c/2*((t-="2)*t*t*t*t" +="" 2)="" +="" b;="" },="" easeinsine:="" function="" (t,="" b,="" c,="" d)="" {="" return="" -c="" *="" math.cos(t/d="" *="" (math.pi/2))="" +="" c="" +="" b;="" },="" easeoutsine:="" function="" (t,="" b,="" c,="" d)="" {="" return="" c="" *="" math.sin(t/d="" *="" (math.pi/2))="" +="" b;="" },="" easeinoutsine:="" function="" (t,="" b,="" c,="" d)="" {="" return="" -c/2="" *="" (math.cos(math.pi*t/d)="" -="" 1)="" +="" b;="" },="" easeinexpo:="" function="" (t,="" b,="" c,="" d)="" {="" return="" (t="=0)" b="" :="" c="" *="" math.pow(2,="" 10="" *="" (t/d="" -="" 1))="" +="" b;="" },="" easeoutexpo:="" function="" (t,="" b,="" c,="" d)="" {="" return="" (t="=d)" b+c="" :="" c="" *="" (-math.pow(2,="" -10="" *="" t/d)="" +="" 1)="" +="" b;="" },="" easeinoutexpo:="" function="" (t,="" b,="" c,="" d)="" {="" if="" (t="=0)" return="" b;="" if="" (t="=d)" return="" b+c;="" if="" ((t/="d/2)">< 1)="" return="" c/2="" *="" math.pow(2,="" 10="" *="" (t="" -="" 1))="" +="" b;="" return="" c/2="" *="" (-math.pow(2,="" -10="" *="" --t)="" +="" 2)="" +="" b;="" },="" easeincirc:="" function="" (t,="" b,="" c,="" d)="" {="" return="" -c="" *="" (math.sqrt(1="" -="" (t/="d)*t)" -="" 1)="" +="" b;="" },="" easeoutcirc:="" function="" (t,="" b,="" c,="" d)="" {="" return="" c="" *="" math.sqrt(1="" -="" (t="t/d-1)*t)" +="" b;="" },="" easeinoutcirc:="" function="" (t,="" b,="" c,="" d)="" {="" if="" ((t/="d/2)">< 1)="" return="" -c/2="" *="" (math.sqrt(1="" -="" t*t)="" -="" 1)="" +="" b;="" return="" c/2="" *="" (math.sqrt(1="" -="" (t-="2)*t)" +="" 1)="" +="" b;="" },="" easeinelastic:="" function="" (t,="" b,="" c,="" d)="" {="" var="" s="1.70158;var" p="0;var" a="c;" if="" (t="=0)" return="" b;="" if="" ((t/="d)==1)" return="" b+c;="" if="" (!p)="" p="d*0.3;" if="" (a="">< math.abs(c))="" {="" a="c;" s="p/4;" }="" else="" s="p/(2*Math.PI)" *="" math.asin="" (c/a);="" return="" -(a*math.pow(2,10*(t-="1))" *="" math.sin(="" (t*d-s)*(2*math.pi)/p="" ))="" +="" b;="" },="" easeoutelastic:="" function="" (t,="" b,="" c,="" d)="" {="" var="" s="1.70158;var" p="0;var" a="c;" if="" (t="=0)" return="" b;="" if="" ((t/="d)==1)" return="" b+c;="" if="" (!p)="" p="d*0.3;" if="" (a="">< math.abs(c))="" {="" a="c;" s="p/4;" }="" else="" s="p/(2*Math.PI)" *="" math.asin="" (c/a);="" return="" a*math.pow(2,-10*t)="" *="" math.sin(="" (t*d-s)*(2*math.pi)/p="" )="" +="" c="" +="" b;="" },="" easeinoutelastic:="" function="" (t,="" b,="" c,="" d)="" {="" jshint="" eqeqeq:="" false,="" -w041:="" true="" var="" s="1.70158;var" p="0;var" a="c;" if="" (t="=0)" return="" b;="" if="" ((t/="d/2)==2)" return="" b+c;="" if="" (!p)="" p="d*(0.3*1.5);" if="" (a="">< math.abs(c))="" {="" a="c;" s="p/4;" }="" else="" s="p/(2*Math.PI)" *="" math.asin="" (c/a);="" if="" (t="">< 1)="" return="" -0.5*(a*math.pow(2,10*(t-="1))" *="" math.sin(="" (t*d-s)*(2*math.pi)/p="" ))="" +="" b;="" return="" a*math.pow(2,-10*(t-="1))" *="" math.sin(="" (t*d-s)*(2*math.pi)/p="" )*0.5="" +="" c="" +="" b;="" },="" easeinback:="" function="" (t,="" b,="" c,="" d,="" s)="" {="" jshint="" eqeqeq:="" false,="" -w041:="" true="" if="" (s="=" undefined)="" s="1.70158;" return="" c*(t/="d)*t*((s+1)*t" -="" s)="" +="" b;="" },="" easeoutback:="" function="" (t,="" b,="" c,="" d,="" s)="" {="" jshint="" eqeqeq:="" false,="" -w041:="" true="" if="" (s="=" undefined)="" s="1.70158;" return="" c*((t="t/d-1)*t*((s+1)*t" +="" s)="" +="" 1)="" +="" b;="" },="" easeinoutback:="" function="" (t,="" b,="" c,="" d,="" s)="" {="" jshint="" eqeqeq:="" false,="" -w041:="" true="" if="" (s="=" undefined)="" s="1.70158;" if="" ((t/="d/2)">< 