Please indicate the nature of your injury or reason for your appointment

Please indicate the nature of your injury or reason for your appointment
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Choose the reason for your visit 

Choose the reason for your visit 
  • [[{"field_id":29850,"subrules":{"field_id":29854,"value":"New Patient","operator":"Match"}},{"field_id":29850,"subrules":{"field_id":29854,"value":"New Patient","operator":"Match"}}],[{"field_id":29850,"subrules":{"field_id":29854,"value":"Recheck","operator":"Match"}},{"field_id":29850,"subrules":{"field_id":29854,"value":"Recheck","operator":"Match"}}]]

What type of appointment would you like to schedule?

What type of appointment would you like to schedule?
[[{"field_id":29851,"subrules":{"field_id":29850,"value":"Injury","operator":"Match"}},{"field_id":29851,"subrules":{"field_id":29850,"value":"Injury","operator":"Match"}}],[{"field_id":29856,"subrules":{"field_id":29850,"value":"Chronic Pain","operator":"Match"}},{"field_id":29856,"subrules":{"field_id":29850,"value":"Chronic Pain","operator":"Match"}}]]

Does any of the following pertain to your injury?

Does any of the following pertain to your injury?
  • [[{"field_id":29856,"subrules":{"field_id":29851,"value":"None","operator":"Match"}},{"field_id":29856,"subrules":{"field_id":29851,"value":"None","operator":"Match"}}]]

Are you using insurance for this visit?

Are you using insurance for this visit?
  • [[{"field_id":29852,"subrules":{"field_id":29856,"value":"Yes","operator":"Match"}},{"field_id":29852,"subrules":{"field_id":29856,"value":"Yes","operator":"Match"}}],[{"field_id":29853,"subrules":{"field_id":29856,"value":"No","operator":"Match"}},{"field_id":29853,"subrules":{"field_id":29856,"value":"No","operator":"Match"}}]]

Please select your preferred insurance for this visit.

Please select your preferred insurance for this visit.
  • [[{"field_id":29853,"subrules":{"field_id":29852,"value":"My Insurance Is Not Listed\n","operator":"Match"}},{"field_id":29853,"subrules":{"field_id":29852,"value":"My Insurance Is Not Listed\n","operator":"Match"}}]]

Have you been diagnosed with or suspected of having a fracture?

Have you been diagnosed with or suspected of having a fracture?