Pediatric Online Patient Message

YOU WILL NOT RECEIVE AN ELECTRONIC RESPONSE FROM PEDIATRIC STAFF!

If you have not received a phone call from the Pediatric office within 4 hours of submitting a request regarding your sick child, please call our office at 252-451-3100. Please do not send more than one message per patient within 24 hours. All submissions regarding prescription refills, shot records, forms or basic information should receive a response within 24 to 48 hours by phone.

Online Messaging is available Monday - Friday, 8:30am - 5:00pm. It is not available after hours and weekends.

Complete the fields below and submit your message:

Date:

*Patient Name: *DOB:

*Phone Number:

Name & Relationship to Patient:

*Patient's Physician:

Patient Allergies:

Pharmacy:

Please check any of the below symptoms your child may be experiencing:

Fever

Diarrhea

Nausea/Vomiting

Congestion

Cough

Runny/Stuffy Nose


	Problems Sleeping			Problems Voiding/Bowel			Problems Eating/Drinking

Other:

Additional Information/Concerns:

Boice-Willis Clinic Pediatrics is not responsible for any submission not received due to firewalls, antivirus programs or other technical difficulties. If you have not received a response regarding a sick patient within 4 hours, please contact our office by phone at 252-451-3100. Please note this form should be submitted during normal business hours only. If you need to speak to a physician or nurse after hours, please refer to our after hours contact information by clicking here.