Please select the preferred department

    • [[{"field_id":15001,"subrules":{"field_id":15000,"value":"Women's Health","operator":"Match"}}],[{"field_id":15002,"subrules":{"field_id":15000,"value":"Primary Care","operator":"Match"}}]]

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

    • [[{"field_id":15328,"subrules":{"field_id":15001,"value":"New Patient","operator":"Match"}}],[{"field_id":15003,"subrules":{"field_id":15001,"value":"Returning Patient","operator":"Match"}}]]

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

    • [[{"field_id":15005,"subrules":{"field_id":15002,"value":"New Patient","operator":"Match"}}],[{"field_id":15006,"subrules":{"field_id":15002,"value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

    • [[{"field_id":15004,"subrules":{"field_id":15003,"value":"Gynecology Follow-Up or Problem Visit","operator":"Match"}}],[{"field_id":15004,"subrules":{"field_id":15003,"value":"Gynecology NP - Annual Gynecology Exam","operator":"Match"}}],[{"field_id":15004,"subrules":{"field_id":15003,"value":"Video Telehealth - Returning Patient Visit","operator":"Match"}}]]

Please choose the type of visit

    • [[{"field_id":15004,"subrules":{"field_id":15328,"value":"Gynecology NP - New Patient Visit - In-Office","operator":"Match"}}],[{"field_id":15004,"subrules":{"field_id":15328,"value":"Menopause Patient Consult\n","operator":"Match"}}]]

Is your PCP a MFM Health or AllaraCare Medical Group Provider?

Please choose the type of visit

    • [[{"field_id":15007,"subrules":{"field_id":15005,"value":"New Child Annual Physical","operator":"Match"}}],[{"field_id":15007,"subrules":{"field_id":15005,"value":"New Patient Annual Physical","operator":"Match"}}],[{"field_id":15007,"subrules":{"field_id":15005,"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?