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

    • [[{"field_id":15847,"subrules":{"field_id":15845,"value":"New Patient","operator":"Match"}}],[{"field_id":15846,"subrules":{"field_id":15845,"value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

    • [[{"field_id":15848,"subrules":{"field_id":15846,"value":"Gynecology Routine Exam","operator":"Match"}}],[{"field_id":15848,"subrules":{"field_id":15846,"value":"Gynecology Follow-Up or Problem Visit","operator":"Match"}}],[{"field_id":15848,"subrules":{"field_id":15846,"value":"Video Telehealth - Returning Patient Visit","operator":"Match"}}],[{"field_id":15848,"subrules":{"field_id":15846,"value":"Menopause Patient Consult","operator":"Match"}}],[{"field_id":15848,"subrules":{"field_id":15846,"value":"Menopause Patient Follow-Up\n","operator":"Match"}}]]

Please choose the type of visit

    • [[{"field_id":15848,"subrules":{"field_id":15847,"value":"Gynecology Patient Consult","operator":"Match"}}],[{"field_id":15848,"subrules":{"field_id":15847,"value":"Menopause Patient Consult","operator":"Match"}}]]

Select your preferred provider

    • [[{"field_id":15849,"subrules":{"field_id":15848,"value":"Barry Burrows, MD","operator":"Match"}}],[{"field_id":15851,"subrules":{"field_id":15848,"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 MFM Health or AllaraCare Medical Group Provider?