Are you a new patient or an existing patient?

  • [[{"field_id":20438,"subrules":{"field_id":20437,"value":"New Patient","operator":"Match"}}],[{"field_id":20438,"subrules":{"field_id":20437,"value":"Existing Patient","operator":"Match"}}]]

Welcome to our practice! What type of visit would you like to schedule.

  • [[{"field_id":20439,"subrules":{"field_id":20438,"value":"Well visit","operator":"Match"}}],[{"field_id":20444,"subrules":{"field_id":20438,"value":"Sick visit","operator":"Match"}}]]

How many children do you have?

  • [[{"field_id":20440,"subrules":{"field_id":20439,"value":"1 child","operator":"Match"}}]]

How old is your child?

  • [[{"field_id":20442,"subrules":{"field_id":20440,"value":"3 months or older","operator":"Match"}}]]

To help us serve you better, please let us know if your child has any of the following medical conditions:

How many children do you have?

  • [[{"field_id":20445,"subrules":{"field_id":20444,"value":"1 child","operator":"Match"}}]]

How old is your child?

  • [[{"field_id":20447,"subrules":{"field_id":20445,"value":"3 months or older","operator":"Match"}}]]

What symptoms is your child experiencing (please check all that apply)?

  • [[{"field_id":20450,"subrules":{"field_id":20447,"value":"Congestion","operator":"Match"}}],[{"field_id":20450,"subrules":{"field_id":20447,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":20450,"subrules":{"field_id":20447,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":20450,"subrules":{"field_id":20447,"value":"Ear pain","operator":"Match"}}],[{"field_id":20450,"subrules":{"field_id":20447,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":20450,"subrules":{"field_id":20447,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":20450,"subrules":{"field_id":20447,"value":"Sore throat","operator":"Match"}}]]

To help us serve you better, please let us know if your child has any of the following medical conditions: