Pediatric Online Consultation

Get expert advice for your child's health concerns

Consultation Fee: $5-10 per form submission

Our experts will review your case and respond via email within 24-48 hours

Maximum 5 questions per consultation

Parent/Guardian Information

Full Name

Email Address

We will send the consultation response to this email address

Relationship to Child Select One Mother Father Grandparent Legal Guardian Other (please specify)

Please Specify Relationship

Child Information

Child's Full Name

Date of Birth

Age

Gender

Male

Female

Other

Current Weight

kg lb

Current Height

cm in

Medical History

Any Existing Medical Conditions?

Asthma

Allergies

Eczema

Epilepsy/Seizures

Diabetes

Other

Please Specify Other Conditions

Allergies (if any)

Current Medications

Is your child up to date with immunizations?

Yes

No

Unsure

Please Provide Details

Previous Hospitalizations or Surgeries

Relevant Family Medical History

Current Concern

Main Reason for Consultation

How long has your child been experiencing these symptoms? Select One Less than 24 hours 1-3 days 4-7 days 1-2 weeks 2-4 weeks 1-3 months More than 3 months

Symptom Severity

Mild

Moderate

Severe

Does your child have a fever?

Yes

No

Highest Temperature Recorded

°C °F

What treatments have you tried so far?

Your Questions (Maximum 5)

Please list specific questions you would like addressed

Question 1

Question 2

Question 3

Question 4

Question 5

Additional Information

Anything else you would like to share?

Upload Files (Optional)

You can upload previous medical reports, photos of rashes, etc. to help with the diagnosis

I understand that this online consultation does not replace in-person medical care. In case of emergency, I should seek immediate medical attention at the nearest healthcare facility.

I agree to the privacy policy and consent to my child's medical information being reviewed for consultation purposes.

Consultation Summary - Please Review