{"id":113,"date":"2022-07-27T08:45:47","date_gmt":"2022-07-27T08:45:47","guid":{"rendered":"https:\/\/intouchwellness.co\/?page_id=113"},"modified":"2022-08-05T16:20:33","modified_gmt":"2022-08-05T16:20:33","slug":"request-an-appointment","status":"publish","type":"page","link":"https:\/\/intouchwellness.co\/index.php\/request-an-appointment\/","title":{"rendered":"Request an Appointment"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Fill out the form below to request an appointment with one of our providers.<\/p>\n\n\n<div class=\"wpforms-container wpforms-container-full wpforms-block\" id=\"wpforms-107\"><form id=\"wpforms-form-107\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"107\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/113\" data-token=\"0d658df3a43bd610b50c95fa580da5d2\" data-token-time=\"1782070732\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-107-field_5-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"5\"><label class=\"wpforms-field-label\">Visit Type<\/label><ul id=\"wpforms-107-field_5\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-107-field_5_1\" name=\"wpforms[fields][5]\" value=\"In-Office Visit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-107-field_5_1\">In-Office Visit<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-107-field_5_2\" name=\"wpforms[fields][5]\" value=\"Virtual Visit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-107-field_5_2\">Virtual Visit<\/label><\/li><\/ul><\/div><div id=\"wpforms-107-field_7-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"7\"><label class=\"wpforms-field-label\">Are you a new or returning patient?<\/label><ul id=\"wpforms-107-field_7\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-107-field_7_1\" name=\"wpforms[fields][7]\" value=\"New\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-107-field_7_1\">New<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-107-field_7_2\" name=\"wpforms[fields][7]\" value=\"Returning\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-107-field_7_2\">Returning<\/label><\/li><\/ul><\/div><div id=\"wpforms-107-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-107-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-107-field_0\" class=\"wpforms-field-sublabel 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class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\" step=\"any\" ><\/div><div id=\"wpforms-107-field_9-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"9\"><label class=\"wpforms-field-label\">Phone Number Type<\/label><ul id=\"wpforms-107-field_9\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-107-field_9_1\" name=\"wpforms[fields][9]\" value=\"Cell Phone\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-107-field_9_1\">Cell Phone<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-107-field_9_2\" name=\"wpforms[fields][9]\" value=\"Landline\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-107-field_9_2\">Landline<\/label><\/li><\/ul><\/div><div id=\"wpforms-107-field_10-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-107-field_10\">Date of Birth<\/label><input type=\"number\" id=\"wpforms-107-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" step=\"any\" ><\/div><div id=\"wpforms-107-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-107-field_2\">Reason for Visit <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-107-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" required><\/textarea><\/div><div id=\"wpforms-107-field_14-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-107-field_14\">Insurance Carrier <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-107-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" required><\/textarea><\/div><div id=\"wpforms-107-field_15-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"15\"><label 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