{"id":44,"date":"2019-03-07T11:32:36","date_gmt":"2019-03-07T11:32:36","guid":{"rendered":"http:\/\/localhost\/prizm_rosenberg\/?page_id=44"},"modified":"2021-01-25T16:52:40","modified_gmt":"2021-01-25T16:52:40","slug":"request-an-appointment","status":"publish","type":"page","link":"https:\/\/www.prizmpain.com\/request-an-appointment\/","title":{"rendered":"Request an Appointment"},"content":{"rendered":"<p>Same-day appointments may often be available, so please call our office if you want an appointment today. Please be aware that you are submitting a request only. A representative from our office will contact you within 24 to 48 business hours to confirm a date and time.If this is a medical emergency, please do not fill out this form, call 911.<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_safari gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' ><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1'  action='\/wp-json\/wp\/v2\/pages\/44#gf_1' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_1_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\" ><label class='gfield_label gform-field-label' for='input_1_2'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_1_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_2_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_2' class='gform_hidden' value='https:\/\/www.prizmpain.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_1_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_3_1' id='input_1_3_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_1_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_3_3' id='input_1_3_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_3_4_container' >\n                                        <input type='text' name='input_3.4' id='input_1_3_4' value=''      aria-required='true'    \/>\n                                        <label for='input_1_3_4' id='input_1_3_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_1_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_3_5' id='input_1_3_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_1_3_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><label class='gfield_label gform-field-label' for='input_1_4'>Daytime Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><label class='gfield_label gform-field-label' for='input_1_5'>Cell Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><label class='gfield_label gform-field-label' for='input_1_6'>E-mail Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><label class='gfield_label gform-field-label' for='input_1_7'>Confirm E-mail Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\" ><label class='gfield_label gform-field-label' for='input_1_8'>Who is your insurance carrier?<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\" ><label class='gfield_label gform-field-label' for='input_1_9'>What type of insurance do you have? i.e. PPO, HMO, etc.<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><label class='gfield_label gform-field-label' for='input_1_10'>Do you have a secondary insurance? If so, please provide the name of the carrier.<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\" ><label class='gfield_label gform-field-label' for='input_1_11'>Best way of reaching you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_1_11' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Daytime Phone' >Daytime Phone<\/option><option value='Cell Phone' >Cell Phone<\/option><\/select><\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\" ><label class='gfield_label gform-field-label' >Type of Patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_12'>\n\t\t\t<li class='gchoice gchoice_1_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='New'  id='choice_1_12_0'    \/>\n\t\t\t\t<label for='choice_1_12_0' id='label_1_12_0' class='gform-field-label gform-field-label--type-inline'>New<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='Existing'  id='choice_1_12_1'    \/>\n\t\t\t\t<label for='choice_1_12_1' id='label_1_12_1' class='gform-field-label gform-field-label--type-inline'>Existing<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\" ><label class='gfield_label gform-field-label' >Type of Appointment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_13'>\n\t\t\t<li class='gchoice gchoice_1_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='New'  id='choice_1_13_0'    \/>\n\t\t\t\t<label for='choice_1_13_0' id='label_1_13_0' class='gform-field-label gform-field-label--type-inline'>New<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Follow Up'  id='choice_1_13_1'    \/>\n\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>Follow Up<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\" ><label class='gfield_label gform-field-label' for='input_1_14'>Reason for Appointment<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_1_14' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_15\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >How did you hear about us?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_15'><li class='gchoice gchoice_1_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='Doctor\/Dentist\/Physician'  id='choice_1_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>Doctor\/Dentist\/Physician<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='Friend\/family member'  id='choice_1_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_2' id='label_1_15_2' class='gform-field-label gform-field-label--type-inline'>Friend\/family member<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='Co-worker'  id='choice_1_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_3' id='label_1_15_3' class='gform-field-label gform-field-label--type-inline'>Co-worker<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='Web\/internet'  id='choice_1_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_4' id='label_1_15_4' class='gform-field-label gform-field-label--type-inline'>Web\/internet<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_15_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.5' type='checkbox'  value='Print ad'  id='choice_1_15_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_5' id='label_1_15_5' class='gform-field-label gform-field-label--type-inline'>Print ad<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_15_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.6' type='checkbox'  value='Drive by'  id='choice_1_15_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_6' id='label_1_15_6' class='gform-field-label gform-field-label--type-inline'>Drive by<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_15_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.7' type='checkbox'  value='Other'  id='choice_1_15_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_7' id='label_1_15_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_16\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\" ><label class='gfield_label gform-field-label' for='input_1_16'>Who may we thank for referring you?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_1_16' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_17\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\" ><label class='gfield_label gform-field-label' for='input_1_17'>Select Provider<\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_1_17' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Jeffrey M. Rosenberg, MD, PhD' >Jeffrey M. Rosenberg, MD, PhD<\/option><option value='Fawad H. Rizvi, DO' >Fawad H. Rizvi, DO<\/option><option value='Michael Brennan, PA-C' >Michael Brennan, PA-C<\/option><option value='Timothy Petrosky, PA-C' >Timothy Petrosky, PA-C<\/option><option value='James W. Gilson, PA-C' >James W. Gilson, PA-C<\/option><\/select><\/div><\/li><li id=\"field_1_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Preferred Day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_18'><li class='gchoice gchoice_1_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='First Available'  id='choice_1_18_1'   aria-describedby=\"gfield_description_1_18\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>First Available<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Monday'  id='choice_1_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_2' id='label_1_18_2' class='gform-field-label gform-field-label--type-inline'>Monday<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Tuesday'  id='choice_1_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_3' id='label_1_18_3' class='gform-field-label gform-field-label--type-inline'>Tuesday<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Wednesday'  id='choice_1_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_4' id='label_1_18_4' class='gform-field-label gform-field-label--type-inline'>Wednesday<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_18_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.5' type='checkbox'  value='Thursday'  id='choice_1_18_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_5' id='label_1_18_5' class='gform-field-label gform-field-label--type-inline'>Thursday<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_1_18'>Check which days are best.<\/div><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Preferred Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_19'><li class='gchoice gchoice_1_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='First Available'  id='choice_1_19_1'   aria-describedby=\"gfield_description_1_19\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_19_1' id='label_1_19_1' class='gform-field-label gform-field-label--type-inline'>First Available<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Early Morning'  id='choice_1_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_19_2' id='label_1_19_2' class='gform-field-label gform-field-label--type-inline'>Early Morning<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Mid Morning'  id='choice_1_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_19_3' id='label_1_19_3' class='gform-field-label gform-field-label--type-inline'>Mid Morning<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='Afternoon'  id='choice_1_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_19_4' id='label_1_19_4' class='gform-field-label gform-field-label--type-inline'>Afternoon<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_1_19'>Select the time that best suits your schedule\n<\/div><\/li><li id=\"field_1_20\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Disclaimer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_20.1' id='input_1_20_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_20\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_20_1' >I agree to the disclaimer below:<\/label><input type='hidden' name='input_20.2' value='I agree to the disclaimer below:' class='gform_hidden' \/><input type='hidden' name='input_20.3' value='2' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_20'>This form should not be used to communicate any confidential personal or medical information (PHI), but should only be used for appointment requests and general questions.<\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=1&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='WyJ7XCIyMC4xXCI6XCI5MTRmOWY4NDM4OGJlNTE1YjY3MDE4YTRiNDliNDRkYVwiLFwiMjAuMlwiOlwiMjQ5MjIzMTRiNzJjYjUzMjA4OTMzNDllNDA3NWNmODlcIixcIjIwLjNcIjpcIjQzODNhNTE1ZTIyMjljNTZmMjdjMTEzN2I0ZDA5YjlmXCJ9IiwiYjk3ZTkzYjhkYmYwM2VlMGU4YjdlY2ZiMGIxZjcyNGIiXQ==' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_1' id='gform_ajax_frame_1' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/www.prizmpain.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_1').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_1').val();gformInitSpinner( 1, 'https:\/\/www.prizmpain.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [1, current_page]);window['gf_submitting_1'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_1').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_1').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [1]);window['gf_submitting_1'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_1').text());}, 50);}else{jQuery('#gform_1').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"1\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);                if (event.defaultPrevented) {                return;         }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_1\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_1\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_1\" );        let postRenderFired = false;                function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            jQuery( document ).trigger( 'gform_post_render', [1, current_page] );            gform.utils.trigger( { event: 'gform\/postRender', native: false, data: { formId: 1, currentPage: current_page } } );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n\n<style>\n.in-service_left ul li {\nbackground: none !important;\n}\ninput#gform_submit_button_1 {\n    background-color: #4CAF50;\n    font-size: 20px;\n    color: white;\n    padding: 14px 50px;\n    margin: 8px 0;\n    border: none;\n    border-radius: 4px;\n    cursor: pointer;\n}\n<\/style>\n","protected":false},"excerpt":{"rendered":"<p>Same-day appointments may often be available, so please call our office if you want an appointment today. Please be aware that you are submitting a request only. A representative from our office will contact you within 24 to 48 business hours to confirm a date and time.If this is a medical emergency, please do not [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":329,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"acf":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.prizmpain.com\/wp-json\/wp\/v2\/pages\/44"}],"collection":[{"href":"https:\/\/www.prizmpain.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.prizmpain.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.prizmpain.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.prizmpain.com\/wp-json\/wp\/v2\/comments?post=44"}],"version-history":[{"count":0,"href":"https:\/\/www.prizmpain.com\/wp-json\/wp\/v2\/pages\/44\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.prizmpain.com\/wp-json\/wp\/v2\/media\/329"}],"wp:attachment":[{"href":"https:\/\/www.prizmpain.com\/wp-json\/wp\/v2\/media?parent=44"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}