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?