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

    • [[{"field_id":12758,"subrules":{"field_id":12756,"value":"New Patient","operator":"Match"}}],[{"field_id":12757,"subrules":{"field_id":12756,"value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

    • [[{"field_id":12760,"subrules":{"field_id":12757,"value":"Gynecology Routine Exam","operator":"Match"}}],[{"field_id":12759,"subrules":{"field_id":12757,"value":"Gynecology Follow-Up or Problem Visit","operator":"Match"}}],[{"field_id":12763,"subrules":{"field_id":12757,"value":"Gynecology NP - Annual Gynecology Exam","operator":"Match"}}],[{"field_id":12759,"subrules":{"field_id":12757,"value":"Video Telehealth - Returning Patient Visit","operator":"Match"}}]]

Please choose the type of visit

    • [[{"field_id":12760,"subrules":{"field_id":12758,"value":"Gynecology MD - New Patient Visit - In-Office","operator":"Match"}}],[{"field_id":12763,"subrules":{"field_id":12758,"value":"Gynecology NP - New Patient Visit - In-Office","operator":"Match"}}]]

Select your preferred doctor

    • [[{"field_id":12760,"subrules":{"field_id":12759,"value":"Barry Burrows, MD","operator":"Match"}}],[{"field_id":12763,"subrules":{"field_id":12759,"value":"Katelynne Abbott, NP","operator":"Match"}}]]

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

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

Is your PCP a Middleton Family Medicine or Allaracare Medical Group Provider?