Is this a request for a new or a returning patient?

  • [[{"field_id":15838,"subrules":{"field_id":15836,"value":"New Patient","operator":"Match"}}],[{"field_id":15837,"subrules":{"field_id":15836,"value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":15841,"subrules":{"field_id":15837,"value":"Child Annual Physical with Dr. Allara (Age 0-20)","operator":"Match"}}],[{"field_id":15841,"subrules":{"field_id":15837,"value":"Child Annual Physical (Not Dr. Allara) (Age 0-20)","operator":"Match"}}],[{"field_id":15841,"subrules":{"field_id":15837,"value":"In-Office - Sick Visit","operator":"Match"}}],[{"field_id":15841,"subrules":{"field_id":15837,"value":"In-Office - Follow-Up Visit","operator":"Match"}}],[{"field_id":15841,"subrules":{"field_id":15837,"value":"Video Telehealth - Returning Patient Visit","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":15840,"subrules":{"field_id":15838,"value":"New Child Annual Physical with Dr. Allara (Age 0-20)","operator":"Match"}}],[{"field_id":15840,"subrules":{"field_id":15838,"value":"New Child Annual Physical (Not Dr. Allara) (Age 0-20)","operator":"Match"}}],[{"field_id":15840,"subrules":{"field_id":15838,"value":"New Patient Annual Physical Exam","operator":"Match"}}],[{"field_id":15840,"subrules":{"field_id":15838,"value":"New Patient Visit (Excluding Annual Physical)","operator":"Match"}}]]

Have you requested an insurance referral if required by your insurance plan?

Do you have copies of your records from your previous provider?

  • [[{"field_id":15841,"subrules":{"field_id":15840,"value":"Yes","operator":"Match"}}],[{"field_id":15841,"subrules":{"field_id":15840,"value":"No","operator":"Match"}}]]

Please choose the patient's age