{"id":2317,"date":"2020-02-19T12:45:13","date_gmt":"2020-02-19T12:45:13","guid":{"rendered":"https:\/\/driveoffaith.com\/?page_id=2317"},"modified":"2024-01-21T00:30:22","modified_gmt":"2024-01-21T00:30:22","slug":"appointment-form","status":"publish","type":"page","link":"https:\/\/driveoffaith.com\/?page_id=2317","title":{"rendered":"APPOINTMENT FORM"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2316-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=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F2317#wpcf7-f2316-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=\"2316\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.7.7\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2316-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"row-fluid\">\n\t<p class=\"span6 field\">Appointment Date <span class=\"wpcf7-form-control-wrap\" data-name=\"appointment\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"appointment\" \/><\/span>\n\t<\/p>\n\t<p class=\"span6 field\">Time:<span class=\"wpcf7-form-control-wrap\" data-name=\"time\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"time\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row-fluid\">\n\t<p class=\"span6 field\"> Resident\u2019s Name:<span class=\"wpcf7-form-control-wrap\" data-name=\"residentname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"residentname\" \/><\/span>\n\t<\/p>\n\t<p class=\"span6 field\">Room: <span class=\"wpcf7-form-control-wrap\" data-name=\"room\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"room\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row-fluid\">\n\t<p class=\"span12 field\"> Pick up address:<span class=\"wpcf7-form-control-wrap\" data-name=\"destination\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"destination\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row-fluid\">\n\t<p class=\"span12 field\"> Destination:<span class=\"wpcf7-form-control-wrap\" data-name=\"destination\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"destination\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row-fluid\">\n\t<p class=\"span12 field\"> Address:<span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"address\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row-fluid\">\n\t<p class=\"span6 field\"> Phone #:<span class=\"wpcf7-form-control-wrap\" data-name=\"phonenumber\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"phonenumber\" \/><\/span>\n\t<\/p>\n\t<p class=\"span6 field\">Suite:<span class=\"wpcf7-form-control-wrap\" data-name=\"suite\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"suite\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row-fluid\">\n\t<p class=\"span12 field\" style=\"text-align:center;padding-top:30px;\"><span class=\"wpcf7-form-control-wrap\" data-name=\"additional\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"additional[]\" value=\"Wheelchair\" \/><span class=\"wpcf7-list-item-label\">Wheelchair<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"additional[]\" value=\"Ambulatory\" \/><span class=\"wpcf7-list-item-label\">Ambulatory<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"additional[]\" value=\"Oxygen\" \/><span class=\"wpcf7-list-item-label\">Oxygen<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"additional[]\" value=\"Geriatric Chair\" \/><span class=\"wpcf7-list-item-label\">Geriatric Chair<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"span12 field\" style=\"text-align:center;padding-top:30px;\"><span class=\"wpcf7-form-control-wrap\" data-name=\"escort\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"escort[]\" value=\"Family Escort\" \/><span class=\"wpcf7-list-item-label\">Family Escort<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"escort[]\" value=\"Staff Escort\" \/><span class=\"wpcf7-list-item-label\">Staff Escort<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row-fluid\">\n\t<p class=\"span12 field\"> Family, Friend or RP Meeting at Appointment:<span class=\"wpcf7-form-control-wrap\" data-name=\"family\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"family\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row-fluid\">\n\t<p class=\"span3 field\" style=\"padding-top:30px;\"><span class=\"wpcf7-form-control-wrap\" data-name=\"privatepay\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"privatepay[]\" value=\"Private Pay\" \/><span class=\"wpcf7-list-item-label\">Private Pay<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"span9 field\"> Contact Phone Number:<span class=\"wpcf7-form-control-wrap\" data-name=\"contactformnumber\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"contactformnumber\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row-fluid\">\n\t<p class=\"span12 field\"> Comments:<span class=\"wpcf7-form-control-wrap\" data-name=\"comments\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"comments\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row-fluid\">\n\t<p class=\"span12 field\"> Confirmation By:<span class=\"wpcf7-form-control-wrap\" data-name=\"confirmationby\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"confirmationby\" \/><\/span>\n\t<\/p>\n<\/div>\n<p>Thank You for your business!\n<\/p>\n<p><input class=\"wpcf7-form-control has-spinner wpcf7-submit\" type=\"submit\" value=\"Send\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2317","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/driveoffaith.com\/index.php?rest_route=\/wp\/v2\/pages\/2317","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/driveoffaith.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/driveoffaith.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/driveoffaith.com\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/driveoffaith.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2317"}],"version-history":[{"count":6,"href":"https:\/\/driveoffaith.com\/index.php?rest_route=\/wp\/v2\/pages\/2317\/revisions"}],"predecessor-version":[{"id":2353,"href":"https:\/\/driveoffaith.com\/index.php?rest_route=\/wp\/v2\/pages\/2317\/revisions\/2353"}],"wp:attachment":[{"href":"https:\/\/driveoffaith.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2317"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}