SECURE MESSAGE

Name: Pediatric People
Price range: $

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Patient's Name*

Patient's Date of Birth*

Phone*

Email*

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Medication refill requests CANNOT be requested here. To request a medication refill, follow these steps:

1. Login to the patient portal.

2. Click the "Request a Medication Refill" tile (see below).

3. Click the "Refill" link located on the right-hand side of the page (see below).

Upload Insurance Card - Front*

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Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, txt, heif, jpeg, Max. file size: 512 MB, Max. files: 1.

Upload Insurance Card - Back*

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Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, txt, heif, jpeg, Max. file size: 512 MB, Max. files: 1.

Name of Primary Insured*

Primary Insured Date of Birth*

Upload Files

DO NOT upload images or photos for medical diagnosis or evaluation.

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Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, txt, heif, jpeg, Max. file size: 512 MB, Max. files: 15.

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