{"id":12884,"date":"2025-05-13T13:58:44","date_gmt":"2025-05-13T19:58:44","guid":{"rendered":"https:\/\/radiologyassist.com\/StagingAvada\/?page_id=12884"},"modified":"2025-05-26T20:22:52","modified_gmt":"2025-05-27T02:22:52","slug":"schedule-appointment","status":"publish","type":"page","link":"https:\/\/radiologyassist.com\/StagingAvada\/schedule-appointment\/","title":{"rendered":"Appointment Scheduling Forms"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-no-small-visibility fusion-no-medium-visibility\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-min-height:70px;--awb-background-color:#6d0d26;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1331.2px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_4 1_4 fusion-flex-column fusion-flex-align-self-center\" style=\"--awb-padding-top:10px;--awb-bg-size:cover;--awb-width-large:25%;--awb-margin-top-large:0px;--awb-spacing-right-large:7.68%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:7.68%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-center fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\" style=\"--awb-font-size:18px;--awb-text-color:#ffffff;--awb-text-font-family:-apple-system, BlinkMacSystemFont, &#039;Segoe UI&#039;, Roboto, Oxygen-Sans, Ubuntu, Cantarell, &#039;Helvetica Neue&#039; ,sans-serif;--awb-text-font-style:normal;--awb-text-font-weight:400;\"><p>Appointments : (855) 346 5152<\/p>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_3_4 3_4 fusion-flex-column fusion-flex-align-self-center\" style=\"--awb-padding-top:10px;--awb-bg-size:cover;--awb-width-large:75%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.56%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:2.56%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><nav class=\"awb-menu awb-menu_row awb-menu_em-click mobile-mode-collapse-to-button awb-menu_icons-left awb-menu_dc-yes mobile-trigger-fullwidth-off awb-menu_mobile-toggle mobile-size-full-absolute loading mega-menu-loading awb-menu_desktop awb-menu_flyout awb-menu_flyout__fade\" style=\"--awb-margin-top:-16px;--awb-gap:50px;--awb-align-items:center;--awb-justify-content:flex-end;--awb-color:#ffffff;--awb-active-color:#ffffff;--awb-main-justify-content:flex-start;--awb-mobile-justify:flex-start;--awb-mobile-caret-left:auto;--awb-mobile-caret-right:0;--awb-fusion-font-family-typography:-apple-system, BlinkMacSystemFont, &#039;Segoe UI&#039;, Roboto, Oxygen-Sans, Ubuntu, Cantarell, &#039;Helvetica Neue&#039; ,sans-serif;--awb-fusion-font-style-typography:normal;--awb-fusion-font-weight-typography:400;--awb-fusion-font-family-submenu-typography:inherit;--awb-fusion-font-style-submenu-typography:normal;--awb-fusion-font-weight-submenu-typography:400;--awb-fusion-font-family-mobile-typography:inherit;--awb-fusion-font-style-mobile-typography:normal;--awb-fusion-font-weight-mobile-typography:400;\" aria-label=\"Landing(Info Bar Menu)\" data-breakpoint=\"1024\" data-count=\"0\" data-transition-type=\"fade\" data-transition-time=\"300\"><button type=\"button\" class=\"awb-menu__m-toggle awb-menu__m-toggle_no-text\" aria-expanded=\"false\" aria-controls=\"menu-landinginfo-bar-menu\"><span class=\"awb-menu__m-toggle-inner\"><span class=\"collapsed-nav-text\"><span class=\"screen-reader-text\">Toggle Navigation<\/span><\/span><span class=\"awb-menu__m-collapse-icon awb-menu__m-collapse-icon_no-text\"><span class=\"awb-menu__m-collapse-icon-open awb-menu__m-collapse-icon-open_no-text fa-bars fas\"><\/span><span class=\"awb-menu__m-collapse-icon-close awb-menu__m-collapse-icon-close_no-text fa-times fas\"><\/span><\/span><\/span><\/button><button type=\"button\" class=\"awb-menu__flyout-close\" onClick=\"fusionNavCloseFlyoutSub(this);\"><\/button><ul id=\"menu-landinginfo-bar-menu\" class=\"fusion-menu awb-menu__main-ul awb-menu__main-ul_row\"><li  id=\"menu-item-12486\"  class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-12486 awb-menu__li awb-menu__main-li awb-menu__main-li_regular\"  data-item-id=\"12486\"><span class=\"awb-menu__main-background-default awb-menu__main-background-default_fade\"><\/span><span class=\"awb-menu__main-background-active awb-menu__main-background-active_fade\"><\/span><a  href=\"https:\/\/radiologyassist.com\/StagingAvada\/program-details-mri\/\" class=\"awb-menu__main-a awb-menu__main-a_regular\"><span class=\"menu-text\">MRI<\/span><\/a><\/li><li  id=\"menu-item-12482\"  class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-12482 awb-menu__li awb-menu__main-li awb-menu__main-li_regular\"  data-item-id=\"12482\"><span class=\"awb-menu__main-background-default awb-menu__main-background-default_fade\"><\/span><span class=\"awb-menu__main-background-active awb-menu__main-background-active_fade\"><\/span><a  href=\"https:\/\/radiologyassist.com\/StagingAvada\/program-detail-page-ct-scan\/\" class=\"awb-menu__main-a awb-menu__main-a_regular\"><span class=\"menu-text\">CT Scan<\/span><\/a><\/li><li  id=\"menu-item-12485\"  class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-12485 awb-menu__li awb-menu__main-li awb-menu__main-li_regular\"  data-item-id=\"12485\"><span class=\"awb-menu__main-background-default awb-menu__main-background-default_fade\"><\/span><span class=\"awb-menu__main-background-active awb-menu__main-background-active_fade\"><\/span><a  href=\"https:\/\/radiologyassist.com\/StagingAvada\/program-details-xray\/\" class=\"awb-menu__main-a awb-menu__main-a_regular\"><span class=\"menu-text\">X-Ray<\/span><\/a><\/li><li  id=\"menu-item-12484\"  