New or Established Patient * New PatientEstablished Patient Date of Birth * Sex * —Please choose an option—MaleFemalePrefer not to say Payment Method * —Please choose an option—Self-PayMedicaidCommercial Your Medical Home * Almouie Pediatrics Location You Prefer to Visit * —Please choose an option— Tentative Date and Time of Appointment * Reason For Visit * —Please choose an option—SickSick (Follow-up)Well-visitNew Patient - SickNew Patient - WellMedication refillCOVID-19 TestFlu VaccineNewbornSports/ School PhysicalOther Short Description * Requested appointments for a period less than 24 hours are not guaranteed. You should receive an email to confirm your appointment. Accept By checking this box and clicking submit below, I expressly authorize Almouie Pediatrics to deliver to my phone number and/or email address, communications, advertising of services, products, promotions, appointment, account information.
