{"id":110,"date":"2019-06-09T06:12:30","date_gmt":"2019-06-09T06:12:30","guid":{"rendered":"https:\/\/dubuqueent.fm1.dev\/request-appointment\/"},"modified":"2021-10-22T17:12:31","modified_gmt":"2021-10-22T22:12:31","slug":"request-appointment","status":"publish","type":"page","link":"https:\/\/dubuqueent.com\/request-appointment\/","title":{"rendered":"Request Appointment"},"content":{"rendered":"\n<div class=\"contact contain js-intersect\">\n\t\t<div class=\"home-contact-wrap\">\n\t\t\t<div class=\"contact-left\">\n\t\t\t\t<h2>Contact Us<\/h2>\n\t\t\t\t<div class=\"contact-hide\">\n\t\t\t\t\t<div class=\"home-contact-desc\">\n\t\t\t\t\t\t<p><strong>If you are experiencing a medical emergency, please call 911.<\/strong><\/p>\n\t\t\t\t\t\t<p>Please complete the form and our team will contact you during our regular business hours.<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\t\n\t\t\t<\/div>\t\n\t\t\t<div class=\"contact-right\">\n\t\t\t\t<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><div class=\"fuel-gf-wrapper\">\n                <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><p><strong>If you are experiencing a medical emergency, please call 911.<\/strong><\/p>\r\n<p>Our friendly providers are here, and ready, to help you. Call to schedule an appointment today!<\/p><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1'  action='\/wp-json\/wp\/v2\/pages\/110\/#gf_1' data-formid='1' novalidate><div class=\"fuel-gf-alert\" role=\"alert\"><\/div>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_1\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\" ><label class='gfield_label gform-field-label' for='input_1_1'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\" ><label class='gfield_label gform-field-label' for='input_1_2'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_1_2' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><label class='gfield_label gform-field-label' for='input_1_5'>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_7\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><label class='gfield_label gform-field-label' for='input_1_7'>Reason for Contact<\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_1_7' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Billing Question' >Billing Question<\/option><option value='ENT Visit' >ENT Visit<\/option><option value='Audiology Visit' >Audiology Visit<\/option><option value='New Patient' >New Patient<\/option><option value='General Inquiry' >General Inquiry<\/option><option value='Set up Patient Portal' >Set up Patient Portal<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\" ><label class='gfield_label gform-field-label' for='input_1_8'>Comments<\/label><div class='gfield_description' id='gfield_description_1_8'>Please do not send personal information or medical requests using this form. 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