class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-12484 awb-menu__li awb-menu__main-li awb-menu__main-li_regular\"  data-item-id=\"12484\"><span class=\"awb-menu__main-background-default awb-menu__main-background-default_fade\"><\/span><span class=\"awb-menu__main-background-active awb-menu__main-background-active_fade\"><\/span><a  href=\"https:\/\/radiologyassist.com\/StagingAvada\/program-details-ultrasound\/\" class=\"awb-menu__main-a awb-menu__main-a_regular\"><span class=\"menu-text\">Ultrasound<\/span><\/a><\/li><li  id=\"menu-item-12483\"  class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-12483 awb-menu__li awb-menu__main-li awb-menu__main-li_regular fusion-flyout-menu-item-last\"  data-item-id=\"12483\"><span class=\"awb-menu__main-background-default awb-menu__main-background-default_fade\"><\/span><span class=\"awb-menu__main-background-active awb-menu__main-background-active_fade\"><\/span><a  href=\"https:\/\/radiologyassist.com\/StagingAvada\/program-details-mammogram\/\" class=\"awb-menu__main-a awb-menu__main-a_regular\"><span class=\"menu-text\">Mammogram<\/span><\/a><\/li><\/ul><\/nav><\/div><\/div><\/div><\/div>\n<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:30px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1331.2px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_2_3 2_3 fusion-flex-column gravity-upload-referral-form\" style=\"--awb-bg-size:cover;--awb-width-large:66.666666666667%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.88%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:2.88%;--awb-width-medium:60%;--awb-order-medium:0;--awb-spacing-right-medium:3.2%;--awb-spacing-left-medium:3.2%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-text fusion-title-size-one\" style=\"--awb-text-color:#520a1c;--awb-font-size:30px;\"><h1 class=\"fusion-title-heading title-heading-left sm-text-align-center\" style=\"font-family:&quot;Open Sans&quot;;font-style:normal;font-weight:700;margin:0;font-size:1em;line-height:36px;\">Appointment Scheduling Forms<\/h1><\/div><div class=\"fusion-text fusion-text-2\" style=\"--awb-content-alignment:left;--awb-font-size:18px;--awb-line-height:24px;--awb-text-color:#520a1c;--awb-text-font-family:&quot;Open Sans&quot;;--awb-text-font-style:normal;--awb-text-font-weight:400;\">\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_52' style='display:none'><div id='gf_52' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_52' id='gform_52'  action='\/StagingAvada\/wp-json\/wp\/v2\/pages\/12884#gf_52'>\n        <div id='gf_progressbar_wrapper_52' class='gf_progressbar_wrapper'>\n            <h3 class='gf_progressbar_title'>Step 1 of 4 - Your info\n        <\/h3>\n            <div class='gf_progressbar' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body'><div id='gform_page_52_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_52' class='gform_fields top_label form_sublabel_below description_below'><li id='field_52_85'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><script src=\"https:\/\/unpkg.com\/imask\"><\/script>\n<script type='text\/javascript' src=\"\/js\/Procedure_Schedule_Form_JS\/Procedure_Schedule_Form_JS.js\"><\/script><\/li><li id='field_52_63'  class='gfield field_sublabel_below field_description_below gfield_visibility_hidden' ><label class='gfield_label' for='input_52_63' >CPT Codes<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_52_63' type='text' value='' class='large'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_52_64'  class='gfield field_sublabel_below field_description_below gfield_visibility_hidden' ><label class='gfield_label' for='input_52_64' >fid<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_52_64' type='text' value='' class='large'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_52_65'  class='gfield field_sublabel_below field_description_below gfield_visibility_hidden' ><label class='gfield_label' for='input_52_65' >OriginID_SessionStorage<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_52_65' type='text' value='' class='large'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_52_66'  class='gfield field_sublabel_below field_description_below gfield_visibility_hidden' ><label class='gfield_label' for='input_52_66' >OriginID_LocalStorage<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_52_66' type='text' value='' class='large'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_52_106'  class='gfield field_sublabel_below field_description_below gfield_visibility_hidden' ><label class='gfield_label' for='input_52_106' >Scheduling Preferences Required<\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_52_106' type='text' value='' class='large'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_52_16'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Patient Information<\/h2><\/li><li id='field_52_3'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_52_3'>\n                            \n                            <span id='input_52_3_3_container' class='name_first' >\n                                                    <input type='text' name='input_3.3' id='input_52_3_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_52_3_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_52_3_6_container' class='name_last' >\n                                                    <input type='text' name='input_3.6' id='input_52_3_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_52_3_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_52_5'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_5' >Date of birth<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_52_5' type='text' value='' class='datepicker large mdy datepicker_no_icon'    aria-describedby='input_52_5_date_format' \/>\n                            <span id='input_52_5_date_format' class='screen-reader-text'>Date Format: MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_52_5' class='gform_hidden' value='https:\/\/radiologyassist.com\/StagingAvada\/wp-content\/plugins\/gravityforms-2.4.20\/images\/calendar.png'\/><\/li><li id='field_52_7'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_7' >Gender<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_52_7' class='large gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><\/li><li id='field_52_8'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_8' >Phone<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_52_8' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id='field_52_9'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_9' >Email<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_52_9' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_52_9\"\/>\n                        <\/div><div class='gfield_description' id='gfield_description_52_9'>All important communication regarding appointments will be sent to this address. Double-check for accuracy.<\/div><\/li><li id='field_52_10'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Address<span class='gfield_required'>*<\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_52_10' >\n                         <span class='ginput_full address_line_1' id='input_52_10_1_container' >\n                                        <input type='text' name='input_10.1' id='input_52_10_1' value=''    aria-required=\"true\"\/>\n                                        <label for='input_52_10_1' id='input_52_10_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_52_10_2_container' >\n                                        <input type='text' name='input_10.2' id='input_52_10_2' value=''   \/>\n                                        <label for='input_52_10_2' id='input_52_10_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_52_10_3_container' >\n                                    <input type='text' name='input_10.3' id='input_52_10_3' value=''    aria-required=\"true\"\/>\n                                    <label for='input_52_10_3' id='input_52_10_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_52_10_4_container' >\n                                        <select name='input_10.4' id='input_52_10_4'     aria-required=\"true\"><option value='' selected='selected'><\/option><option value='AL' >Alabama<\/option><option value='AK' >Alaska<\/option><option value='AZ' >Arizona<\/option><option value='AR' >Arkansas<\/option><option value='CA' >California<\/option><option value='CO' >Colorado<\/option><option value='CT' >Connecticut<\/option><option value='DE' >Delaware<\/option><option value='DC' >District of Columbia<\/option><option value='FL' >Florida<\/option><option value='GA' >Georgia<\/option><option value='GU' >Guam<\/option><option value='HI' >Hawaii<\/option><option value='ID' >Idaho<\/option><option value='IL' >Illinois<\/option><option value='IN' >Indiana<\/option><option value='IA' >Iowa<\/option><option value='KS' >Kansas<\/option><option value='KY' >Kentucky<\/option><option value='LA' >Louisiana<\/option><option value='ME' >Maine<\/option><option value='MD' >Maryland<\/option><option value='MA' >Massachusetts<\/option><option value='MI' >Michigan<\/option><option value='MN' >Minnesota<\/option><option value='MS' >Mississippi<\/option><option value='MO' >Missouri<\/option><option value='MT' >Montana<\/option><option value='NE' >Nebraska<\/option><option value='NV' >Nevada<\/option><option value='NH' >New Hampshire<\/option><option value='NJ' >New Jersey<\/option><option value='NM' >New Mexico<\/option><option value='NY' >New York<\/option><option value='NC' >North Carolina<\/option><option value='ND' >North Dakota<\/option><option value='OH' >Ohio<\/option><option value='OK' >Oklahoma<\/option><option value='OR' >Oregon<\/option><option value='PA' >Pennsylvania<\/option><option value='PR' >Puerto Rico<\/option><option value='RI' >Rhode Island<\/option><option value='SC' >South Carolina<\/option><option value='SD' >South Dakota<\/option><option value='TN' >Tennessee<\/option><option value='TX' >Texas<\/option><option value='UT' >Utah<\/option><option value='VT' >Vermont<\/option><option value='VA' >Virginia<\/option><option value='WA' >Washington<\/option><option value='WV' >West Virginia<\/option><option value='WI' >Wisconsin<\/option><option value='WY' >Wyoming<\/option><\/select>\n                                        <label for='input_52_10_4' id='input_52_10_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_52_10_5_container' >\n                                    <input type='text' name='input_10.5' id='input_52_10_5' value=''    aria-required=\"true\"\/>\n                                    <label for='input_52_10_5' id='input_52_10_5_label' >Zip Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_10.6' id='input_52_10_6' value='USAB'\/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_52_105'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Other<\/h2><\/li><li id='field_52_92'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Text Message Opt-in<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_52_92'><li class='gchoice_52_92_1'>\n\t\t\t\t\t\t\t\t<input name='input_92.1' type='checkbox'  value='I agree to receive text messages for scheduling and appointment reminders. This is required to ensure timely communication regarding my appointments. No marketing text messages will be sent and you can opt-out by replying STOP.' checked='checked' id='choice_52_92_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_92_1' id='label_52_92_1'>I agree to receive text messages for scheduling and appointment reminders. This is required to ensure timely communication regarding my appointments. No marketing text messages will be sent and you can opt-out by replying STOP.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_52_97'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Authorized Contact<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_52_97'><li class='gchoice_52_97_1'>\n\t\t\t\t\t\t\t\t<input name='input_97.1' type='checkbox'  value='Would you like to designate an authorized contact to discuss your scheduling and medical information on your behalf?'  id='choice_52_97_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_97_1' id='label_52_97_1'>Would you like to designate an authorized contact to discuss your scheduling and medical information on your behalf?<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_52_98'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Benefits Code<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_52_98'><li class='gchoice_52_98_1'>\n\t\t\t\t\t\t\t\t<input name='input_98.1' type='checkbox'  value='Were you provided a benefits code by your plan or employer?'  id='choice_52_98_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_98_1' id='label_52_98_1'>Were you provided a benefits code by your plan or employer?<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_52_93'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Authorized Contact<\/h2><\/li><li id='field_52_94'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_94' >Authorized Contact Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_52_94' type='text' value='' class='large'  aria-describedby=\"gfield_description_52_94\"   aria-required=\"true\" aria-invalid=\"false\" \/><\/div><div class='gfield_description' id='gfield_description_52_94'>Provide details for any individual authorized to discuss your appointment scheduling and medical records on your behalf.<\/div><\/li><li id='field_52_96'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_96' >Authorized Contact Phone<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_96' id='input_52_96' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id='field_52_99'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Benefits Code<\/h2><\/li><li id='field_52_11'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_11' >Benefits Referral Code<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_52_11' type='text' value='' class='large'  aria-describedby=\"gfield_description_52_11\"    aria-invalid=\"false\" \/><\/div><div class='gfield_description' id='gfield_description_52_11'>If you were provided a benefits referral code by your plan or employer, please enter it here<\/div><\/li><li id='field_52_88'  class='gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible' >\n<div class=\"\" style=\"padding: 20px 20px;background-color: #FFF0DC;width: 90%;\n    border-radius: 10px;\">\n<h2 style=\"color: #911536;\n    font-size: 18px;\n    font-weight: 600;\">Member Benefit<\/h2>\n    <p style=\"color: #911536; margin-bottom: 0px;\">As a valued member, you are entitled to a $10 off voucher for any lab test scheduled with our lab program, LaboratoryAssist. You will automatically receive the voucher via email once your appointment is completed.<\/p>\n  <\/div><\/li><li id='field_52_100'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Insurance Use<\/h2><\/li><li id='field_52_101'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you plan to use your insurance for this appointment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_52_101'><li class='gchoice_52_101_0'><input name='input_101' type='radio' value='Yes, I plan to use insurance'  id='choice_52_101_0'    \/><label for='choice_52_101_0' id='label_52_101_0'>Yes, I plan to use insurance<\/label><\/li><li class='gchoice_52_101_1'><input name='input_101' type='radio' value='No, I do not plan to use insurance'  id='choice_52_101_1'    \/><label for='choice_52_101_1' id='label_52_101_1'>No, I do not plan to use insurance<\/label><\/li><li class='gchoice_52_101_2'><input name='input_101' type='radio' value='I\u2019m not sure yet'  id='choice_52_101_2'    \/><label for='choice_52_101_2' id='label_52_101_2'>I\u2019m not sure yet<\/label><\/li><\/ul><\/div><\/li><li id='field_52_104'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"background-color: #FFF0DC; border-radius: 5px; padding: 20px;  color: #B1294D; line-height: 1.6;\">\n    <p style=\"font-weight: bold; margin: 0 0 8px 0;\">RadiologyAssist is a self-pay program<\/p>\n    <p style=\"margin: 0 0 16px 0;color:#191818;\">\n        We are unable to bill your insurance, however, you may use our services as a self-pay patient and can request reimbursement from your insurance after. RadiologyAssist will provide you with an invoice with codes and ids required by your insurance.\n<\/p>\n<\/div><\/li><li id='field_52_102'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_102' >What insurance plan do you have?