Are you a new patient or an existing patient?

    • [[{"field_id":17112,"subrules":{"field_id":17111,"value":"New Patient","operator":"Match"}}],[{"field_id":17112,"subrules":{"field_id":17111,"value":"Existing Patient","operator":"Match"}}]]

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

    • [[{"field_id":17113,"subrules":{"field_id":17112,"value":"Well visit","operator":"Match"}}],[{"field_id":17118,"subrules":{"field_id":17112,"value":"Sick visit","operator":"Match"}}]]

How many children do you have?

    • [[{"field_id":17114,"subrules":{"field_id":17113,"value":"1 child","operator":"Match"}}]]

How old is your child?

    • [[{"field_id":17115,"subrules":{"field_id":17114,"value":"Newborn to 1 month old","operator":"Match"}}],[{"field_id":17116,"subrules":{"field_id":17114,"value":"Between 1 month old and 13 years old","operator":"Match"}}],[{"field_id":17117,"subrules":{"field_id":17114,"value":"13 years old or older","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":17119,"subrules":{"field_id":17118,"value":"1 child","operator":"Match"}}]]

How old is your child?

    • [[{"field_id":17120,"subrules":{"field_id":17119,"value":"Newborn to 2 months old","operator":"Match"}}],[{"field_id":17121,"subrules":{"field_id":17119,"value":"Between 2 months old and 13 years old","operator":"Match"}}],[{"field_id":17122,"subrules":{"field_id":17119,"value":"13 years old or older","operator":"Match"}}]]

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

    • [[{"field_id":17123,"subrules":{"field_id":17120,"value":"Congestion","operator":"Match"}}],[{"field_id":17123,"subrules":{"field_id":17120,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":17123,"subrules":{"field_id":17120,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":17123,"subrules":{"field_id":17120,"value":"Ear pain","operator":"Match"}}],[{"field_id":17123,"subrules":{"field_id":17120,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":17123,"subrules":{"field_id":17120,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":17123,"subrules":{"field_id":17120,"value":"Sore throat","operator":"Match"}}]]

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

    • [[{"field_id":17124,"subrules":{"field_id":17121,"value":"Congestion","operator":"Match"}}],[{"field_id":17124,"subrules":{"field_id":17121,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":17124,"subrules":{"field_id":17121,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":17124,"subrules":{"field_id":17121,"value":"Ear pain","operator":"Match"}}],[{"field_id":17124,"subrules":{"field_id":17121,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":17124,"subrules":{"field_id":17121,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":17124,"subrules":{"field_id":17121,"value":"Sore throat","operator":"Match"}}]]

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

    • [[{"field_id":17125,"subrules":{"field_id":17122,"value":"Congestion","operator":"Match"}}],[{"field_id":17125,"subrules":{"field_id":17122,"value":"Nausea and vomiting for less than 24 hours\n\n

    <\/p>\n","operator":"Match"}}],[{"field_id":17125,"subrules":{"field_id":17122,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":17125,"subrules":{"field_id":17122,"value":"Ear pain","operator":"Match"}}],[{"field_id":17125,"subrules":{"field_id":17122,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":17125,"subrules":{"field_id":17122,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":17125,"subrules":{"field_id":17122,"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: