{"id":223,"date":"2014-04-04T10:46:56","date_gmt":"2014-04-04T10:46:56","guid":{"rendered":"http:\/\/medical.madza-wordpress-premium-themes.com\/?page_id=223"},"modified":"2024-01-11T13:15:39","modified_gmt":"2024-01-11T21:15:39","slug":"reservation","status":"publish","type":"page","link":"https:\/\/www.laxurgentcare.com\/?page_id=223","title":{"rendered":"Appointment Form"},"content":{"rendered":"<div class=\"mt_style_row row \" style='  text-align:left;'><div class=\"container mt-madza-container\"><div class=\"row\">\n\t<div class=\"vc_col-sm-8 wpb_column vc_column_container\">\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t\n\t<div class=\"wpb_text_column wpb_content_element \">\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<h3><div class=\"everest-forms\"><div class=\"evf-container default\" id=\"evf-2636\"><form id=\"evf-form-2636\" class=\"everest-form\" data-formid=\"2636\" data-ajax_submission=\"0\" data-keyboard_friendly_form=\"0\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F223\"><div class=\"evf-field-container\"><input type=\"hidden\" id=\"_wpnonce2636\" name=\"_wpnonce2636\" value=\"df2f36945a\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F223\" \/><div class=\"evf-frontend-row\" data-row=\"row_1\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-1\" data-grid=\"grid_1\"><div id=\"evf-2636-field_hvvUcmFqw4-1-container\" class=\"evf-field evf-field-first-name form-row validate-required\" data-required-field-message=\"This field is required.\" data-field-id=\"hvvUcmFqw4-1\"><label class=\"evf-field-label\" for=\"evf-2636-field_hvvUcmFqw4-1\"><span class=\"evf-label\">Patient Full Name<\/span> <abbr class=\"required\" title=\"Required\">*<\/abbr><\/label><input type=\"text\" id=\"evf-2636-field_hvvUcmFqw4-1\" class=\"input-text\" name=\"everest_forms[form_fields][hvvUcmFqw4-1]\" required><\/div><div id=\"evf-2636-field_c940UwsEYJ-10-container\" class=\"evf-field evf-field-number form-row validate-required\" data-required-field-message=\"Please enter a valid number.\" data-field-id=\"c940UwsEYJ-10\"><label class=\"evf-field-label\" for=\"evf-2636-field_c940UwsEYJ-10\"><span class=\"evf-label\">Phone Number<\/span> <abbr class=\"required\" title=\"Required\">*<\/abbr><\/label><input type=\"number\" id=\"evf-2636-field_c940UwsEYJ-10\" class=\"input-text\" name=\"everest_forms[form_fields][c940UwsEYJ-10]\" step=\"1\" required\/><\/div><div id=\"evf-2636-field_xL6viStGfI-2-container\" class=\"evf-field evf-field-date-time form-row\" data-field-id=\"xL6viStGfI-2\"><label class=\"evf-field-label\" for=\"evf-2636-field_xL6viStGfI-2\"><span class=\"evf-label\">Date of Birth<\/span> <\/label><input type=\"text\" id=\"evf-2636-field_xL6viStGfI-2\" class=\"flatpickr-field input-text\" name=\"everest_forms[form_fields][xL6viStGfI-2]\" data-time-interval=\"15\" data-date-time=\"date\" data-mode=\"single\" data-locale=\"en\" data-date-format=\"Y-m-d\"  ><\/div><div id=\"evf-2636-field_6jnCs9d4c3-3-container\" class=\"evf-field evf-field-radio form-row validate-required\" data-required-field-message=\"This field is required.\" data-field-id=\"6jnCs9d4c3-3\"><label class=\"evf-field-label\" for=\"evf-2636-field_6jnCs9d4c3-3\"><span class=\"evf-label\">Gender<\/span> <abbr class=\"required\" title=\"Required\">*<\/abbr><\/label><ul id=\"evf-2636-field_6jnCs9d4c3-3\" class=\" evf-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"evf-2636-field_6jnCs9d4c3-3_1\" class=\"input-text\" name=\"everest_forms[form_fields][6jnCs9d4c3-3]\" value=\"Male\" required ><label class=\"everest-forms-field-label-inline\" for=\"evf-2636-field_6jnCs9d4c3-3_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"evf-2636-field_6jnCs9d4c3-3_2\" class=\"input-text\" name=\"everest_forms[form_fields][6jnCs9d4c3-3]\" value=\"Female\" required ><label class=\"everest-forms-field-label-inline\" for=\"evf-2636-field_6jnCs9d4c3-3_2\">Female<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"evf-2636-field_6jnCs9d4c3-3_3\" class=\"input-text\" name=\"everest_forms[form_fields][6jnCs9d4c3-3]\" value=\"Other\" required ><label class=\"everest-forms-field-label-inline\" for=\"evf-2636-field_6jnCs9d4c3-3_3\">Other<\/label><\/li><\/ul><\/div><div id=\"evf-2636-field_CpFdRYhTQ4-4-container\" class=\"evf-field evf-field-email form-row validate-required validate-email\" data-required-field-message=\"Please enter a valid email address.\" data-field-id=\"CpFdRYhTQ4-4\"><label class=\"evf-field-label\" for=\"evf-2636-field_CpFdRYhTQ4-4\"><span class=\"evf-label\">Email<\/span> <abbr class=\"required\" title=\"Required\">*<\/abbr><\/label><input type=\"email\" id=\"evf-2636-field_CpFdRYhTQ4-4\" class=\"input-text\" name=\"everest_forms[form_fields][CpFdRYhTQ4-4]\" required ><\/div><div id=\"evf-2636-field_dVXZsSUKPY-5-container\" class=\"evf-field evf-field-select form-row\" data-field-id=\"dVXZsSUKPY-5\"><label class=\"evf-field-label\" for=\"evf-2636-field_dVXZsSUKPY-5\"><span class=\"evf-label\">Select Department<\/span> <\/label><select id=\"evf-2636-field_dVXZsSUKPY-5\" class=\"input-text\" name=\"everest_forms[form_fields][dVXZsSUKPY-5]\" ><option value=\"General Surgery\" >General Surgery<\/option><option value=\"Pediatric Clinic\" >Pediatric Clinic<\/option><option value=\"Dental Clinic\" >Dental Clinic<\/option><option value=\"Gynaecological Clinic\" >Gynaecological Clinic<\/option><option value=\"Rehabilitation Therapy\" >Rehabilitation Therapy<\/option><option value=\"Diagnosis With Precise\" >Diagnosis With Precise<\/option><\/select><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_2\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_1\"><div id=\"evf-2636-field_3FjiSK9Ge2-6-container\" class=\"evf-field evf-field-date-time form-row validate-required\" data-required-field-message=\"This field is required.\" data-field-id=\"3FjiSK9Ge2-6\"><label class=\"evf-field-label\" for=\"evf-2636-field_3FjiSK9Ge2-6\"><span class=\"evf-label\">Appointment Date<\/span> <abbr class=\"required\" title=\"Required\">*<\/abbr><\/label><input type=\"text\" id=\"evf-2636-field_3FjiSK9Ge2-6\" class=\"flatpickr-field input-text\" name=\"everest_forms[form_fields][3FjiSK9Ge2-6]\" data-time-interval=\"15\" data-date-time=\"date\" data-mode=\"single\" data-locale=\"en\" data-date-format=\"Y-m-d\" required ><div class=\"evf-field-description\">The preferred date may vary upon the doctor's availability.<\/div><\/div><\/div><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_2\"><div id=\"evf-2636-field_iyBtrqV0cn-7-container\" class=\"evf-field evf-field-date-time form-row validate-required\" data-required-field-message=\"This field is required.\" data-field-id=\"iyBtrqV0cn-7\"><label class=\"evf-field-label\" for=\"evf-2636-field_iyBtrqV0cn-7\"><span class=\"evf-label\">Preferred Time<\/span> <abbr class=\"required\" title=\"Required\">*<\/abbr><\/label><input type=\"text\" id=\"evf-2636-field_iyBtrqV0cn-7\" class=\"flatpickr-field input-text\" name=\"everest_forms[form_fields][iyBtrqV0cn-7]\" data-time-interval=\"15\" data-date-time=\"time\" data-date-format=\"h:i K\" required ><div class=\"evf-field-description\">Available hours are below.<\/div><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_3\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-1\" data-grid=\"grid_1\"><div id=\"evf-2636-field_9nehMwTTjV-8-container\" class=\"evf-field evf-field-radio form-row\" data-field-id=\"9nehMwTTjV-8\"><label class=\"evf-field-label\" for=\"evf-2636-field_9nehMwTTjV-8\"><span class=\"evf-label\">Have you been at out Medical before?<\/span> <\/label><ul id=\"evf-2636-field_9nehMwTTjV-8\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"evf-2636-field_9nehMwTTjV-8_1\" class=\"input-text\" name=\"everest_forms[form_fields][9nehMwTTjV-8]\" value=\"Yes\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-2636-field_9nehMwTTjV-8_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"evf-2636-field_9nehMwTTjV-8_2\" class=\"input-text\" name=\"everest_forms[form_fields][9nehMwTTjV-8]\" value=\"No\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-2636-field_9nehMwTTjV-8_2\">No<\/label><\/li><\/ul><\/div><div id=\"evf-2636-field_6hRHC3lzht-9-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"6hRHC3lzht-9\"><label class=\"evf-field-label\" for=\"evf-2636-field_6hRHC3lzht-9\"><span class=\"evf-label\">Description<\/span> <\/label><textarea id=\"evf-2636-field_6hRHC3lzht-9\" class=\"input-text\" name=\"everest_forms[form_fields][6hRHC3lzht-9]\" placeholder=\"Tell us about your health issues\"  ><\/textarea><\/div><\/div><\/div><\/div><div class=\"evf-honeypot-container evf-field-hp\"><label for=\"evf-2636-field-hp\" class=\"evf-field-label\">Message<\/label><input type=\"text\" name=\"everest_forms[hp]\" id=\"evf-2636-field-hp\" class=\"input-text\"><\/div><div class=\"evf-submit-container \" ><input type=\"hidden\" name=\"everest_forms[id]\" value=\"2636\"><input type=\"hidden\" name=\"everest_forms[author]\" value=\"1\"><button type='submit' name='everest_forms[submit]' class='everest-forms-submit-button button evf-submit ' id='evf-submit-2636' value='evf-submit' data-process-text=\"Processing\u2026\" conditional_rules='&quot;&quot;' conditional_id='evf-submit-2636'  id=\"evf-submit-2636\" aria-live=\"assertive\">Submit<\/button><\/div><\/form><\/div><!-- .evf-container --><\/div><\/h3>\n<h3>Opening Hours<\/h3>\n\n\t\t<\/div> \n\t<\/div> \n\t<div class=\"wpb_text_column wpb_content_element \">\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<table border=\"1\">\n<tbody>\n<tr>\n<th>Days<\/th>\n<th>Hours<\/th>\n<\/tr>\n<tr>\n<td>Monday &#8211; Friday<\/td>\n<td>24 Hours<\/td>\n<\/tr>\n<tr>\n<td>Saturday<\/td>\n<td>24 Hours<\/td>\n<\/tr>\n<tr>\n<td>Sunday<\/td>\n<td>24 Hours<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\t\t<\/div> \n\t<\/div> \n\t\t<\/div> \n\t<\/div> \n<\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"Patient Full Name *Phone Number *Date of Birth Gender *MaleFemaleOtherEmail *Select Department General SurgeryPediatric ClinicDental ClinicGynaecological ClinicRehabilitation TherapyDiagnosis With PreciseAppointment Date *The preferred date may vary upon the doctor's availability.Preferred Time *Available hours are below.Have you been at out Medical before? YesNoDescription EmailSubmit Opening Hours Days Hours Monday - Friday 24 Hours Saturday 24 Hours Sunday 24 Hours","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"jetpack_post_was_ever_published":false},"jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/PbSKWk-3B","_links":{"self":[{"href":"https:\/\/www.laxurgentcare.com\/index.php?rest_route=\/wp\/v2\/pages\/223"}],"collection":[{"href":"https:\/\/www.laxurgentcare.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.laxurgentcare.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.laxurgentcare.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.laxurgentcare.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=223"}],"version-history":[{"count":3,"href":"https:\/\/www.laxurgentcare.com\/index.php?rest_route=\/wp\/v2\/pages\/223\/revisions"}],"predecessor-version":[{"id":2647,"href":"https:\/\/www.laxurgentcare.com\/index.php?rest_route=\/wp\/v2\/pages\/223\/revisions\/2647"}],"wp:attachment":[{"href":"https:\/\/www.laxurgentcare.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=223"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}