For the convenience of our patients, the New Patient and Slide Fee Forms that you will need for your visit to our Primary Care and Dental Care centers are located below. Please print the forms and bring them with you completed to your visit with us. We look forward to serving your families Health and Dental Care Needs.
Apply for our sliding fee program. Our current slide fee program starts as low as $10 for a visit & includes most labs.
As a Federally Qualifying Health Center, we may be able to discount your deductible if you have Medicare and qualify for the sliding fee program.
Make sure to download the additional forms for your center below.
Crestview Health Center & Crestview Dental Center – Crestview, Florida
Eastpoint Medical Center – Eastpoint, Florida
Family Medical Practice – Cross City, Florida
Jessie Furlow Medical Center – Quincy Florida
Chiropractic New Patient Packet English | Spanish (undergoing translation)
River Valley Medical Center – Mayo, Florida
Taylor Medical Center – Perry, Florida
Madison Medical Center – Madison, Florida
Wakulla Medical Center – Panacea, Florida
Wewahitchka Medical Center – Wewahitchka, Florida
Medical Release Forms
If you are moving to another practice or need a copy of your records for a specialty provider the forms for those are listed below:
Limited Medical Records Release Form (when you only want to release specific results- ie for a specialist)
Full Medical Records Release Form (when you want a full copy of your records)