Child's Name: Sex: Male  Female Date of Birth: mm/dd/yyyy Chart :# Guarantor: Daytime Phone: Your E-mail Address:     Appointment Type: Please Select... Well Visit Problem-Focused Visit Sports Visit Other Visit IMPORTANT: This should not be used for urgent matters. In emergencies, call your doctor's office, call 911 or visit an emergency room. Physician/Clinician: Please Select... Ana Collazos, MD Cassia Portugal, M.D, FAAP Esther Song, MD Helen Young, MD, FAAP Luisa Carrasquero, MD Rosemarie Sison, MD No Preference     Appointment Choice 1:   AM   PM Appointment Choice 2:   AM   PM     Comments:     Copyright © 2003 - First Choice Pediatrics