Is the patient 18 years of age or older?

  • [[{"field_id":12788,"subrules":{"field_id":12781,"value":"Yes","operator":"Match"}}]]

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

  • [[{"field_id":12805,"subrules":{"field_id":12788,"value":"New Patient","operator":"Match"}}],[{"field_id":12798,"subrules":{"field_id":12788,"value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":12801,"subrules":{"field_id":12805,"value":"Beverly New Patient Annual Physical Exam","operator":"Match"}}],[{"field_id":12801,"subrules":{"field_id":12805,"value":"New Patient Visit (Excluding Annual Physical)","operator":"Match"}}]]

Please choose the type of visit

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