graphic: kids

Is Your Child Sick?TM

Visual Symptom Checker


Medical Emergency:
Poison Control:

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

(808) 524-2575

Prescription Refill Request

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Patient Information

Date of Birth:

Guardian Information

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




Prescription Information

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


If Send to Pharmacy




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.: