graphic: kids

Is Your Child Sick?TM

Visual Symptom Checker

Emergencies

Medical Emergency:
Poison Control:

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

(808) 524-2575

Prescription Refill Request

Patient Information




Date of Birth:
CalendarNow



Guardian Information




* Telephone number(s) you can be reached at during the day.:

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Prescription Information

NOTE: All Class II medications (Ritalin, Adderall, Concerta, Metadate,etc) must be picked up at the office:


 
 

If Send to Pharmacy

 

 
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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.: