{"id":392,"date":"2025-03-01T19:25:33","date_gmt":"2025-03-01T19:25:33","guid":{"rendered":"https:\/\/www.westonpediatrics.org\/about\/?page_id=392"},"modified":"2025-03-01T19:25:36","modified_gmt":"2025-03-01T19:25:36","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/www.westonpediatrics.org\/about\/referral-form\/","title":{"rendered":"Referral Form"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; _builder_version=&#8221;4.27.3&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#729fb5&#8243; global_colors_info=&#8221;{}&#8221; theme_builder_area=&#8221;post_content&#8221;][et_pb_fullwidth_menu menu_id=&#8221;2&#8243; menu_style=&#8221;centered&#8221; _builder_version=&#8221;4.27.3&#8243; _module_preset=&#8221;default&#8221; menu_font=&#8221;|600|||||||&#8221; menu_font_size=&#8221;17px&#8221; background_color=&#8221;#729fb5&#8243; background_layout=&#8221;dark&#8221; border_color_top=&#8221;#cc092f&#8221; border_color_bottom=&#8221;#cc092f&#8221; global_colors_info=&#8221;{}&#8221; theme_builder_area=&#8221;post_content&#8221;][\/et_pb_fullwidth_menu][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.27.3&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221; theme_builder_area=&#8221;post_content&#8221;][et_pb_row _builder_version=&#8221;4.27.3&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221; theme_builder_area=&#8221;post_content&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.27.3&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221; theme_builder_area=&#8221;post_content&#8221;][et_pb_text admin_label=&#8221;Page Title&#8221; _builder_version=&#8221;4.27.3&#8243; _module_preset=&#8221;default&#8221; text_text_color=&#8221;#000000&#8243; text_font_size=&#8221;15px&#8221; header_font=&#8221;||||||||&#8221; header_text_color=&#8221;#729fb5&#8243; header_font_size=&#8221;34px&#8221; header_3_font=&#8221;|600|||||||&#8221; header_3_text_color=&#8221;#729fb5&#8243; header_3_font_size=&#8221;30px&#8221; background_color=&#8221;rgba(255,255,255,0.62)&#8221; custom_padding=&#8221;||||false|false&#8221; hover_enabled=&#8221;0&#8243; border_radii=&#8221;on|3px|3px|3px|3px&#8221; global_colors_info=&#8221;{}&#8221; theme_builder_area=&#8221;post_content&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<h1>Referral Form<\/h1>\n<p>[\/et_pb_text][et_pb_text admin_label=&#8221;Page Title&#8221; _builder_version=&#8221;4.27.3&#8243; _module_preset=&#8221;default&#8221; text_text_color=&#8221;#000000&#8243; text_font_size=&#8221;15px&#8221; header_font=&#8221;||||||||&#8221; header_text_color=&#8221;#729fb5&#8243; header_font_size=&#8221;34px&#8221; header_3_font=&#8221;|600|||||||&#8221; header_3_text_color=&#8221;#729fb5&#8243; header_3_font_size=&#8221;30px&#8221; background_color=&#8221;rgba(255,255,255,0.62)&#8221; custom_padding=&#8221;||||false|false&#8221; hover_enabled=&#8221;0&#8243; border_radii=&#8221;on|3px|3px|3px|3px&#8221; global_colors_info=&#8221;{}&#8221; theme_builder_area=&#8221;post_content&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_2_container\" data-token=\"0312743d0d5812a44ef7c1998af27c3b\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_referrals\" data-token=\"0312743d0d5812a44ef7c1998af27c3b\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Referrals<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"2\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_2\" id=\"frm_hide_fields_2\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"referrals\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_2\" name=\"frm_submit_entry_2\" value=\"26c6e417dd\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/about\/wp-json\/wp\/v2\/pages\/392\" \/><div id=\"frm_field_7_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_1tkz5_label\" class=\"frm_primary_label\">Your Name\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_1tkz5_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tYour Name\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_7\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_7-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_1tkz5_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\tid=\"field_1tkz5_first\"\n\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\tname=\"item_meta[7][first]\"  data-reqmsg=\"Your Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Your Name is invalid\" aria-invalid=\"false\"  \t\t\t\t\t\t\/>\n\t\t\t\t\t\t<div class=\"frm_description\" id=\"frm_field_7_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_7-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_1tkz5_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\tid=\"field_1tkz5_last\"\n\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\tname=\"item_meta[7][last]\"  data-reqmsg=\"Your Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Your Name is invalid\" aria-invalid=\"false\"  \t\t\t\t\t\t\/>\n\t\t\t\t\t\t<div class=\"frm_description\" id=\"frm_field_7_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_9_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first\">\r\n\t<div  