Are you new to the practice?

    • [[{"field_id":12814,"subrules":{"field_id":12813,"value":"Yes","operator":"Match"}}],[{"field_id":12814,"subrules":{"field_id":12813,"value":"No","operator":"Match"}}]]

What type of visit would you like to schedule?

    • [[{"field_id":12815,"subrules":{"field_id":12814,"value":"Well Child Visit","operator":"Match"}}],[{"field_id":12819,"subrules":{"field_id":12814,"value":"Sick visit","operator":"Match"}}]]

How many children do you have?

    • [[{"field_id":12816,"subrules":{"field_id":12815,"value":"1 child","operator":"Match"}}]]

How old is your child?

    • [[{"field_id":12817,"subrules":{"field_id":12816,"value":"Less than 1 month","operator":"Match"}}],[{"field_id":12818,"subrules":{"field_id":12816,"value":"Greater than 1 month and less than 13 year","operator":"Match"}}],[{"field_id":12820,"subrules":{"field_id":12816,"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":12821,"subrules":{"field_id":12819,"value":"1 child","operator":"Match"}}]]

How old is your child?

    • [[{"field_id":12823,"subrules":{"field_id":12821,"value":"Less than 2 month","operator":"Match"}}],[{"field_id":12829,"subrules":{"field_id":12821,"value":"Greater than 2 month and less than 13 year","operator":"Match"}}],[{"field_id":12830,"subrules":{"field_id":12821,"value":"Greater than or equal to 13 year","operator":"Match"}}]]

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

    • [[{"field_id":12831,"subrules":{"field_id":12823,"value":"Congestion","operator":"Match"}}],[{"field_id":12831,"subrules":{"field_id":12823,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":12831,"subrules":{"field_id":12823,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":12831,"subrules":{"field_id":12823,"value":"Ear Pain","operator":"Match"}}],[{"field_id":12831,"subrules":{"field_id":12823,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":12831,"subrules":{"field_id":12823,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":12831,"subrules":{"field_id":12823,"value":"Sore Throat","operator":"Match"}}]]

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

    • [[{"field_id":12832,"subrules":{"field_id":12829,"value":"Fever greater than 100.4","operator":"Match"}}],[{"field_id":12832,"subrules":{"field_id":12829,"value":"Rash","operator":"Match"}}],[{"field_id":12832,"subrules":{"field_id":12829,"value":"Congestion","operator":"Match"}}],[{"field_id":12832,"subrules":{"field_id":12829,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":12832,"subrules":{"field_id":12829,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":12832,"subrules":{"field_id":12829,"value":"Ear Pain","operator":"Match"}}],[{"field_id":12832,"subrules":{"field_id":12829,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":12832,"subrules":{"field_id":12829,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":12832,"subrules":{"field_id":12829,"value":"Sore Throat","operator":"Match"}}]]

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

    • [[{"field_id":12833,"subrules":{"field_id":12830,"value":"Fever greater than 100.4","operator":"Match"}}],[{"field_id":12833,"subrules":{"field_id":12830,"value":"Rash","operator":"Match"}}],[{"field_id":12833,"subrules":{"field_id":12830,"value":"Congestion","operator":"Match"}}],[{"field_id":12833,"subrules":{"field_id":12830,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":12833,"subrules":{"field_id":12830,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":12833,"subrules":{"field_id":12830,"value":"Ear Pain","operator":"Match"}}],[{"field_id":12833,"subrules":{"field_id":12830,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":12833,"subrules":{"field_id":12830,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":12833,"subrules":{"field_id":12830,"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: