Remember, to communicate with us through the web or by e-mail, you must first have signed an e-mail consent form in our office. If you e-mail us without first giving us your written consent, we will be unable to respond to or act on the message. Please enter the following information: Child's name: Child's date of birth: Medication and dose: Pharmacy: Bell Pharmacy CVS Pharmacy Eckerd Pharmacy John Smith Pharmacy K-Mart Pharmacy Kroger Pharmacy Medicine Shoppe Plaza Drug Center Wal-Mart Pharmacy Other [specify below] Comments: Your name: Your e-mail address: Click here to send: Return to our home page Last revised 5/14/04 (C) 2001, 2002, 2003 Plateau Pediatrics, PLC. Contact us. Please view important information about this web site.
Remember, to communicate with us through the web or by e-mail, you must first have signed an e-mail consent form in our office. If you e-mail us without first giving us your written consent, we will be unable to respond to or act on the message. Please enter the following information: Child's name: Child's date of birth: Medication and dose: Pharmacy: Bell Pharmacy CVS Pharmacy Eckerd Pharmacy John Smith Pharmacy K-Mart Pharmacy Kroger Pharmacy Medicine Shoppe Plaza Drug Center Wal-Mart Pharmacy Other [specify below] Comments: Your name: Your e-mail address: Click here to send:
Please enter the following information:
Child's name: Child's date of birth: Medication and dose: Pharmacy: Bell Pharmacy CVS Pharmacy Eckerd Pharmacy John Smith Pharmacy K-Mart Pharmacy Kroger Pharmacy Medicine Shoppe Plaza Drug Center Wal-Mart Pharmacy Other [specify below] Comments: Your name: Your e-mail address:
Child's name:
Child's date of birth:
Medication and dose:
Pharmacy: Bell Pharmacy CVS Pharmacy Eckerd Pharmacy John Smith Pharmacy K-Mart Pharmacy Kroger Pharmacy Medicine Shoppe Plaza Drug Center Wal-Mart Pharmacy Other [specify below]
Comments:
Your name:
Your e-mail address:
Click here to send:
Return to our home page
Last revised 5/14/04
(C) 2001, 2002, 2003 Plateau Pediatrics, PLC. Contact us. Please view important information about this web site.