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

  • [[{"field_id":"12808","subrules":{"field_id":"12622","value":"New Patient","operator":"Match"}}],[{"field_id":"12623","subrules":{"field_id":"12622","value":"Returning Patient","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":"13068","subrules":{"field_id":"12623","value":"Child Annual Physical with Dr. Allara (Age 0-20)","operator":"Match"}}],[{"field_id":"13068","subrules":{"field_id":"12623","value":"Child Annual Physical (Not Dr. Allara) (Age 0-20)","operator":"Match"}}],[{"field_id":"13068","subrules":{"field_id":"12623","value":"In-Office - Sick Visit","operator":"Match"}}],[{"field_id":"13068","subrules":{"field_id":"12623","value":"In-Office - Follow-Up Visit","operator":"Match"}}],[{"field_id":"13068","subrules":{"field_id":"12623","value":"Video Telehealth - Returning Patient Visit","operator":"Match"}}]]

Please choose the type of visit

  • [[{"field_id":"12773","subrules":{"field_id":"12808","value":"New Child Annual Physical with Dr. Allara (Age 0-20)","operator":"Match"}}],[{"field_id":"12773","subrules":{"field_id":"12808","value":"New Child Annual Physical (Not Dr. Allara) (Age 0-20)","operator":"Match"}}],[{"field_id":"12773","subrules":{"field_id":"12808","value":"New Patient Annual Physical Exam","operator":"Match"}}],[{"field_id":"12773","subrules":{"field_id":"12808","value":"New Patient Visit (Excluding Annual Physical)","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?

  • [[{"field_id":"13068","subrules":{"field_id":"12773","value":"Yes","operator":"Match"}}],[{"field_id":"13068","subrules":{"field_id":"12773","value":"No","operator":"Match"}}]]

Please choose the patient's age