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_52_102' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_52_103'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_103' >What type of plan?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_103' id='input_52_103' class='large gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='PPO' >PPO<\/option><option value='HMO' >HMO<\/option><option value='Health Sharing' >Health Sharing<\/option><option value='Other' >Other<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                         <input type='button' id='gform_next_button_52_13' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_52\").val(\"2\");  jQuery(\"#gform_52\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_52\").val(\"2\");  jQuery(\"#gform_52\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_52_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_52_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_52_17'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Scheduling Preferences<\/h2><\/li><li id='field_52_18'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' >\n  <p style=\"color: #191818;\n    font-size: 18px;\">RadiologyAssist will schedule an appointment based on the preferences entered below.<\/p>\n <\/li><li id='field_52_67'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"background-color: #FFF0DC; border-radius: 5px; padding: 20px;  color: #B1294D; line-height: 1.6;\">\n    <p style=\"font-weight: bold; margin: 0 0 8px 0;\">Xray Appointments Instructions<\/p>\n    <p style=\"margin: 0 0 16px 0;color:#191818;\">\n        Xray appointments at this center are scheduled on a walk-in basis so this section does not need to be completed. \n        <span style=\"font-weight: bold;\">Just click next<\/span>\n    <\/p>\n    \n    <p style=\"font-weight: bold; margin: 0 0 8px 0;\">How do walk-in appointments work?<\/p>\n    <p style=\"margin: 0;color:#191818;\">\n        For walk-in appointments, you are simply provided a link to make payment and download a voucher to present at the imaging center.\n    <\/p>\n<\/div><\/li><li id='field_52_20'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Preferred Dates<\/h2><\/li><li id='field_52_58'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"display: flex;\n    align-items: center;\n    background-color: #FFF0DC;\n    border: 1px solid #ffeaf3;\n    color: #6D0D26;\n    padding: 10px 15px;\n    border-radius: 5px;\n    \/* font-family: Arial, sans-serif; *\/\n    font-size: 18px;\n    font-weight: 600;\">\n    <span style=\"font-size: 30px;\n    margin-right: 10px;\n    color: #6D0D26;\">&#9888;<\/span>\n    <span>Only enter dates and times you are absolutely sure you can keep. For special instructions use the box below.<\/span>\n<\/div><\/li><li id='field_52_21'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_21' >Preferrred Date<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_21' id='input_52_21' type='text' value='' class='datepicker large mdy datepicker_no_icon'    aria-describedby='input_52_21_date_format' \/>\n                            <span id='input_52_21_date_format' class='screen-reader-text'>Date Format: MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_52_21' class='gform_hidden' value='https:\/\/radiologyassist.com\/StagingAvada\/wp-content\/plugins\/gravityforms-2.4.20\/images\/calendar.png'\/><\/li><li id='field_52_61'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_61' >Preferrred Time<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_52_61' class='large gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='' ><\/option><option value='Morning' >Morning (8am - 12pm)<\/option><option value='Afternoon' >Afternoon (12pm - 6pm)<\/option><option value='AllDay' >All day (8am - 6pm)<\/option><\/select><\/div><\/li><li id='field_52_23'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_23' >Alternate Preferred Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_23' id='input_52_23' type='text' value='' class='datepicker large mdy datepicker_no_icon'    aria-describedby='input_52_23_date_format' \/>\n                            <span id='input_52_23_date_format' class='screen-reader-text'>Date Format: MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_52_23' class='gform_hidden' value='https:\/\/radiologyassist.com\/StagingAvada\/wp-content\/plugins\/gravityforms-2.4.20\/images\/calendar.png'\/><\/li><li id='field_52_62'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_62' >Alternate Preferred Time<\/label><div class='ginput_container ginput_container_select'><select name='input_62' id='input_52_62' class='large gfield_select'    aria-invalid=\"false\"><option value='' ><\/option><option value='Morning' >Morning (8am - 12pm)<\/option><option value='Afternoon' >Afternoon (12pm - 6pm)<\/option><option value='AllDay' >All day (8am - 6pm)<\/option><\/select><\/div><\/li><li id='field_52_25'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_25' >Any other instructions about your availability<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_52_25' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_52_27'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"line-height: 30px;\">\n<div>\n  <p style=\"font-weight: bold; margin-bottom: 5px; color: #6d0d26\">\n    More Information\n  <\/p>\n  <div class=\"faq-title\" onclick=\"toggleContent(this)\">\n    What happens if my preferred dates are unavailable?