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 (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":"(Child Annual Physical (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