Catalina Pediatrics Web Site

Thank you for submitting a medication refill request by using our website.  Please confirm the information below.  If any is incorrect, use your browser's BACK button, correct the information, and re-submit the form.  If you do not hear from us (by telephone or email) within 3 business days, then please call our office to inquire about your request.

Your Name:  Parent_Name

Patient's Name:  Patient_Name

Patient's Date of Birth:  Patient_DOB

Your Email Address:  Email_Address

Contact Phone Number:  Patient_Phone_Number

Your Pediatrician:  Pediatrician

Medication:  Medication

Dosage:  Dosage

Pharmacy:  Pharmacy

Pharmacy Phone Number:  Pharmacy_Phone

Special Requests:  Special_Request

If you find a problem with this website (such as an incorrect hyperlink), please email the webmaster by clicking HERE.