\n  <\/div>\n  <div class=\"faq-content\">\n    If your preferred and alternate date is unavailable, RadiologyAssist will schedule the first available appointment after your specified preferred dates. Agents do try to take into account any special instructions.\n  <\/div>\n<\/div>\n\n<div>\n  <div class=\"faq-title\" onclick=\"toggleContent(this)\">\n    Can I change the appointment scheduled for me?\n  <\/div>\n  <div class=\"faq-content\">\n    If you do not like the appointment scheduled, you can request to cancel or reschedule the appointment. Reschedules do take longer to complete than initial appointments, so it is recommended you select dates where you are certain you can keep the appointment.\n  <\/div>\n<\/div>\n\n<div>\n  <div class=\"faq-title\" onclick=\"toggleContent(this)\">\n    What if I am available only during a portion of the selected timeframe?\n  <\/div>\n  <div class=\"faq-content\">\n    We recommend you select another day where you are available for the entire 4 hour timeframe. We are unable to handle requests for partial timeframes at this time.\n  <\/div>\n<\/div>\n<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_52_34' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_52\").val(\"1\");  jQuery(\"#gform_52\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_52\").val(\"1\");  jQuery(\"#gform_52\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_52_34' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_52\").val(\"3\");  jQuery(\"#gform_52\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_52\").val(\"3\");  jQuery(\"#gform_52\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_52_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_52_3' class='gform_fields top_label form_sublabel_below description_below'><li id='field_52_35'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Referral Information<\/h2><\/li><li id='field_52_36'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><p style=\"color: #191818;\n    margin-bottom: 0px;\">RadiologyAssist will need a copy of your provider order to schedule your appointment.<\/p><\/li><li id='field_52_37'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >How do you prefer to send us your referral?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_52_37'><li class='gchoice_52_37_0'><input name='input_37' type='radio' value='Upload'  id='choice_52_37_0'    \/><label for='choice_52_37_0' id='label_52_37_0'>Upload here (recommended)<\/label><\/li><li class='gchoice_52_37_1'><input name='input_37' type='radio' value='Later'  id='choice_52_37_1'    \/><label for='choice_52_37_1' id='label_52_37_1'>I will send a referral at a later time<\/label><\/li><li class='gchoice_52_37_2'><input name='input_37' type='radio' value='I do not have a referral'  id='choice_52_37_2'    \/><label for='choice_52_37_2' id='label_52_37_2'>I do not have a referral<\/label><\/li><\/ul><\/div><\/li><li id='field_52_39'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_39' >File<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='12582912' \/><input name='input_39' id='input_52_39' type='file' class='large' aria-describedby='validation_message_52_39 live_validation_message_52_39 extensions_message_52_39' onchange='javascript:gformValidateFileSize( this, 12582912 );'  \/><span id='extensions_message_52_39' class='screen-reader-text'><\/span><div class='validation_message' id='live_validation_message_52_39'><\/div><\/div><div class='gfield_description' id='gfield_description_52_39'>Pro tip : Visit this form from a mobile device so that you can take a picture of your referral.<\/div><\/li><li id='field_52_43'  class='gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"background-color: #FFF0DC;padding: 25px;border-radius: 5px;\">\n    <h4 style=\"margin: 0;font-size: 18px;font-weight: bold;color:#B1294D;\">Instructions<\/h4>\n    <p style=\"margin: 8px 0 0 0;font-size: 15px;color: #191818;\">\nWe will email you instructions on how to submit your referral.\n      RadiologyAssist will keep your information on hold until a referral is received. If a referral is not received within 7 days, the request will be automatically closed.\n    <\/p>\n  <\/div><\/li><li id='field_52_44'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"\n    background-color: #FFF0DC;\n    color: #B1294D;\n    padding: 25px;\n    border-radius: 5px;\n    \">\n<div style=\"display: flex;\n    align-items: center;\n    border: 1px solid #ffeaf3;\n    font-size: 20px;\n    font-weight: 600;\">\n    <span style=\"font-size: 20px;\n    margin-right: 10px;\n    color: #B1294D;\">\u26a0<\/span>\n    <span>REFERRAL IS REQUIRED<\/span><br>\n   \n<\/div>\n    <p style=\"margin: 8px 0 0 0;font-size: 18px;color: #191818;\">\n      RadiologyAssist is unable to schedule diagnostic imaging without a provider referral. You may use our <a href=\"https:\/\/radiologyassist.com\/StagingAvada\/patients\/virtual-consultations\/\" style=\"\n    font-weight: 600;\n    color: #191818;\n    text-decoration: underline;\n\">Virtual Consultation<\/a> service to obtain a referral.\n    <\/p>\n<\/div><\/li><li id='field_52_40'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"line-height: 30px;\">\n<div>\n  <p style=\"font-weight: bold; margin-bottom: 5px; color: #6d0d26\">\n    More Information\n  <\/p>\n  <div class=\"faq-title\" onclick=\"toggleContent(this)\">\n     Do referrals need to be made out to RadiologyAssist?\n  <\/div>\n  <div class=\"faq-content\">\n     No. We accept referrals made out to any provider.\n  <\/div>\n<\/div>\n\n<div>\n  <div class=\"faq-title\" onclick=\"toggleContent(this)\">\n   Can my provider send the referral directly to RadiologyAssist?