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About
Services
Our Team
Mark Ginsburg, MD
Patricia Jimenez Rivero, DO
Karen Lee Kuhn, MD
Lisa Miller, MD
Jana Myers, MD
Maricarmen Dionisio Santos, MD
Macie Hurtado, MD
Lourdes Roiz, APRN
Office Manager
Patient Resources
Registration Forms
Request Prenatal Visit
Request Medication Refills
Accepted Insurances
FAQ
Vaccine Policy
Medical Resources
Schedule of Immunizations
Schedule of Well Visits
PPA Mental health tips
Symptom Checker
Contact
Pay My Bill
Patient Information Sheet
Financial Responsibility Agreement
Financial Policy for Pediatric Professional Associates
Acknowledgement of Receipt of Notice of Privacy Practices
Request Medical Records from Previous Doctor
Notice of Nondiscrimination Taglines
Notice of Non-Discrimination
Registration Forms & Vaccination Records Request
To request forms, please fill out the information below and make a payment. Please allow our office up to 48 BUSINESS hours to complete your request.
School Registration Forms
Child's Name
First Name
(Required)
First
Last Name
(Required)
Last
School Name
(Required)
Child's Date of Birth
(Required)
Month
Day
Year
Upload School Forms (blank)
Drop files here or
Select files
Max. file size: 2 MB, Max. files: 5.
Upload Medication Forms (blank)
Drop files here or
Select files
Max. file size: 2 MB, Max. files: 5.
School Form 3040 (Yellow)
Form 3040 - Qty: 0
Form 3040 - Qty: 1
Form 3040 - Qty: 2
Form 3040 - Qty: 3
$5 for Form 3040
School Form 680 (Blue)
Form 680 - Qty: 0
Form 680 - Qty: 1
Form 680 - Qty: 2
Form 680 - Qty: 3
$5 for Form 680
Sports Form
Form EL2 - Qty: 0
Form EL2 - Qty: 1
Form EL2 - Qty: 2
Form EL2 - Qty: 3
$20 for Form EL2
Vaccination History
Vaccination History - Qty: 0
Vaccination History - Qty: 1
Vaccination History - Qty: 2
Vaccination History - Qty: 3
$0 - No Cost
Over the Counter Medication Form
OTC Medication Form - Qty: 0
OTC Medication Form - Qty: 1
OTC Medication Form - Qty: 2
OTC Medication Form - Qty: 3
$5 for OTC Meds Form
Allergy & Rx Meds Form
Allergy & Rx Meds Form - Qty: 0
Allergy & Rx Meds Form - Qty: 1
Allergy & Rx Meds Form - Qty: 2
Allergy & Rx Meds Form - Qty: 3
$10 for Allergy & Rx Meds Form
Camp Forms Request
Upload Camp Forms (blank)
Drop files here or
Select files
Max. file size: 2 MB, Max. files: 5.
Questions must be answered for camp forms to be completed.
Will your child be taking any medications at camp this summer?
Yes
No
Will your child be eating a regular or special diet while at camp?
Yes
No
Have there been any changes in your child’s health since their last visit?
Yes
No
Does your child have any medication or food allergies?
Yes
No
Contact Phone
(Required)
Contact Email
(Required)
Delivery Method
(Required)
Pick Up
Email
For a $20 convenience fee, the forms may be emailed to you.
Total
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