id=\"field_tc71s_label\" class=\"frm_primary_label\">Address\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_tc71s_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tAddress<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_9-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_tc71s_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_tc71s_line1\" value=\"\" name=\"item_meta[9][line1]\"  data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_9-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_tc71s_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_tc71s_line2\" value=\"\" name=\"item_meta[9][line2]\"  data-invmsg=\"Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_9-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_tc71s_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_tc71s_city\" value=\"\" name=\"item_meta[9][city]\"  data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_9-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_tc71s_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t\t<select name=\"item_meta[9][state]\" id=\"field_tc71s_state\"  data-frmval=\"Massachusetts\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Alabama\">Alabama<\/option><option  value=\"Alaska\">Alaska<\/option><option  value=\"Arkansas\">Arkansas<\/option><option  value=\"Arizona\">Arizona<\/option><option  value=\"California\">California<\/option><option  value=\"Colorado\">Colorado<\/option><option  value=\"Connecticut\">Connecticut<\/option><option  value=\"Delaware\">Delaware<\/option><option  value=\"District of Columbia\">District of Columbia<\/option><option  value=\"Florida\">Florida<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Hawaii\">Hawaii<\/option><option  value=\"Idaho\">Idaho<\/option><option  value=\"Illinois\">Illinois<\/option><option  value=\"Indiana\">Indiana<\/option><option  value=\"Iowa\">Iowa<\/option><option  value=\"Kansas\">Kansas<\/option><option  value=\"Kentucky\">Kentucky<\/option><option  value=\"Louisiana\">Louisiana<\/option><option  value=\"Maine\">Maine<\/option><option  value=\"Maryland\">Maryland<\/option><option  value=\"Massachusetts\" selected='selected'>Massachusetts<\/option><option  value=\"Michigan\">Michigan<\/option><option  value=\"Minnesota\">Minnesota<\/option><option  value=\"Mississippi\">Mississippi<\/option><option  value=\"Missouri\">Missouri<\/option><option  value=\"Montana\">Montana<\/option><option  value=\"Nebraska\">Nebraska<\/option><option  value=\"Nevada\">Nevada<\/option><option  value=\"New Hampshire\">New Hampshire<\/option><option  value=\"New Jersey\">New Jersey<\/option><option  value=\"New Mexico\">New Mexico<\/option><option  value=\"New York\">New York<\/option><option  value=\"North Carolina\">North Carolina<\/option><option  value=\"North Dakota\">North Dakota<\/option><option  value=\"Ohio\">Ohio<\/option><option  value=\"Oklahoma\">Oklahoma<\/option><option  value=\"Oregon\">Oregon<\/option><option  value=\"Pennsylvania\">Pennsylvania<\/option><option  value=\"Rhode Island\">Rhode Island<\/option><option  value=\"South Carolina\">South Carolina<\/option><option  value=\"South Dakota\">South Dakota<\/option><option  value=\"Tennessee\">Tennessee<\/option><option  value=\"Texas\">Texas<\/option><option  value=\"Utah\">Utah<\/option><option  value=\"Vermont\">Vermont<\/option><option  value=\"Virginia\">Virginia<\/option><option  value=\"Washington\">Washington<\/option><option  value=\"West Virginia\">West Virginia<\/option><option  value=\"Wisconsin\">Wisconsin<\/option><option  value=\"Wyoming\">Wyoming<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_9-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_tc71s_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_tc71s_zip\" value=\"\" name=\"item_meta[9][zip]\"  data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_10_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_xdz5h\" id=\"field_xdz5h_label\" class=\"frm_primary_label\">Home Phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_xdz5h\" name=\"item_meta[10]\" value=\"\"  data-invmsg=\"Home Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_11_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_qvy9e\" id=\"field_qvy9e_label\" class=\"frm_primary_label\">Work Phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_qvy9e\" name=\"item_meta[11]\" value=\"\"  data-invmsg=\"Work Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_12_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_t66q6_label\" class=\"frm_primary_label\">Child's Name\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_t66q6_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tChild&#039;s Name\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_12\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_12-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_t66q6_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\tid=\"field_t66q6_first\"\n\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\tname=\"item_meta[12][first]\"  data-reqmsg=\"Child&#039;s Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Child&#039;s Name is invalid\" aria-invalid=\"false\"  \t\t\t\t\t\t\/>\n\t\t\t\t\t\t<div class=\"frm_description\" id=\"frm_field_12_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_12-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_t66q6_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\tid=\"field_t66q6_last\"\n\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\tname=\"item_meta[12][last]\"  data-reqmsg=\"Child&#039;s Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Child&#039;s Name is invalid\" aria-invalid=\"false\"  \t\t\t\t\t\t\/>\n\t\t\t\t\t\t<div class=\"frm_description\" id=\"frm_field_12_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_13_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_x13t0\" id=\"field_x13t0_label\" class=\"frm_primary_label\">Child's Date of Birth\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_x13t0\" name=\"item_meta[13]\" value=\"\"  maxlength=\"10\" data-invmsg=\"Child&#039;s Date of Birth is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_14_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_llxqh\" id=\"field_llxqh_label\" class=\"frm_primary_label\">Child's Insurer's Name\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_llxqh\" name=\"item_meta[14]\" value=\"\"  data-invmsg=\"Child&#039;s Insurer&#039;s Name is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_15_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_drafe\" id=\"field_drafe_label\" class=\"frm_primary_label\">Insurance Subscriber ID\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_drafe\" name=\"item_meta[15]\" value=\"\"  data-invmsg=\"Insurance Subscriber ID is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_16_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_8iohh\" id=\"field_8iohh_label\" class=\"frm_primary_label\">Child's Primary Care Provider\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[16]\" id=\"field_8iohh\"  data-invmsg=\"Child&#039;s Primary Care Provider is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"Karen Ashworth, FNP, AE-C\">Karen Ashworth, FNP, AE-C<\/option><option  value=\"Robert H. Andler, MD, FAAP\">Robert H. Andler, MD, FAAP<\/option><option  value=\"Shelly C. Bernstein, MD\">Shelly C. Bernstein, MD<\/option><option  value=\"Andrea Bertorelli, NP\">Andrea Bertorelli, NP<\/option><option  value=\"Colleen Brownell-Krupat, MD\">Colleen Brownell-Krupat, MD<\/option><option  value=\"Katherine M. Bui, MD\">Katherine M. Bui, MD<\/option><option  value=\"Rosemarie Dieffenbach, MD, MPH\">Rosemarie Dieffenbach, MD, MPH<\/option><option  value=\"Joshua Gundersheimer, MD\">Joshua Gundersheimer, MD<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_17_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_upchc\" id=\"field_upchc_label\" class=\"frm_primary_label\">Name of Specialist\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_upchc\" name=\"item_meta[17]\" value=\"\"  data-invmsg=\"Name of Specialist is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_18_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_wjw09\" id=\"field_wjw09_label\" class=\"frm_primary_label\">Specialist's Provider Number (if available)\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_wjw09\" name=\"item_meta[18]\" value=\"\"  data-invmsg=\"Specialist&#039;s Provider Number (if available) is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_19_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<div  id=\"field_f4237_label\" class=\"frm_primary_label\">Specialist's Address\/Hospital Affiliation\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_f4237_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tSpecialist&#039;s Address\/Hospital Affiliation<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_19-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_f4237_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tSpecialist&#039;s Address\/Hospital Affiliation\t<\/label>\n\t\t<input type=\"text\" id=\"field_f4237_line1\" value=\"\" name=\"item_meta[19][line1]\"  data-invmsg=\"Specialist&#039;s Address\/Hospital Affiliation is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_19-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_f4237_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tSpecialist&#039;s Address\/Hospital Affiliation\t<\/label>\n\t\t<input type=\"text\" id=\"field_f4237_line2\" value=\"\" name=\"item_meta[19][line2]\"  data-invmsg=\"Specialist&#039;s Address\/Hospital Affiliation is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_19-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_f4237_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_f4237_city\" value=\"\" name=\"item_meta[19][city]\"  data-invmsg=\"Specialist&#039;s Address\/Hospital Affiliation is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_19-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_f4237_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t\t<select name=\"item_meta[19][state]\" id=\"field_f4237_state\"  data-frmval=\"Massachusetts\" data-invmsg=\"Specialist&#039;s Address\/Hospital Affiliation is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Alabama\">Alabama<\/option><option  value=\"Alaska\">Alaska<\/option><option  value=\"Arkansas\">Arkansas<\/option><option  value=\"Arizona\">Arizona<\/option><option  value=\"California\">California<\/option><option  value=\"Colorado\">Colorado<\/option><option  value=\"Connecticut\">Connecticut<\/option><option  value=\"Delaware\">Delaware<\/option><option  value=\"District of Columbia\">District of Columbia<\/option><option  value=\"Florida\">Florida<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Hawaii\">Hawaii<\/option><option  value=\"Idaho\">Idaho<\/option><option  value=\"Illinois\">Illinois<\/option><option  value=\"Indiana\">Indiana<\/option><option  value=\"Iowa\">Iowa<\/option><option  value=\"Kansas\">Kansas<\/option><option  value=\"Kentucky\">Kentucky<\/option><option  value=\"Louisiana\">Louisiana<\/option><option  value=\"Maine\">Maine<\/option><option  value=\"Maryland\">Maryland<\/option><option  value=\"Massachusetts\" selected='selected'>Massachusetts<\/option><option  value=\"Michigan\">Michigan<\/option><option  value=\"Minnesota\">Minnesota<\/option><option  value=\"Mississippi\">Mississippi<\/option><option  value=\"Missouri\">Missouri<\/option><option  value=\"Montana\">Montana<\/option><option  value=\"Nebraska\">Nebraska<\/option><option  value=\"Nevada\">Nevada<\/option><option  value=\"New Hampshire\">New Hampshire<\/option><option  value=\"New Jersey\">New Jersey<\/option><option  value=\"New Mexico\">New Mexico<\/option><option  value=\"New York\">New York<\/option><option  value=\"North Carolina\">North Carolina<\/option><option  value=\"North Dakota\">North Dakota<\/option><option  value=\"Ohio\">Ohio<\/option><option  value=\"Oklahoma\">Oklahoma<\/option><option  value=\"Oregon\">Oregon<\/option><option  value=\"Pennsylvania\">Pennsylvania<\/option><option  value=\"Rhode Island\">Rhode Island<\/option><option  value=\"South Carolina\">South Carolina<\/option><option  value=\"South Dakota\">South Dakota<\/option><option  value=\"Tennessee\">Tennessee<\/option><option  value=\"Texas\">Texas<\/option><option  value=\"Utah\">Utah<\/option><option  value=\"Vermont\">Vermont<\/option><option  value=\"Virginia\">Virginia<\/option><option  value=\"Washington\">Washington<\/option><option  value=\"West Virginia\">West Virginia<\/option><option  value=\"Wisconsin\">Wisconsin<\/option><option  value=\"Wyoming\">Wyoming<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_19-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_f4237_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_f4237_zip\" value=\"\" name=\"item_meta[19][zip]\"  data-invmsg=\"Specialist&#039;s Address\/Hospital Affiliation is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_20_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_vjz5y\" id=\"field_vjz5y_label\" class=\"frm_primary_label\">Specialist's Phone Number\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_vjz5y\" name=\"item_meta[20]\" value=\"\"  data-invmsg=\"Specialist&#039;s Phone Number is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_21_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_x3w0w\" id=\"field_x3w0w_label\" class=\"frm_primary_label\">Reason for Referral\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[21]\" id=\"field_x3w0w\" rows=\"3\"  data-invmsg=\"Reason for Referral is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n\t<div  id=\"field_5tu72_label\" class=\"frm_primary_label\">First visit to this specialist?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_5tu72_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_23-0\">\t\t\t<label  for=\"field_5tu72-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[23]\" id=\"field_5tu72-0\" value=\"Yes\"\n\t\t   data-invmsg=\"First visit to this specialist? is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_23-1\">\t\t\t<label  for=\"field_5tu72-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[23]\" id=\"field_5tu72-1\" value=\"No\"\n\t\t   data-invmsg=\"First visit to this specialist? is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_25_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_y1ccq\" id=\"field_y1ccq_label\" class=\"frm_primary_label\">Date of Appointment\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_y1ccq\" name=\"item_meta[25]\" value=\"\"  maxlength=\"10\" data-invmsg=\"Date of Appointment is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n\t<div  id=\"field_obw54_label\" class=\"frm_primary_label\">How shall we confirm this appointment?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_obw54_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_26-0\">\t\t\t<label  for=\"field_obw54-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[26]\" id=\"field_obw54-0\" value=\"Mail to my home address\"\n\t\t   data-invmsg=\"How shall we confirm this appointment? is invalid\" aria-invalid=\"false\"  \/> Mail to my home address<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_26-1\">\t\t\t<label  for=\"field_obw54-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[26]\" id=\"field_obw54-1\" value=\"Leave a message on my home phone\"\n\t\t   data-invmsg=\"How shall we confirm this appointment? is invalid\" aria-invalid=\"false\"  \/> Leave a message on my home phone<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_27_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_5hg0q\" id=\"field_5hg0q_label\" class=\"frm_primary_label\">Additional information or special instructions\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[27]\" id=\"field_5hg0q\" rows=\"3\"  data-invmsg=\"Additional information or special instructions is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_6_container\" class=\"frm_form_field form-field  frm12 frm_first\">\r\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n\r\n\r\n<\/div>\r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t\t<div class=\"frm__67c34bca6e549\">\n\t\t\t\t<label for=\"frm_email_2\" >\n\t\t\t\t\tIf you are human, leave this field blank.\t\t\t\t<\/label>\n\t\t\t\t<input  id=\"frm_email_2\" type=\"text\" class=\"frm_verify\" name=\"frm__67c34bca6e549\" value=\"\" autocomplete=\"off\"  \/>\n\t\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"KWgWAuWbX6\/l85zlrbdQ1pOCZAogeAK1XWDc3r\/Uuoo=\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Referral Form<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_2_container\" data-token=\"0312743d0d5812a44ef7c1998af27c3b\" data-token=\"0312743d0d5812a44ef7c1998af27c3b\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_referrals\" data-token=\"0312743d0d5812a44ef7c1998af27c3b\" data-token=\"0312743d0d5812a44ef7c1998af27c3b\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Referrals<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"2\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_2\" id=\"frm_hide_fields_2\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"referrals\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_2\" name=\"frm_submit_entry_2\" value=\"26c6e417dd\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/about\/wp-json\/wp\/v2\/pages\/392\" \/><div id=\"frm_field_7_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_1tkz5_label\" class=\"frm_primary_label\">Your Name\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_1tkz5_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tYour Name\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_7\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_7-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_1tkz5_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\tid=\"field_1tkz5_first\"\n\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\tname=\"item_meta[7][first]\"  data-reqmsg=\"Your Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Your Name is invalid\" aria-invalid=\"false\"  \t\t\t\t\t\t\/>\n\t\t\t\t\t\t<div class=\"frm_description\" id=\"frm_field_7_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_7-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_1tkz5_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\tid=\"field_1tkz5_last\"\n\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\tname=\"item_meta[7][last]\"  data-reqmsg=\"Your Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Your Name is invalid\" aria-invalid=\"false\"  \t\t\t\t\t\t\/>\n\t\t\t\t\t\t<div class=\"frm_description\" id=\"frm_field_7_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_9_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first\">\r\n\t<div  id=\"field_tc71s_label\" class=\"frm_primary_label\">Address\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_tc71s_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tAddress<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_9-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_tc71s_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_tc71s_line1\" value=\"\" name=\"item_meta[9][line1]\"  data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_9-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_tc71s_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_tc71s_line2\" value=\"\" name=\"item_meta[9][line2]\"  data-invmsg=\"Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_9-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_tc71s_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_tc71s_city\" value=\"\" name=\"item_meta[9][city]\"  data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_9-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_tc71s_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t\t<select name=\"item_meta[9][state]\" id=\"field_tc71s_state\"  data-frmval=\"Massachusetts\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Alabama\">Alabama<\/option><option  value=\"Alaska\">Alaska<\/option><option  value=\"Arkansas\">Arkansas<\/option><option  value=\"Arizona\">Arizona<\/option><option  value=\"California\">California<\/option><option  value=\"Colorado\">Colorado<\/option><option  value=\"Connecticut\">Connecticut<\/option><option  value=\"Delaware\">Delaware<\/option><option  value=\"District of Columbia\">District of Columbia<\/option><option  value=\"Florida\">Florida<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Hawaii\">Hawaii<\/option><option  value=\"Idaho\">Idaho<\/option><option  value=\"Illinois\">Illinois<\/option><option  value=\"Indiana\">Indiana<\/option><option  value=\"Iowa\">Iowa<\/option><option  value=\"Kansas\">Kansas<\/option><option  value=\"Kentucky\">Kentucky<\/option><option  value=\"Louisiana\">Louisiana<\/option><option  value=\"Maine\">Maine<\/option><option  value=\"Maryland\">Maryland<\/option><option  value=\"Massachusetts\" selected='selected'>Massachusetts<\/option><option  value=\"Michigan\">Michigan<\/option><option  value=\"Minnesota\">Minnesota<\/option><option  value=\"Mississippi\">Mississippi<\/option><option  value=\"Missouri\">Missouri<\/option><option  value=\"Montana\">Montana<\/option><option  value=\"Nebraska\">Nebraska<\/option><option  value=\"Nevada\">Nevada<\/option><option  value=\"New Hampshire\">New Hampshire<\/option><option  value=\"New Jersey\">New Jersey<\/option><option  value=\"New Mexico\">New Mexico<\/option><option  value=\"New York\">New York<\/option><option  value=\"North Carolina\">North Carolina<\/option><option  value=\"North Dakota\">North Dakota<\/option><option  value=\"Ohio\">Ohio<\/option><option  value=\"Oklahoma\">Oklahoma<\/option><option  value=\"Oregon\">Oregon<\/option><option  value=\"Pennsylvania\">Pennsylvania<\/option><option  value=\"Rhode Island\">Rhode Island<\/option><option  value=\"South Carolina\">South Carolina<\/option><option  value=\"South Dakota\">South Dakota<\/option><option  value=\"Tennessee\">Tennessee<\/option><option  value=\"Texas\">Texas<\/option><option  value=\"Utah\">Utah<\/option><option  value=\"Vermont\">Vermont<\/option><option  value=\"Virginia\">Virginia<\/option><option  value=\"Washington\">Washington<\/option><option  value=\"West Virginia\">West Virginia<\/option><option  value=\"Wisconsin\">Wisconsin<\/option><option  value=\"Wyoming\">Wyoming<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_9-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_tc71s_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_tc71s_zip\" value=\"\" name=\"item_meta[9][zip]\"  data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_10_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_xdz5h\" id=\"field_xdz5h_label\" class=\"frm_primary_label\">Home Phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_xdz5h\" name=\"item_meta[10]\" value=\"\"  data-invmsg=\"Home Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_11_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_qvy9e\" id=\"field_qvy9e_label\" class=\"frm_primary_label\">Work Phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_qvy9e\" name=\"item_meta[11]\" value=\"\"  data-invmsg=\"Work Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_12_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_t66q6_label\" class=\"frm_primary_label\">Child's Name\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_t66q6_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tChild&#039;s Name\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_12\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_12-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_t66q6_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\tid=\"field_t66q6_first\"\n\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\tname=\"item_meta[12][first]\"  data-reqmsg=\"Child&#039;s Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Child&#039;s Name is invalid\" aria-invalid=\"false\"  \t\t\t\t\t\t\/>\n\t\t\t\t\t\t<div class=\"frm_description\" id=\"frm_field_12_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_12-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_t66q6_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\tid=\"field_t66q6_last\"\n\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\tname=\"item_meta[12][last]\"  data-reqmsg=\"Child&#039;s Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Child&#039;s Name is invalid\" aria-invalid=\"false\"  \t\t\t\t\t\t\/>\n\t\t\t\t\t\t<div class=\"frm_description\" id=\"frm_field_12_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_13_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_x13t0\" id=\"field_x13t0_label\" class=\"frm_primary_label\">Child's Date of Birth\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_x13t0\" name=\"item_meta[13]\" value=\"\"  maxlength=\"10\" data-invmsg=\"Child&#039;s Date of Birth is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_14_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_llxqh\" id=\"field_llxqh_label\" class=\"frm_primary_label\">Child's Insurer's Name\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_llxqh\" name=\"item_meta[14]\" value=\"\"  data-invmsg=\"Child&#039;s Insurer&#039;s Name is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_15_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_drafe\" id=\"field_drafe_label\" class=\"frm_primary_label\">Insurance Subscriber ID\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_drafe\" name=\"item_meta[15]\" value=\"\"  data-invmsg=\"Insurance Subscriber ID is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_16_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_8iohh\" id=\"field_8iohh_label\" class=\"frm_primary_label\">Child's Primary Care Provider\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[16]\" id=\"field_8iohh\"  data-invmsg=\"Child&#039;s Primary Care Provider is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"Karen Ashworth, FNP, AE-C\">Karen Ashworth, FNP, AE-C<\/option><option  value=\"Robert H. Andler, MD, FAAP\">Robert H. Andler, MD, FAAP<\/option><option  value=\"Shelly C. Bernstein, MD\">Shelly C. Bernstein, MD<\/option><option  value=\"Andrea Bertorelli, NP\">Andrea Bertorelli, NP<\/option><option  value=\"Colleen Brownell-Krupat, MD\">Colleen Brownell-Krupat, MD<\/option><option  value=\"Katherine M. Bui, MD\">Katherine M. Bui, MD<\/option><option  value=\"Rosemarie Dieffenbach, MD, MPH\">Rosemarie Dieffenbach, MD, MPH<\/option><option  value=\"Joshua Gundersheimer, MD\">Joshua Gundersheimer, MD<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_17_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_upchc\" id=\"field_upchc_label\" class=\"frm_primary_label\">Name of Specialist\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_upchc\" name=\"item_meta[17]\" value=\"\"  data-invmsg=\"Name of Specialist is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_18_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_wjw09\" id=\"field_wjw09_label\" class=\"frm_primary_label\">Specialist's Provider Number (if available)\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_wjw09\" name=\"item_meta[18]\" value=\"\"  data-invmsg=\"Specialist&#039;s Provider Number (if available) is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_19_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<div  id=\"field_f4237_label\" class=\"frm_primary_label\">Specialist's Address\/Hospital Affiliation\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_f4237_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tSpecialist&#039;s Address\/Hospital Affiliation<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_19-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_f4237_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tSpecialist&#039;s Address\/Hospital Affiliation\t<\/label>\n\t\t<input type=\"text\" id=\"field_f4237_line1\" value=\"\" name=\"item_meta[19][line1]\"  data-invmsg=\"Specialist&#039;s Address\/Hospital Affiliation is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_19-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_f4237_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tSpecialist&#039;s Address\/Hospital Affiliation\t<\/label>\n\t\t<input type=\"text\" id=\"field_f4237_line2\" value=\"\" name=\"item_meta[19][line2]\"  data-invmsg=\"Specialist&#039;s Address\/Hospital Affiliation is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_19-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_f4237_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_f4237_city\" value=\"\" name=\"item_meta[19][city]\"  data-invmsg=\"Specialist&#039;s Address\/Hospital Affiliation is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_19-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_f4237_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t\t<select name=\"item_meta[19][state]\" id=\"field_f4237_state\"  data-frmval=\"Massachusetts\" data-invmsg=\"Specialist&#039;s Address\/Hospital Affiliation is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Alabama\">Alabama<\/option><option  value=\"Alaska\">Alaska<\/option><option  value=\"Arkansas\">Arkansas<\/option><option  value=\"Arizona\">Arizona<\/option><option  value=\"California\">California<\/option><option  value=\"Colorado\">Colorado<\/option><option  value=\"Connecticut\">Connecticut<\/option><option  value=\"Delaware\">Delaware<\/option><option  value=\"District of Columbia\">District of Columbia<\/option><option  value=\"Florida\">Florida<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Hawaii\">Hawaii<\/option><option  value=\"Idaho\">Idaho<\/option><option  value=\"Illinois\">Illinois<\/option><option  value=\"Indiana\">Indiana<\/option><option  value=\"Iowa\">Iowa<\/option><option  value=\"Kansas\">Kansas<\/option><option  value=\"Kentucky\">Kentucky<\/option><option  value=\"Louisiana\">Louisiana<\/option><option  value=\"Maine\">Maine<\/option><option  value=\"Maryland\">Maryland<\/option><option  value=\"Massachusetts\" selected='selected'>Massachusetts<\/option><option  value=\"Michigan\">Michigan<\/option><option  value=\"Minnesota\">Minnesota<\/option><option  value=\"Mississippi\">Mississippi<\/option><option  value=\"Missouri\">Missouri<\/option><option  value=\"Montana\">Montana<\/option><option  value=\"Nebraska\">Nebraska<\/option><option  value=\"Nevada\">Nevada<\/option><option  value=\"New Hampshire\">New Hampshire<\/option><option  value=\"New Jersey\">New Jersey<\/option><option  value=\"New Mexico\">New Mexico<\/option><option  value=\"New York\">New York<\/option><option  value=\"North Carolina\">North Carolina<\/option><option  value=\"North Dakota\">North Dakota<\/option><option  value=\"Ohio\">Ohio<\/option><option  value=\"Oklahoma\">Oklahoma<\/option><option  value=\"Oregon\">Oregon<\/option><option  value=\"Pennsylvania\">Pennsylvania<\/option><option  value=\"Rhode Island\">Rhode Island<\/option><option  value=\"South Carolina\">South Carolina<\/option><option  value=\"South Dakota\">South Dakota<\/option><option  value=\"Tennessee\">Tennessee<\/option><option  