1)="" return="" c/2*(t*t*(((s*="(1.525))+1)*t" -="" s))="" +="" b;="" return="" c/2*((t-="2)*t*(((s*=(1.525))+1)*t" +="" s)="" +="" 2)="" +="" b;="" },="" easeinbounce:="" function="" (t,="" b,="" c,="" d)="" {="" return="" c="" -="" service.animations.easeoutbounce="" (d-t,="" 0,="" c,="" d)="" +="" b;="" },="" easeoutbounce:="" function="" (t,="" b,="" c,="" d)="" {="" if="" ((t/="d)">< (1/2.75))="" {="" return="" c*(7.5625*t*t)="" +="" b;="" }="" else="" if="" (t="">< (2/2.75))="" {="" return="" c*(7.5625*(t-="(1.5/2.75))*t" +="" 0.75)="" +="" b;="" }="" else="" if="" (t="">< (2.5/2.75))="" {="" return="" c*(7.5625*(t-="(2.25/2.75))*t" +="" 0.9375)="" +="" b;="" }="" else="" {="" return="" c*(7.5625*(t-="(2.625/2.75))*t" +="" 0.984375)="" +="" b;="" }="" },="" easeinoutbounce:="" function="" (t,="" b,="" c,="" d)="" {="" if="" (t="">< d/2)="" return="" service.animations.easeinbounce="" (t*2,="" 0,="" c,="" d)="" *="" 0.5="" +="" b;="" return="" service.animations.easeoutbounce="" (t*2-d,="" 0,="" c,="" d)="" *="" 0.5="" +="" c*0.5="" +="" b;="" }="" };="" return="" service;="" }]);="" 'use="" strict';="" angular.module('angular-svg-round-progress')="" .directive('roundprogress',="" ['$window',="" 'roundprogressservice',="" 'roundprogressconfig',="" function($window,="" service,="" roundprogressconfig){="" var="" base="{" restrict:="" "ea",="" replace:="" true,="" transclude:="" true,="" scope:{="" current:="" "=", max: " =",="" semi:="" "=", rounded: " =",="" clockwise:="" "=", responsive: " =",="" radius:="" "@",="" color:="" "@",="" bgcolor:="" "@",="" stroke:="" "@",="" duration:="" "@",="" animation:="" "@",="" offset:="" "@"="" }="" };="" if(!service.issupported){="" return="" angular.extend(base,="" {="" placeholder="" element="" to="" keep="" the="" structure="" template:="">
' }); } return angular.extend(base, { link: function(scope, element){ var isNested = !element.hasClass('round-progress-wrapper'); var svg = isNested ? element : element.find('svg').eq(0); var ring = svg.find('path').eq(0); var background = svg.find('circle').eq(0); var options = angular.copy(roundProgressConfig); var lastAnimationId; var parentChangedListener; scope.getOptions = function(){ return options; }; var renderCircle = function(){ var isSemicircle = options.semi; var responsive = options.responsive; var radius = +options.radius || 0; var stroke = +options.stroke; var diameter = radius*2; var backgroundSize = radius - (stroke/2) - service.getOffset(element, options); svg.css({ "top": 0, "left": 0, "position": responsive ? "absolute" : "static", "width": responsive ? "100%" : (diameter + "px"), "height": responsive ? "100%" : (isSemicircle ? radius : diameter) + "px", "overflow": "hidden" // on some browsers the background overflows, if in semicircle mode }); // when nested, the element shouldn't define its own viewBox if(!isNested){ // note that we can't use .attr, because if jQuery is loaded, // it lowercases all attributes and viewBox is case-sensitive svg[0].setAttribute('viewBox', '0 0 ' + diameter + ' ' + (isSemicircle ? radius : diameter)); element.css({ "width": responsive ? "100%" : "auto", "position": "relative", "padding-bottom": responsive ? (isSemicircle ? "50%" : "100%") : 0 }); } element.css({ "width": responsive ? "100%" : "auto", "position": "relative", "padding-bottom": responsive ? (isSemicircle ? "50%" : "100%") : 0 }); ring.css({ "stroke": service.resolveColor(options.color), "stroke-width": stroke, "stroke-linecap": options.rounded ? "round": "butt" }); if(isSemicircle){ ring.attr("transform", options.clockwise ? "translate("+ 0 +","+ diameter +") rotate(-90)" : "translate("+ diameter +", "+ diameter +") rotate(90) scale(-1, 1)"); }else{ ring.attr("transform", options.clockwise ? "" : "scale(-1, 1) translate("+ (-diameter) +" 0)"); } background.attr({ "cx": radius, "cy": radius, "r": backgroundSize >= 0 ? backgroundSize : 0 }).css({ "stroke": service.resolveColor(options.bgcolor), "stroke-width": stroke }); }; var renderState = function(newValue, oldValue, preventAnimationOverride){ var max = service.toNumber(options.max || 0); var end = newValue > 0 ? $window.Math.min(newValue, max) : 0; var start = (oldValue === end || oldValue < 0)="" 0="" :="" (oldvalue="" ||="" 0);="" fixes="" the="" initial="" animation="" var="" changeinvalue="end" -="" start;="" var="" easinganimation="service.animations[options.animation];" var="" starttime="new" $window.date();="" var="" duration="+options.duration" ||="" 0;="" var="" preventanimation="preventAnimationOverride" ||="" (newvalue=""> max && oldValue > max) || (newValue < 0="" &&="" oldvalue="">< 0)="" ||="" duration="">< 25;="" var="" radius="options.radius;" var="" circlesize="radius" -="" (options.stroke/2)="" -="" service.getoffset(element,="" options);="" var="" elementsize="radius*2;" var="" issemicircle="options.semi;" stops="" some="" expensive="" animating="" if="" the="" value="" is="" above="" the="" max="" or="" under="" 0="" if(preventanimation){="" service.updatestate(end,="" max,="" circlesize,="" ring,="" elementsize,="" issemicircle);="" }else{="" $window.cancelanimationframe(lastanimationid);="" (function="" animation(){="" var="" currenttime="$window.Math.min(new" date()="" -="" starttime,="" duration);="" service.updatestate(="" easinganimation(currenttime,="" start,="" changeinvalue,="" duration),="" max,="" circlesize,="" ring,="" elementsize,="" issemicircle);="" if(currenttime="">< duration){="" lastanimationid="$window.requestAnimationFrame(animation);" }="" })();="" }="" };="" var="" keys="Object.keys(base.scope).filter(function(key){" return="" key="" !="=" 'current';="" });="" properties="" that="" are="" used="" only="" for="" presentation="" scope.$watchgroup(keys,="" function(newvalue){="" for(var="" i="0;" i="">< newvalue.length;="" i++){="" if(typeof="" newvalue[i]="" !="=" 'undefined'){="" options[keys[i]]="newValue[i];" }="" }="" rendercircle();="" scope.$broadcast('$parentoffsetchanged');="" it="" doesn't="" have="" to="" listen="" for="" changes="" on="" the="" parent="" unless="" it="" inherits="" if(options.offset="==" 'inherit'="" &&="" !parentchangedlistener){="" parentchangedlistener="scope.$on('$parentOffsetChanged'," function(){="" renderstate(scope.current,="" scope.current,="" true);="" rendercircle();="" });="" }else="" if(options.offset="" !="=" 'inherit'="" &&="" parentchangedlistener){="" parentchangedlistener();="" }="" });="" properties="" that="" are="" used="" during="" animation.="" some="" of="" these="" overlap="" with="" the="" ones="" that="" are="" used="" for="" presentation="" scope.$watchgroup(['current',="" 'max',="" 'animation',="" 'duration',="" 'radius',="" 'stroke',="" 'semi',="" 'offset'],="" function(newvalue,="" oldvalue){="" renderstate(service.tonumber(newvalue[0]),="" service.tonumber(oldvalue[0]));="" });="" },="" template:="" function(element){="" var="" parent="element.parent();" var="" directivename='round-progress' ;="" var="" template="[">', '', '', '', '' ]; while(parent.length && !service.isDirective(parent)){ parent = parent.parent(); } if(!parent || !parent.length){ template.unshift('
'); template.push('
'); } return template.join('\n'); } }); }]);