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: Appointment type: Well baby exam School, daycare, sports, or camp physical Immunizations only Recheck of chronic problem Behavioral problem Dietary/nutrition problem Other (please describe below) Remarks (do not include confidential details): Preferred date & time: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 early am (8 am-10 am) late am (10 am-noon) early pm (1 pm-3 pm) late pm (3 pm-5 pm) 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: Appointment type: Well baby exam School, daycare, sports, or camp physical Immunizations only Recheck of chronic problem Behavioral problem Dietary/nutrition problem Other (please describe below) Remarks (do not include confidential details): Preferred date & time: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 early am (8 am-10 am) late am (10 am-noon) early pm (1 pm-3 pm) late pm (3 pm-5 pm) Your name: Your e-mail address: Click here to send:
Please enter the following information:
Child's name: Child's date of birth: Appointment type: Well baby exam School, daycare, sports, or camp physical Immunizations only Recheck of chronic problem Behavioral problem Dietary/nutrition problem Other (please describe below) Remarks (do not include confidential details): Preferred date & time: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 early am (8 am-10 am) late am (10 am-noon) early pm (1 pm-3 pm) late pm (3 pm-5 pm) Your name: Your e-mail address:
Child's name:
Child's date of birth:
Appointment type: Well baby exam School, daycare, sports, or camp physical Immunizations only Recheck of chronic problem Behavioral problem Dietary/nutrition problem Other (please describe below)
Remarks (do not include confidential details):
Preferred date & time: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 early am (8 am-10 am) late am (10 am-noon) early pm (1 pm-3 pm) late pm (3 pm-5 pm)
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.