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for Children
Weight
for Children
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Do you see a Primary Care Physician?
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If yes, please list name of physician.
When did the symptoms begin?
Symptoms
Body aches
Diarrhea
Fever greater than 100.4 F
Nausea
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Stuffy Nose
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List any conditions below that you being currently treated for:
Have you received a flu vaccine?
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No
If yes, when was the last vaccination?
Did you take something like Tylenol (acetaminophen), Aleve (naproxen), or Motrin/Advil (ibuprofen) before you came to the clinic?
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If yes, what did you take (type/amount)?
If yes, when did you last take the medication?
Enter name for consent:
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Appointment
Select Testing Service
Rapid Strep Test
Rapid Combo Test for Flu A, Flu B, & Covid
Rapid Covid Antigen Test
Rapid Flu A+B Antigen Test
*Credit Card Payments Only* - Skip to Submit Form if Paying in Person
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Rapid Strep Test
$
35.00
15 minute testing result for Group A Streptococcal Pharyngitis
Rapid Flu A, Flu B, COVID Combo Test
$
65.00
15 minute test results for all 3 in 1 test (Flu A, Flu B, & COVID)
Rapid Antigen Covid Test
$
35.00
15 minute testing result for Covid
Quantity
1
2
3
4
5
6
7
8
9
10
Rapid Flu A+B Antigen Test
$
35.00
15 minute rapid antigen test
Quantity
1
2
3
4
5
6
7
8
9
10
Total
$
0.00
Credit Card
Submit Form
Office Use Only
Value
Temperature
Blood Pressure
Pulse Ox
Tonsillopharyngeal inflammation
Patchy tonsillopharyngeal exudates
Palatal petechiae
Anterior cervical adenitis
Office Use Only
Result
Flu A
Flu B
SARS COVID
Strep A
Office Use Only (Strep A Treatment)
Verify Treatment
Amoxicilin 25mg/kg (max 500mg) PO BID x10d
Cephalexin 20mg/kg/dose (max 500mg/dose) PO BID x10d
Azithromycin 12mg/kg (max 500mg) PO QD x5d
Clindamycin 7mg/kg/dose (max 300mg/dose) PO TID x10d
Clarithromycin 7.5mg/kg/dose (max 250mg/dpse_ PO BID x10d
Office Use Only (UTI Treatment)
Verify Treatment
Nitrofurantoin macrocrystals 100mg 1 PO BID x5d
Trimethoprim-sulfamethoxazole 160mg-800mg 1 PO BID x3d
Ciprofloxacin 250mg 1 PO bid x3d
Phenazopyridine 200mg ! PO TID after meals as needed for dysuria #6 *Do not use for more than 2 days*
Office Use Only (Influenza Treatment)
Verify Treatment
Olseltamivir: Adults: 75mg BID x5d;
Olseltamivir: Children: 15kg or less (30mg BID); >15 to 23kg (45mg BID); >23 to 40kg (60mg BID); >40kg (75kg BID)
Zanamivir: Adults: 10mg (two 5mg inhalations) BID x5d
Zanamivir: Children (7 years or older) - 10mg (two 5mg inhalations) BID x5d
Oral Baloxavir (7 years or older): 20mg or 40mg one-time dose
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