Pediatric Online Patient Message

Pediatric Online Patient Message

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.

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Patient Name(*)
Patient name is required.

Date of Birth(*)
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please use date format "mm/dd/yyyy"

Phone Number(*)
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Name & Relationship to Patient
Please let us know your first name.

Patient's Physician(*)
Please select a Physician

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

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Additional Information/Concerns
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(Maximum characters: 255)
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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.

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