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

  • [[{"field_id":"12724","subrules":{"field_id":"12722","value":"New Patient","operator":"Match"}}],[{"field_id":"12723","subrules":{"field_id":"12722","value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":"12725","subrules":{"field_id":"12723","value":"Derm Office Visit (Not Full Skin Exam)","operator":"Match"}}],[{"field_id":"12725","subrules":{"field_id":"12723","value":"Skin Check (Full Skin Exam)","operator":"Match"}}],[{"field_id":"12725","subrules":{"field_id":"12723","value":"Video Telehealth - Returning Patient Visit","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":"12728","subrules":{"field_id":"12724","value":"Derm Office Visit (Not Full Skin Exam)","operator":"Match"}}],[{"field_id":"12728","subrules":{"field_id":"12724","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":"12727","subrules":{"field_id":"12728","value":"Yes","operator":"Match"}}],[{"field_id":"12727","subrules":{"field_id":"12728","value":"Not Required","operator":"Match"}}]]

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