Please select the preferred department

  • [[{"field_id":13094,"subrules":{"field_id":13093,"value":"Primary Care","operator":"Match"}}],[{"field_id":13100,"subrules":{"field_id":13093,"value":"Dermatology","operator":"Match"}}],[{"field_id":13186,"subrules":{"field_id":13093,"value":"Gateroentrology","operator":"Match"}}],[{"field_id":13281,"subrules":{"field_id":13093,"value":"Sports Medicine","operator":"Match"}}],[{"field_id":13284,"subrules":{"field_id":13093,"value":"Gynecology","operator":"Match"}}],[{"field_id":13291,"subrules":{"field_id":13093,"value":"Allaracare - Beverly","operator":"Match"}}],[{"field_id":13296,"subrules":{"field_id":13093,"value":"Flu Visit","operator":"Match"}}],[{"field_id":13297,"subrules":{"field_id":13093,"value":"Appointment Request Form","operator":"Match"}}]]

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

  • [[{"field_id":13176,"subrules":{"field_id":13094,"value":"New patient","operator":"Match"}}],[{"field_id":13172,"subrules":{"field_id":13094,"value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":13179,"subrules":{"field_id":13172,"value":"Child Annual Physical with Dr. Allara (Age 0-20)","operator":"Match"}}],[{"field_id":13179,"subrules":{"field_id":13172,"value":"Child Annual Physical (Not Dr. Allara) (Age 0-20)","operator":"Match"}}],[{"field_id":13179,"subrules":{"field_id":13172,"value":"In-Office - Sick Visit","operator":"Match"}}],[{"field_id":13179,"subrules":{"field_id":13172,"value":"In-Office - Follow-Up Visit","operator":"Match"}}],[{"field_id":13179,"subrules":{"field_id":13172,"value":"Video Telehealth - Returning Patient Visit","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":13178,"subrules":{"field_id":13176,"value":"New Child Annual Physical with Dr. Allara (Age 0-20)","operator":"Match"}}],[{"field_id":13178,"subrules":{"field_id":13176,"value":"New Child Annual Physical (Not Dr. Allara) (Age 0-20)","operator":"Match"}}],[{"field_id":13178,"subrules":{"field_id":13176,"value":"New Patient Visit (Excluding Annual Physical)","operator":"Match"}}],[{"field_id":13178,"subrules":{"field_id":13176,"value":"New Patient Annual Physical Exam","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":13179,"subrules":{"field_id":13178,"value":"Yes","operator":"Match"}}],[{"field_id":13179,"subrules":{"field_id":13178,"value":"No","operator":"Match"}}]]

Please choose the patient's age

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

  • [[{"field_id":13181,"subrules":{"field_id":13100,"value":"New patient","operator":"Match"}}],[{"field_id":13180,"subrules":{"field_id":13100,"value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":13182,"subrules":{"field_id":13180,"value":"Derm Office Visit (Not Full Skin Exam)","operator":"Match"}}],[{"field_id":13182,"subrules":{"field_id":13180,"value":"Skin Check (Full Skin Exam)","operator":"Match"}}],[{"field_id":13182,"subrules":{"field_id":13180,"value":"Video Telehealth - Returning Patient Visit","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":13184,"subrules":{"field_id":13181,"value":"Derm Office Visit (Not Full Skin Exam)","operator":"Match"}}],[{"field_id":13184,"subrules":{"field_id":13181,"value":"Skin Check (Full Skin Exam)","operator":"Match"}}]]

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

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

  • [[{"field_id":13185,"subrules":{"field_id":13184,"value":"Yes","operator":"Match"}}],[{"field_id":13185,"subrules":{"field_id":13184,"value":"Not Required","operator":"Match"}}]]

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

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

  • [[{"field_id":13209,"subrules":{"field_id":13186,"value":"New patient","operator":"Match"}}],[{"field_id":13187,"subrules":{"field_id":13186,"value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

Please choose the type of visit

  • [[{"field_id":13276,"subrules":{"field_id":13209,"value":"Gastroenterology - New Patient Visit - In-Office","operator":"Match"}}]]

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

  • [[{"field_id":13277,"subrules":{"field_id":13276,"value":"Yes","operator":"Match"}}]]

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

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

  • [[{"field_id":13283,"subrules":{"field_id":13281,"value":"New Patient","operator":"Match"}}],[{"field_id":13282,"subrules":{"field_id":13281,"value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":13283,"subrules":{"field_id":13282,"value":"Orthopedics - Follow-Up Visit - In-Office","operator":"Match"}}],[{"field_id":13283,"subrules":{"field_id":13282,"value":"Video Telehealth - Returning Patient Visit","operator":"Match"}}]]

Is your PCP a Middleton Family Medicine or Allaracare Medical Group Provider?

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

  • [[{"field_id":13286,"subrules":{"field_id":13284,"value":"New Patient","operator":"Match"}}],[{"field_id":13285,"subrules":{"field_id":13284,"value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":13288,"subrules":{"field_id":13285,"value":"Gynecology Routine Exam","operator":"Match"}}],[{"field_id":13287,"subrules":{"field_id":13285,"value":"Gynecology Follow-Up or Problem Visit","operator":"Match"}}],[{"field_id":13290,"subrules":{"field_id":13285,"value":"Gynecology NP - Annual Gynecology Exam","operator":"Match"}}],[{"field_id":13287,"subrules":{"field_id":13285,"value":"Video Telehealth - Returning Patient Visit","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":13288,"subrules":{"field_id":13286,"value":"Gynecology MD - New Patient Visit - In-Office","operator":"Match"}}],[{"field_id":13290,"subrules":{"field_id":13286,"value":"Gynecology NP - New Patient Visit - In-Office","operator":"Match"}}]]

Select your preferred doctor

  • [[{"field_id":13288,"subrules":{"field_id":13287,"value":"Barry Burrows, MD","operator":"Match"}}],[{"field_id":13290,"subrules":{"field_id":13287,"value":"Katelynne Abbott, NP","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?

Is your PCP a Middleton Family Medicine or Allaracare Medical Group Provider?

Is the patient 18 years of age or older?

  • [[{"field_id":13292,"subrules":{"field_id":13291,"value":"Yes","operator":"Match"}}]]

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

  • [[{"field_id":13294,"subrules":{"field_id":13292,"value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":13295,"subrules":{"field_id":13293,"value":"Beverly New Patient Annual Physical Exam","operator":"Match"}}],[{"field_id":13295,"subrules":{"field_id":13293,"value":"New Patient Visit (Excluding Annual Physical)","operator":"Match"}}]]

Please choose the type of visit

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

Is your PCP a Middleton Family Medicine or Allaracare Medical Group Provider?

Please choose your prefferred location