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

  • [[{"field_id":"12751","subrules":{"field_id":"12749","value":"New Patient","operator":"Match"}}],[{"field_id":"12750","subrules":{"field_id":"12749","value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":"12751","subrules":{"field_id":"12750","value":"Orthopedics - Follow-Up Visit - In-Office","operator":"Match"}}],[{"field_id":"12751","subrules":{"field_id":"12750","value":"Video Telehealth - Returning Patient Visit","operator":"Match"}}]]

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