{"id":1091,"date":"2023-10-13T16:31:25","date_gmt":"2023-10-13T16:31:25","guid":{"rendered":"https:\/\/www.spanimalrehab.com\/?page_id=1091"},"modified":"2023-10-13T16:31:26","modified_gmt":"2023-10-13T16:31:26","slug":"physical-therapy-referral-form","status":"publish","type":"page","link":"https:\/\/www.spanimalrehab.com\/forms-2\/physical-therapy-referral-form\/","title":{"rendered":"Physical Therapy Referral Form"},"content":{"rendered":"\n<div class=\"wp-block-contact-form-7-contact-form-selector\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1088-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/1091#wpcf7-f1088-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"1088\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.4\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1088-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<style>\n .columns {\n display: flex;\n flex-wrap: wrap;\n margin: 0 -10px;\n margin-top: 10px;\n }\n span.required {\n color: red;\n }\n .column {\n flex: 1;\n padding: 0 10px;\n margin-top: 10px;\n }\n fieldset legend {\n font-weight: bold;\n font-size: 16px;\n }\n textarea {\n width: 100%;\n }\n submit {float:right}\n input.wpcf7-form-control.has-spinner.wpcf7-submit {\n float: left;\n margin-top: 25px;\n }\n fieldset {\n color: #111 !important;\nmargin-top: 25px;\n }\n form.wpcf7-form p {\n color: #111 !important;\n }\n<\/style>\n<p class=\"new-client-referraldescription\"><span class=\"required\">*<\/span> = required field.\n<\/p>\n<fieldset>\n\t<div class=\"columns\">\n\t\t<div class=\"column\">\n\t\t\t<legend>Veterinarian Information:\n\t\t\t<\/legend>\n\t\t\t<p><label>Referring Hospital: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"vet-hospital\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"vet-hospital\" \/><\/span><\/label><br \/>\n<label>Referring Doctor: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"vet-doctor\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"vet-doctor\" \/><\/span><\/label><br \/>\n<label>Phone #: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"vet-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"vet-phone\" \/><\/span><\/label><br \/>\n<label>Fax #: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"vet-fax\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"vet-fax\" \/><\/span><\/label><br \/>\n<label>Email: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"vet-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"vet-email\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<fieldset>\n\t\t<div class=\"columns\">\n\t\t\t<div class=\"column\">\n\t\t\t\t<legend>Client Information:\n\t\t\t\t<\/legend>\n\t\t\t\t<p><label>Client Name: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"client-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"client-name\" \/><\/span><\/label><br \/>\n<label>Client Address: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"client-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"client-address\" \/><\/span><\/label><br \/>\n<label>Phone #: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"client-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"client-phone\" \/><\/span><\/label><br \/>\n<label>Email: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"client-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"client-email\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/fieldset>\n\t<fieldset>\n\t\t<div class=\"columns\">\n\t\t\t<div class=\"column\">\n\t\t\t\t<legend>Patient Information:\n\t\t\t\t<\/legend>\n\t\t\t\t<p><label>Patient Name: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-name\" \/><\/span><\/label><br \/>\n<label>Age & DOB: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"age-dob\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"age-dob\" \/><\/span><\/label><br \/>\n<label>Sex: <span class=\"required\">*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"sex-of-animal\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"sex-of-animal\" value=\"M\" \/><span class=\"wpcf7-list-item-label\">M<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"sex-of-animal\" value=\"F\" \/><span class=\"wpcf7-list-item-label\">F<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"sex-of-animal\" value=\"NM\" \/><span class=\"wpcf7-list-item-label\">NM<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"sex-of-animal\" value=\"SF\" \/><span class=\"wpcf7-list-item-label\">SF<\/span><\/label><\/span><\/span><\/span><br \/>\n<label>Breed: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"breed\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"breed\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/fieldset>\n\t<fieldset>\n\t\t<div class=\"columns\">\n\t\t\t<div class=\"column\">\n\t\t\t\t<legend>Medical History: <span class=\"required\">*<\/span>\n\t\t\t\t<\/legend>\n\t\t\t\t<p><label>Diagnosis\/Chief Complaint: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"medical-history\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"medical-history\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/fieldset>\n\t<fieldset>\n\t\t<div class=\"columns\">\n\t\t\t<div class=\"column\">\n\t\t\t\t<legend>History\/Physical Exam Findings: <span class=\"required\">*<\/span>\n\t\t\t\t<\/legend>\n\t\t\t\t<p><label>Details: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"physical-exam\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"physical-exam\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t\t<p>Treatments\/Current Medications:<br \/>\n<label>Details: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"medications\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"medications\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t\t<p>Special Requests\/Comments:<br \/>\n<label>Details: <span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"special-requests\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"special-requests\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/fieldset>\n\t<fieldset>\n\t\t<div class=\"columns\">\n\t\t\t<div class=\"column\">\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n\t\t<\/p>\n\t<\/fieldset>\n<\/fieldset><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":647,"menu_order":5,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"off","_et_pb_old_content":"","_et_gb_content_width":"1080","footnotes":""},"_links":{"self":[{"href":"https:\/\/www.spanimalrehab.com\/wp-json\/wp\/v2\/pages\/1091"}],"collection":[{"href":"https:\/\/www.spanimalrehab.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.spanimalrehab.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.spanimalrehab.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.spanimalrehab.com\/wp-json\/wp\/v2\/comments?post=1091"}],"version-history":[{"count":1,"href":"https:\/\/www.spanimalrehab.com\/wp-json\/wp\/v2\/pages\/1091\/revisions"}],"predecessor-version":[{"id":1092,"href":"https:\/\/www.spanimalrehab.com\/wp-json\/wp\/v2\/pages\/1091\/revisions\/1092"}],"up":[{"embeddable":true,"href":"https:\/\/www.spanimalrehab.com\/wp-json\/wp\/v2\/pages\/647"}],"wp:attachment":[{"href":"https:\/\/www.spanimalrehab.com\/wp-json\/wp\/v2\/media?parent=1091"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}