Are you a new patient or Existing Patient?

    • [[{"field_id":12906,"subrules":{"field_id":12905,"value":"Existing Patient","operator":"Match"}}]]

What type of visit would you like to schedule?

    • [[{"field_id":12907,"subrules":{"field_id":12906,"value":"Well visit","operator":"Match"}}],[{"field_id":12912,"subrules":{"field_id":12906,"value":"Sick visit","operator":"Match"}}]]

How many children do you have?

    • [[{"field_id":12908,"subrules":{"field_id":12907,"value":"1 child","operator":"Match"}}]]

How old is your child?

    • [[{"field_id":12909,"subrules":{"field_id":12908,"value":"Less than 1 month","operator":"Match"}}],[{"field_id":12910,"subrules":{"field_id":12908,"value":"Greater than 1 month and less than 13 year","operator":"Match"}}],[{"field_id":12911,"subrules":{"field_id":12908,"value":"Greater than or equal to 13 year","operator":"Match"}}]]

Tell us a little more about your delivery and newborn:

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

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":12913,"subrules":{"field_id":12912,"value":"1 child","operator":"Match"}}]]

Is this a follow- up to a  hospitalization  or emergency  room visit?

    • [[{"field_id":12914,"subrules":{"field_id":12913,"value":"Yes","operator":"Match"}}],[{"field_id":12914,"subrules":{"field_id":12913,"value":"No","operator":"Match"}}]]

How old is your child?

    • [[{"field_id":12915,"subrules":{"field_id":12914,"value":"Less than 2 month","operator":"Match"}}],[{"field_id":12916,"subrules":{"field_id":12914,"value":"Greater than 2 month and less than 13 year","operator":"Match"}}],[{"field_id":12917,"subrules":{"field_id":12914,"value":"Greater than or equal to 13 year","operator":"Match"}}]]

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

    • [[{"field_id":12918,"subrules":{"field_id":12915,"value":"Congestion","operator":"Match"}}],[{"field_id":12918,"subrules":{"field_id":12915,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":12918,"subrules":{"field_id":12915,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":12918,"subrules":{"field_id":12915,"value":"Ear Pain","operator":"Match"}}],[{"field_id":12918,"subrules":{"field_id":12915,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":12918,"subrules":{"field_id":12915,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":12918,"subrules":{"field_id":12915,"value":"Sore Throat","operator":"Match"}}]]

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

    • [[{"field_id":12919,"subrules":{"field_id":12916,"value":"Fever greater than 100.4","operator":"Match"}}],[{"field_id":12919,"subrules":{"field_id":12916,"value":"Rash","operator":"Match"}}],[{"field_id":12919,"subrules":{"field_id":12916,"value":"Congestion","operator":"Match"}}],[{"field_id":12919,"subrules":{"field_id":12916,"value":"Nausea and vomiting for less than 24 hours\n","operator":"Match"}}],[{"field_id":12919,"subrules":{"field_id":12916,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":12919,"subrules":{"field_id":12916,"value":"Ear Pain","operator":"Match"}}],[{"field_id":12919,"subrules":{"field_id":12916,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":12919,"subrules":{"field_id":12916,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":12919,"subrules":{"field_id":12916,"value":"Sore Throat","operator":"Match"}}]]

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

    • [[{"field_id":12920,"subrules":{"field_id":12917,"value":"Fever greater than 100.4","operator":"Match"}}],[{"field_id":12920,"subrules":{"field_id":12917,"value":"Rash","operator":"Match"}}],[{"field_id":12920,"subrules":{"field_id":12917,"value":"Congestion","operator":"Match"}}],[{"field_id":12920,"subrules":{"field_id":12917,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":12920,"subrules":{"field_id":12917,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":12920,"subrules":{"field_id":12917,"value":"Ear Pain","operator":"Match"}}],[{"field_id":12920,"subrules":{"field_id":12917,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":12920,"subrules":{"field_id":12917,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":12920,"subrules":{"field_id":12917,"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:

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

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