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?