Are you a new patient or Existing Patient?

    • [[{"field_id":12776,"subrules":{"field_id":12774,"value":"Existing Patient","operator":"Match"}}]]

What type of visit would you like to schedule?

    • [[{"field_id":12777,"subrules":{"field_id":12776,"value":"Well visit","operator":"Match"}}],[{"field_id":12785,"subrules":{"field_id":12776,"value":"Sick visit","operator":"Match"}}]]

How many children do you have?

    • [[{"field_id":12778,"subrules":{"field_id":12777,"value":"1 child","operator":"Match"}}]]

How old is your child?

    • [[{"field_id":12779,"subrules":{"field_id":12778,"value":"Less than 1 month","operator":"Match"}}],[{"field_id":12780,"subrules":{"field_id":12778,"value":"Greater than 1 month and less than 13 year","operator":"Match"}}],[{"field_id":12784,"subrules":{"field_id":12778,"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":12786,"subrules":{"field_id":12785,"value":"1 child","operator":"Match"}}]]

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

    • [[{"field_id":12793,"subrules":{"field_id":12786,"value":"Yes","operator":"Match"}}],[{"field_id":12793,"subrules":{"field_id":12786,"value":"No","operator":"Match"}}]]

How old is your child?

    • [[{"field_id":12794,"subrules":{"field_id":12793,"value":"Less than 2 month","operator":"Match"}}],[{"field_id":12796,"subrules":{"field_id":12793,"value":"Greater than 2 month and less than 13 year","operator":"Match"}}],[{"field_id":12797,"subrules":{"field_id":12793,"value":"Greater than or equal to 13 year","operator":"Match"}}]]

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

    • [[{"field_id":12795,"subrules":{"field_id":12794,"value":"Congestion","operator":"Match"}}],[{"field_id":12795,"subrules":{"field_id":12794,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":12795,"subrules":{"field_id":12794,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":12795,"subrules":{"field_id":12794,"value":"Ear Pain","operator":"Match"}}],[{"field_id":12795,"subrules":{"field_id":12794,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":12795,"subrules":{"field_id":12794,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":12795,"subrules":{"field_id":12794,"value":"Sore Throat","operator":"Match"}}]]

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

    • [[{"field_id":12799,"subrules":{"field_id":12796,"value":"Fever greater than 100.4","operator":"Match"}}],[{"field_id":12799,"subrules":{"field_id":12796,"value":"Rash","operator":"Match"}}],[{"field_id":12799,"subrules":{"field_id":12796,"value":"Congestion","operator":"Match"}}],[{"field_id":12799,"subrules":{"field_id":12796,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":12799,"subrules":{"field_id":12796,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":12799,"subrules":{"field_id":12796,"value":"Ear Pain","operator":"Match"}}],[{"field_id":12799,"subrules":{"field_id":12796,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":12799,"subrules":{"field_id":12796,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":12799,"subrules":{"field_id":12796,"value":"Sore Throat","operator":"Match"}}]]

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

    • [[{"field_id":12800,"subrules":{"field_id":12797,"value":"Fever greater than 100.4","operator":"Match"}}],[{"field_id":12800,"subrules":{"field_id":12797,"value":"Rash","operator":"Match"}}],[{"field_id":12800,"subrules":{"field_id":12797,"value":"Congestion","operator":"Match"}}],[{"field_id":12800,"subrules":{"field_id":12797,"value":"Nausea and vomiting for less than 24 hours\n\n

    <\/p>\n","operator":"Match"}}],[{"field_id":12800,"subrules":{"field_id":12797,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":12800,"subrules":{"field_id":12797,"value":"Ear Pain","operator":"Match"}}],[{"field_id":12800,"subrules":{"field_id":12797,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":12800,"subrules":{"field_id":12797,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":12800,"subrules":{"field_id":12797,"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: