graphic: kids

Is Your Child Sick?TM

Emergencies

Medical Emergency:
Poison Control:

Office After Hours:
Call 911
(800) 222-1222

(808) 524-2575

Appointment Request

Patient Information




Patient's DOB:
CalendarNow


Guardian Information




Telephone number you can be reached at during the day.

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Schedule Information




Authorization

Electronic Signature

By entering my name below, I understand that I am providing an electronic signature which will serve as an affirmation that I'm the parent/legal guardian of the patient entered above.: