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Proud member
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
Office Forms and Policies
Vaccine Policy
Request Camp Forms
Request School Forms
Request Prenatal Visit
Request Medication Refills
Accepted Insurances
FAQ
Medical Resources
Schedule of Immunizations
Schedule of Well Visits
PPA Mental health tips
Symptom Checker
Contact
Pay My Bill
Request Camp Forms
To request camp form, please fill out the information below and make a payment. Please allow our office up to 48 BUSINESS hours to complete your request.
"
*
" indicates required fields
Child's Name
First Name
*
First
Last Name
*
Last
Child's Date of Birth
*
Month
Day
Year
Upload Medication or Allergy Forms
Drop files here or
Select files
Max. file size: 2 MB, Max. files: 5.
Upload Camp Forms
Drop files here or
Select files
Max. file size: 2 MB, Max. files: 5.
Vaccination History
*
Select From Below
Vaccination History - Qty: 0
Vaccination History - Qty: 1
Vaccination History - Qty: 2
Vaccination History - Qty: 3
$0 - No Cost
Over the Counter Medication Form
*
Select From Below
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 *Must upload form to be filled in
Allergy & Rx Meds Form
*
Select From Below
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 *Must upload form to be filled in
Questions for camp form.
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
*
Contact Email
*
Delivery Method
*
Pick Up
Email
For a $20 convenience fee, the forms may be emailed to you.
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