Are you a new patient or an existing patient?

    • [[{"field_id":16779,"subrules":{"field_id":16778,"value":"New Patient","operator":"Match"}}],[{"field_id":16779,"subrules":{"field_id":16778,"value":"Existing Patient","operator":"Match"}}]]

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

    • [[{"field_id":16780,"subrules":{"field_id":16779,"value":"Well visit","operator":"Match"}}],[{"field_id":16785,"subrules":{"field_id":16779,"value":"Sick visit","operator":"Match"}}]]

How many children do you have?

    • [[{"field_id":16781,"subrules":{"field_id":16780,"value":"1 child","operator":"Match"}}]]

How old is your child?

    • [[{"field_id":16782,"subrules":{"field_id":16781,"value":"Newborn to 1 month old","operator":"Match"}}],[{"field_id":16783,"subrules":{"field_id":16781,"value":"Between 1 month old and 13 years old","operator":"Match"}}],[{"field_id":16784,"subrules":{"field_id":16781,"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":16787,"subrules":{"field_id":16785,"value":"1 child","operator":"Match"}}]]

How old is your child?

    • [[{"field_id":16788,"subrules":{"field_id":16787,"value":"Newborn to 2 months old","operator":"Match"}}],[{"field_id":16789,"subrules":{"field_id":16787,"value":"Between 2 months old and 13 years old","operator":"Match"}}],[{"field_id":16790,"subrules":{"field_id":16787,"value":"13 years old or older","operator":"Match"}}]]

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

    • [[{"field_id":16791,"subrules":{"field_id":16788,"value":"Congestion","operator":"Match"}}],[{"field_id":16791,"subrules":{"field_id":16788,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":16791,"subrules":{"field_id":16788,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":16791,"subrules":{"field_id":16788,"value":"Ear pain","operator":"Match"}}],[{"field_id":16791,"subrules":{"field_id":16788,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":16791,"subrules":{"field_id":16788,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":16791,"subrules":{"field_id":16788,"value":"Sore throat","operator":"Match"}}]]

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

    • [[{"field_id":16792,"subrules":{"field_id":16789,"value":"Congestion","operator":"Match"}}],[{"field_id":16792,"subrules":{"field_id":16789,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":16792,"subrules":{"field_id":16789,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":16792,"subrules":{"field_id":16789,"value":"Ear pain","operator":"Match"}}],[{"field_id":16792,"subrules":{"field_id":16789,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":16792,"subrules":{"field_id":16789,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":16792,"subrules":{"field_id":16789,"value":"Sore throat","operator":"Match"}}]]

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

    • [[{"field_id":16793,"subrules":{"field_id":16790,"value":"Congestion","operator":"Match"}}],[{"field_id":16793,"subrules":{"field_id":16790,"value":"Nausea and vomiting for less than 24 hours\n\n

    <\/p>\n","operator":"Match"}}],[{"field_id":16793,"subrules":{"field_id":16790,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":16793,"subrules":{"field_id":16790,"value":"Ear pain","operator":"Match"}}],[{"field_id":16793,"subrules":{"field_id":16790,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":16793,"subrules":{"field_id":16790,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":16793,"subrules":{"field_id":16790,"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: