{"id":11552,"date":"2020-02-24T04:29:07","date_gmt":"2020-02-24T04:29:07","guid":{"rendered":"http:\/\/brainchanger.io\/?page_id=11552"},"modified":"2020-02-26T00:39:02","modified_gmt":"2020-02-26T00:39:02","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/brainchanger.io\/referral-form\/","title":{"rendered":"Referral Form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;padding-top:0px;padding-right:25px;padding-bottom:0px;padding-left:25px;margin-bottom: 0px;margin-top: 0px;border-width: 0px 0px 0px 0px;border-color:#000000;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-1\"><h1><b style=\"color: #000000;\">Refer a Patient Form<\/b><\/h1>\n<p style=\"line-height: 31px; letter-spacing: normal; font-size: 16px;\" data-fusion-font=\"true\">The Brain Changer Clinical Director will contact your client within the next business day<\/p>\n<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-11551\"><form id=\"wpforms-form-11551\" class=\"wpforms-validate wpforms-form\" data-formid=\"11551\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wp-json\/wp\/v2\/pages\/11552\/\" data-token=\"6488766ad32ff58a6c09db4b48f5229f\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-11551-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-11551-field_0\">Patient&#039;s full name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-11551-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-11551-field_0\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-11551-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-11551-field_0-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-11551-field_4-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-11551-field_4\">Phone number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-11551-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" required><\/div><div id=\"wpforms-11551-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-11551-field_1\">Email  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-11551-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-11551-field_5-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-11551-field_5\">Insurer information<\/label><textarea id=\"wpforms-11551-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\" ><\/textarea><\/div><div id=\"wpforms-11551-field_6-container\" class=\"wpforms-field wpforms-field-captcha\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-11551-field_6\">Please answer the following math question (captcha) <span class=\"wpforms-required-label\">*<\/span><\/label><p id=\"wpforms-11551-field_6-question\" class=\"wpforms-captcha-question\">What is 7+4?<\/p>\n\t\t\t<input type=\"text\" id=\"wpforms-11551-field_6\" class=\"wpforms-field-medium wpforms-field-required a\" data-rule-wpf-captcha=\"qa\" data-is-wrapped-field=\"1\" data-a=\"11\" name=\"wpforms[fields][6][a]\" aria-describedby=\"wpforms-11551-field_6-question\" required>\n\t\t\t<input type=\"hidden\" name=\"wpforms[fields][6][q]\" value=\"1\">\n\n\t\t\t<\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-11551-field-hp\" class=\"wpforms-field-label\">Comment<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-11551-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"11551\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-11551\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/pages\/11552"}],"collection":[{"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/comments?post=11552"}],"version-history":[{"count":5,"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/pages\/11552\/revisions"}],"predecessor-version":[{"id":11614,"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/pages\/11552\/revisions\/11614"}],"wp:attachment":[{"href":"https:\/\/brainchanger.io\/wp-json\/wp\/v2\/media?parent=11552"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}