\n  <\/div>\n  <div class=\"faq-content\">\n   Yes they can. Just select \"I will send a referral at a later time\" and have your physician fax the order to RadiologyAssist at (972) 445 9990.\n  <\/div>\n<\/div>\n\n<div>\n  <div class=\"faq-title\" onclick=\"toggleContent(this)\">\n      Can RadiologyAssist obtain a referral from my provider?\n  <\/div>\n  <div class=\"faq-content\">\n   No. The patient would need to request their physician to send RadiologyAssist the order.\n  <\/div>\n<\/div>\n<div>\n  <div class=\"faq-title\" onclick=\"toggleContent(this)\">\n     Where should referrals be sent?\n  <\/div>\n  <div class=\"faq-content\">\n  Referrals must be sent to RadiologyAssist using one of the following methods :\n    <ol>\n        <li>Fax : (972) 445-9990<\/li>\n        <li>Email : referrals@radiologyassist.com<\/li>\n        <li>Upload : <a  href=\"https:\/\/radiologyassist.com\/upload\/\"> radiologyassist.com\/upload\/<\/a><\/li>\n    <\/ol>\n    An email and a text message with this information will be sent upon submission.\n  <\/div>\n<\/div>\n<\/div><\/li><li id='field_52_77'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_52_41' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_52\").val(\"2\");  jQuery(\"#gform_52\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_52\").val(\"2\");  jQuery(\"#gform_52\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_52_41' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_52\").val(\"4\");  jQuery(\"#gform_52\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_52\").val(\"4\");  jQuery(\"#gform_52\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_52_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_52_4' class='gform_fields top_label form_sublabel_below description_below'><li id='field_52_42'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Medical History<\/h2><\/li><li id='field_52_45'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Which of the the following studies are you being scheduled for?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_52_45'><li class='gchoice_52_45_1'>\n\t\t\t\t\t\t\t\t<input name='input_45.1' type='checkbox'  value='MRI'  id='choice_52_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_45_1' id='label_52_45_1'>MRI<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_45_2'>\n\t\t\t\t\t\t\t\t<input name='input_45.2' type='checkbox'  value='CT'  id='choice_52_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_45_2' id='label_52_45_2'>CT<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_45_3'>\n\t\t\t\t\t\t\t\t<input name='input_45.3' type='checkbox'  value='Mammogram'  id='choice_52_45_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_45_3' id='label_52_45_3'>Mammogram<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_45_4'>\n\t\t\t\t\t\t\t\t<input name='input_45.4' type='checkbox'  value='None of the above'  id='choice_52_45_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_45_4' id='label_52_45_4'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_52_89'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_89' >Height<\/label><div class='ginput_container ginput_container_select'><select name='input_89' id='input_52_89' class='large gfield_select'    aria-invalid=\"false\"><option value='7' >7<\/option><option value='6' >6<\/option><option value='5' selected='selected'>5<\/option><option value='4' >4<\/option><option value='3' >3<\/option><option value='2' >2<\/option><option value='1' >1<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_52_89'>FT<\/div><\/li><li id='field_52_90'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_52_90' >Height<\/label><div class='ginput_container ginput_container_select'><select name='input_90' id='input_52_90' class='large gfield_select'    aria-invalid=\"false\"><option value='11' >11<\/option><option value='10' >10<\/option><option value='9' >9<\/option><option value='8' >8<\/option><option value='7' >7<\/option><option value='6' >6<\/option><option value='5' >5<\/option><option value='4' >4<\/option><option value='3' >3<\/option><option value='2' >2<\/option><option value='1' >1<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_52_90'>IN<\/div><\/li><li id='field_52_60'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_60' >Weight<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_52_60' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_52_68'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Mammogram Screening Questions<\/h2><\/li><li id='field_52_69'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_69' >When and where was your last mammogram?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_52_69' type='text' value='' class='large'  aria-describedby=\"gfield_description_52_69\"   aria-required=\"true\" aria-invalid=\"false\" \/><\/div><div class='gfield_description' id='gfield_description_52_69'>Enter N\/A if no previous mammogram<\/div><\/li><li id='field_52_70'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Will you be able to obtain those reports\/images to bring into the facility?