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?