{"id":1453,"date":"2023-01-25T12:54:13","date_gmt":"2023-01-25T12:54:13","guid":{"rendered":"https:\/\/tricitypainassociates.com\/?page_id=1453"},"modified":"2023-05-05T14:16:34","modified_gmt":"2023-05-05T14:16:34","slug":"request-an-appointment","status":"publish","type":"page","link":"https:\/\/tricitypainassociates.com\/request-an-appointment\/","title":{"rendered":"Request An Appointment"},"content":{"rendered":"\r\n\r\n<h2>\r\n\t\tRequest An \r\n\t\tAppointment\r\n\t\t\t\t<\/h2>\t\r\n\t<div class=\"forminator-ui forminator-custom-form forminator-custom-form-1452 forminator-design--flat  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1452\" data-uid=\"662d6d9a3ea58\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-1452\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1452 forminator-design--flat  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"1452\"\n\t\t\t\t\n\t\t\t\tdata-design=\"flat\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"662d6d9a3ea58\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_662d6d9a3ea58\" id=\"forminator-field-name-1_662d6d9a3ea58-label\" class=\"forminator-label\">Full Name: <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_662d6d9a3ea58\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_662d6d9a3ea58\" id=\"forminator-field-phone-1_662d6d9a3ea58-label\" class=\"forminator-label\">Phone Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_662d6d9a3ea58\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_662d6d9a3ea58\" id=\"forminator-field-email-1_662d6d9a3ea58-label\" class=\"forminator-label\">Your Email <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_662d6d9a3ea58\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_662d6d9a3ea58\" id=\"forminator-field-date-1-picker_662d6d9a3ea58-label\" class=\"forminator-label\">Date of Birth <span class=\"forminator-required\">*<\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_662d6d9a3ea58\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1924\" data-end-year=\"2124\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_662d6d9a3ea58\" id=\"forminator-field-textarea-1_662d6d9a3ea58-label\" class=\"forminator-label\">Comments<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_662d6d9a3ea58\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:120px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-4\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-1452__field--select-4_662d6d9a3ea58\" id=\"forminator-form-1452__field--select-4_662d6d9a3ea58-label\" class=\"forminator-label\">Are you a new patient?<\/label><select id=\"forminator-form-1452__field--select-4_662d6d9a3ea58\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-4\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-1452__field--select-4_662d6d9a3ea58-label\" aria-describedby=\"forminator-form-1452__field--select-4_662d6d9a3ea58-description\"><option value=\"one\"  data-calculation=\"0\">New patient<\/option><option value=\"two\"  data-calculation=\"0\">Existing patient<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-5\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-1452__field--select-5_662d6d9a3ea58\" id=\"forminator-form-1452__field--select-5_662d6d9a3ea58-label\" class=\"forminator-label\">How were you referred to us? <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-1452__field--select-5_662d6d9a3ea58\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-5\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"---\" data-search=\"false\" aria-labelledby=\"forminator-form-1452__field--select-5_662d6d9a3ea58-label\" aria-describedby=\"forminator-form-1452__field--select-5_662d6d9a3ea58-description\"><option value=\"\">---<\/option><option value=\"Email\/Text\"  data-calculation=\"0\">Email\/Text<\/option><option value=\"Ad\"  data-calculation=\"0\">Ad<\/option><option value=\"Social-Media\"  data-calculation=\"0\">Social Media<\/option><option value=\"Friend-Patient\"  data-calculation=\"0\">Friend\/Patient<\/option><option value=\"Flyer\"  data-calculation=\"0\">Flyer<\/option><option value=\"Search-Engine\"  data-calculation=\"0\">Search Engine<\/option><option value=\"Physician-Referral\"  data-calculation=\"0\">Physician Referral<\/option><option value=\"Other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h3 class=\"forminator-subtitle\">*For New Patients, a Physician Referral is Required<\/h3><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"7f92f3abd9\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/1453\" \/><input type=\"hidden\" name=\"form_id\" value=\"1452\"><input type=\"hidden\" name=\"page_id\" value=\"1453\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/tricitypainassociates.com\/request-an-appointment\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\r\n\r\n","protected":false},"excerpt":{"rendered":"<p>Request An Appointment<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_glsr_average":0,"_glsr_ranking":0,"_glsr_reviews":0,"footnotes":""},"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/pages\/1453"}],"collection":[{"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/comments?post=1453"}],"version-history":[{"count":4,"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/pages\/1453\/revisions"}],"predecessor-version":[{"id":1807,"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/pages\/1453\/revisions\/1807"}],"wp:attachment":[{"href":"https:\/\/tricitypainassociates.com\/wp-json\/wp\/v2\/media?parent=1453"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}