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PNA Announcements

By agreeing to the following terms and conditions I am aware that:

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Pediatric Neurology Associates (PNA) takes appropriate security measures to insure your privacy, but as with most online transactions and methods of communication, any information sent over this medium, personal or private, could potentially be intercepted by another internet user while in transit to us. PNA advises that any information the sender deems confidential should not be transmitted through this form of communication.

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I have read & agree to the terms above.
Patient First Name:
Patient Last Name:
Patient Date of Birth:	xx/xx/xx
Parent/Guardian First Name:
Parent/Guardian Last Name:
Best Contact Phone #:	Between 9AM and 5PM
Best time to call:
Email:
I would like to reschedule or make a follow-up appointment (Please note, this is not an appointment confirmation)
My preferred day:
My preferred appointment time:
My preferred location is:
I will need an interpreter:
I want to cancel my appointment for this date:	xx/xx/xx Time:
Prescriptions
I need a refill:
This is the prescription I need refilled:
Call or fax my refill:
Pharmacy name:
Pharmacy phone or fax- including area code:
Please mail my prescription to me:
I will pick up my prescription. Please call me:
Other
My child had completed:
My child is having medical concerns:

I would like to reschedule or make a follow-up appointment

Prescriptions

Other

I would like to reschedule or make a
follow-up appointment