value=\"Texas\">Texas<\/option><option  value=\"Utah\">Utah<\/option><option  value=\"Vermont\">Vermont<\/option><option  value=\"Virginia\">Virginia<\/option><option  value=\"Washington\">Washington<\/option><option  value=\"West Virginia\">West Virginia<\/option><option  value=\"Wisconsin\">Wisconsin<\/option><option  value=\"Wyoming\">Wyoming<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_19-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_f4237_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_f4237_zip\" value=\"\" name=\"item_meta[19][zip]\"  data-invmsg=\"Specialist&#039;s Address\/Hospital Affiliation is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_20_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_vjz5y\" id=\"field_vjz5y_label\" class=\"frm_primary_label\">Specialist's Phone Number\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_vjz5y\" name=\"item_meta[20]\" value=\"\"  data-invmsg=\"Specialist&#039;s Phone Number is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_21_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_x3w0w\" id=\"field_x3w0w_label\" class=\"frm_primary_label\">Reason for Referral\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[21]\" id=\"field_x3w0w\" rows=\"3\"  data-invmsg=\"Reason for Referral is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n\t<div  id=\"field_5tu72_label\" class=\"frm_primary_label\">First visit to this specialist?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_5tu72_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_23-0\">\t\t\t<label  for=\"field_5tu72-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[23]\" id=\"field_5tu72-0\" value=\"Yes\"\n\t\t   data-invmsg=\"First visit to this specialist? is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_23-1\">\t\t\t<label  for=\"field_5tu72-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[23]\" id=\"field_5tu72-1\" value=\"No\"\n\t\t   data-invmsg=\"First visit to this specialist? is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_25_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_y1ccq\" id=\"field_y1ccq_label\" class=\"frm_primary_label\">Date of Appointment\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_y1ccq\" name=\"item_meta[25]\" value=\"\"  maxlength=\"10\" data-invmsg=\"Date of Appointment is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n\t<div  id=\"field_obw54_label\" class=\"frm_primary_label\">How shall we confirm this appointment?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_obw54_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_26-0\">\t\t\t<label  for=\"field_obw54-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[26]\" id=\"field_obw54-0\" value=\"Mail to my home address\"\n\t\t   data-invmsg=\"How shall we confirm this appointment? is invalid\" aria-invalid=\"false\"  \/> Mail to my home address<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_26-1\">\t\t\t<label  for=\"field_obw54-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[26]\" id=\"field_obw54-1\" value=\"Leave a message on my home phone\"\n\t\t   data-invmsg=\"How shall we confirm this appointment? is invalid\" aria-invalid=\"false\"  \/> Leave a message on my home phone<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_27_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_5hg0q\" id=\"field_5hg0q_label\" class=\"frm_primary_label\">Additional information or special instructions\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[27]\" id=\"field_5hg0q\" rows=\"3\"  data-invmsg=\"Additional information or special instructions is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_6_container\" class=\"frm_form_field form-field  frm12 frm_first\">\r\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n\r\n\r\n<\/div>\r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t\t<div class=\"frm__67c34bca6e549\">\n\t\t\t\t<label for=\"frm_email_2\" >\n\t\t\t\t\tIf you are human, leave this field blank.\t\t\t\t<\/label>\n\t\t\t\t<input  id=\"frm_email_2\" type=\"text\" class=\"frm_verify\" name=\"frm__67c34bca6e549\" value=\"\" autocomplete=\"off\"  \/>\n\t\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"KWgWAuWbX6\/l85zlrbdQ1pOCZAogeAK1XWDc3r\/Uuoo=\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-392","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.westonpediatrics.org\/about\/wp-json\/wp\/v2\/pages\/392","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.westonpediatrics.org\/about\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.westonpediatrics.org\/about\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.westonpediatrics.org\/about\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.westonpediatrics.org\/about\/wp-json\/wp\/v2\/comments?post=392"}],"version-history":[{"count":3,"href":"https:\/\/www.westonpediatrics.org\/about\/wp-json\/wp\/v2\/pages\/392\/revisions"}],"predecessor-version":[{"id":396,"href":"https:\/\/www.westonpediatrics.org\/about\/wp-json\/wp\/v2\/pages\/392\/revisions\/396"}],"wp:attachment":[{"href":"https:\/\/www.westonpediatrics.org\/about\/wp-json\/wp\/v2\/media?parent=392"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}