Are you a new patient or an existing patient?

    • [[{"field_id":17127,"subrules":{"field_id":17126,"value":"New Patient","operator":"Match"}}],[{"field_id":17127,"subrules":{"field_id":17126,"value":"Existing Patient","operator":"Match"}}]]

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

    • [[{"field_id":17128,"subrules":{"field_id":17127,"value":"Well visit","operator":"Match"}}],[{"field_id":17133,"subrules":{"field_id":17127,"value":"Sick visit","operator":"Match"}}]]

How many children do you have?

    • [[{"field_id":17129,"subrules":{"field_id":17128,"value":"1 child","operator":"Match"}}]]

How old is your child?

    • [[{"field_id":17130,"subrules":{"field_id":17129,"value":"Less than 1 month","operator":"Match"}}],[{"field_id":17131,"subrules":{"field_id":17129,"value":"Greater than 1 month and less than 13 year","operator":"Match"}}],[{"field_id":17132,"subrules":{"field_id":17129,"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?

How old is your child?

    • [[{"field_id":17135,"subrules":{"field_id":17134,"value":"Newborn to 2 months old","operator":"Match"}}],[{"field_id":17136,"subrules":{"field_id":17134,"value":"Between 2 months old and 13 years old","operator":"Match"}}],[{"field_id":17137,"subrules":{"field_id":17134,"value":"13 years old or older","operator":"Match"}}]]

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

    • [[{"field_id":17138,"subrules":{"field_id":17135,"value":"Congestion","operator":"Match"}}],[{"field_id":17138,"subrules":{"field_id":17135,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":17138,"subrules":{"field_id":17135,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":17138,"subrules":{"field_id":17135,"value":"Ear pain","operator":"Match"}}],[{"field_id":17138,"subrules":{"field_id":17135,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":17138,"subrules":{"field_id":17135,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":17138,"subrules":{"field_id":17135,"value":"Sore throat","operator":"Match"}}]]

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

    • [[{"field_id":17139,"subrules":{"field_id":17136,"value":"Fever greater than 100.4","operator":"Match"}}],[{"field_id":17139,"subrules":{"field_id":17136,"value":"Rash","operator":"Match"}}],[{"field_id":17139,"subrules":{"field_id":17136,"value":"Congestion","operator":"Match"}}],[{"field_id":17139,"subrules":{"field_id":17136,"value":"Nausea and vomiting for less than 24 hours","operator":"Match"}}],[{"field_id":17139,"subrules":{"field_id":17136,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":17139,"subrules":{"field_id":17136,"value":"Ear pain","operator":"Match"}}],[{"field_id":17139,"subrules":{"field_id":17136,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":17139,"subrules":{"field_id":17136,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":17139,"subrules":{"field_id":17136,"value":"Sore throat","operator":"Match"}}]]

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

    • [[{"field_id":17140,"subrules":{"field_id":17137,"value":"Fever greater than 100.4","operator":"Match"}}],[{"field_id":17140,"subrules":{"field_id":17137,"value":"Rash","operator":"Match"}}],[{"field_id":17140,"subrules":{"field_id":17137,"value":"Congestion","operator":"Match"}}],[{"field_id":17140,"subrules":{"field_id":17137,"value":"Nausea and vomiting for less than 24 hours\n\n

    <\/p>\n","operator":"Match"}}],[{"field_id":17140,"subrules":{"field_id":17137,"value":"Persistent cough without difficulty breathing","operator":"Match"}}],[{"field_id":17140,"subrules":{"field_id":17137,"value":"Ear pain","operator":"Match"}}],[{"field_id":17140,"subrules":{"field_id":17137,"value":"Eye itchiness or redness","operator":"Match"}}],[{"field_id":17140,"subrules":{"field_id":17137,"value":"Pain with urinating","operator":"Match"}}],[{"field_id":17140,"subrules":{"field_id":17137,"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: