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

  • [[{"field_id":12834,"subrules":{"field_id":12742,"value":"New Patient","operator":"Match"}}],[{"field_id":12746,"subrules":{"field_id":12742,"value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

Please choose the type of visit

  • [[{"field_id":12747,"subrules":{"field_id":12834,"value":"Gastroenterology - New Patient Visit - In-Office","operator":"Match"}}]]

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

  • [[{"field_id":12748,"subrules":{"field_id":12747,"value":"Yes","operator":"Match"}}]]

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