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_52_70'><li class='gchoice_52_70_0'><input name='input_70' type='radio' value='Yes'  id='choice_52_70_0'    \/><label for='choice_52_70_0' id='label_52_70_0'>Yes<\/label><\/li><li class='gchoice_52_70_1'><input name='input_70' type='radio' value='No'  id='choice_52_70_1'    \/><label for='choice_52_70_1' id='label_52_70_1'>No<\/label><\/li><li class='gchoice_52_70_2'><input name='input_70' type='radio' value='NA'  id='choice_52_70_2'    \/><label for='choice_52_70_2' id='label_52_70_2'>N\/A<\/label><\/li><\/ul><\/div><\/li><li id='field_52_71'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_71' >Do you have breast implants? if so what kind (saline or silicone) and when did you get them?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_52_71' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_52_74'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have any of the following symptoms?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_52_74'><li class='gchoice_52_74_1'>\n\t\t\t\t\t\t\t\t<input name='input_74.1' type='checkbox'  value='Lumps'  id='choice_52_74_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_74_1' id='label_52_74_1'>Lump(s)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_74_2'>\n\t\t\t\t\t\t\t\t<input name='input_74.2' type='checkbox'  value='Pain'  id='choice_52_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_74_2' id='label_52_74_2'>Pain<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_74_3'>\n\t\t\t\t\t\t\t\t<input name='input_74.3' type='checkbox'  value='DenseBreast'  id='choice_52_74_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_74_3' id='label_52_74_3'>Dense breast<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_74_4'>\n\t\t\t\t\t\t\t\t<input name='input_74.4' type='checkbox'  value='NippleDischarge'  id='choice_52_74_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_74_4' id='label_52_74_4'>Nipple Discharge<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_74_5'>\n\t\t\t\t\t\t\t\t<input name='input_74.5' type='checkbox'  value='SkinChanges'  id='choice_52_74_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_74_5' id='label_52_74_5'>Skin changes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_74_6'>\n\t\t\t\t\t\t\t\t<input name='input_74.6' type='checkbox'  value='None'  id='choice_52_74_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_74_6' id='label_52_74_6'>None<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_52_75'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_52_75' >When was your last menstrual cycle?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_52_75' type='text' value='' class='large'  aria-describedby=\"gfield_description_52_75\"   aria-required=\"true\" aria-invalid=\"false\" \/><\/div><div class='gfield_description' id='gfield_description_52_75'>An estimate is sufficient<\/div><\/li><li id='field_52_48'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>MRI &amp; CT Screening Questions<\/h2><\/li><li id='field_52_49'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have any of these conditions?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_52_49'><li class='gchoice_52_49_1'>\n\t\t\t\t\t\t\t\t<input name='input_49.1' type='checkbox'  value='Do you have any metal part or pacemaker'  id='choice_52_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_49_1' id='label_52_49_1'>Do you have any metal part or pacemaker<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_49_2'>\n\t\t\t\t\t\t\t\t<input name='input_49.2' type='checkbox'  value='Claustrophobic'  id='choice_52_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_49_2' id='label_52_49_2'>Claustrophobic<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_49_3'>\n\t\t\t\t\t\t\t\t<input name='input_49.3' type='checkbox'  value='History of cancer'  id='choice_52_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_49_3' id='label_52_49_3'>History of cancer<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_49_4'>\n\t\t\t\t\t\t\t\t<input name='input_49.4' type='checkbox'  value='Diabetic'  id='choice_52_49_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_49_4' id='label_52_49_4'>Diabetic<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_49_5'>\n\t\t\t\t\t\t\t\t<input name='input_49.5' type='checkbox'  value='Migranes'  id='choice_52_49_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_49_5' id='label_52_49_5'>Migranes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_49_6'>\n\t\t\t\t\t\t\t\t<input name='input_49.6' type='checkbox'  value='Seizures'  id='choice_52_49_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_49_6' id='label_52_49_6'>Seizures<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_49_7'>\n\t\t\t\t\t\t\t\t<input name='input_49.7' type='checkbox'  value='High blood pressure'  id='choice_52_49_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_49_7' id='label_52_49_7'>High blood pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_49_8'>\n\t\t\t\t\t\t\t\t<input name='input_49.8' type='checkbox'  value='Liver or kidney problems'  id='choice_52_49_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_49_8' id='label_52_49_8'>Liver or kidney problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_49_9'>\n\t\t\t\t\t\t\t\t<input name='input_49.9' type='checkbox'  value='Require a wheel chair'  id='choice_52_49_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_49_9' id='label_52_49_9'>Require a wheel chair<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_49_11'>\n\t\t\t\t\t\t\t\t<input name='input_49.11' type='checkbox'  value='Allergic to iodine or shellfish'  id='choice_52_49_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_49_11' id='label_52_49_11'>Allergic to iodine or shellfish<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_49_12'>\n\t\t\t\t\t\t\t\t<input name='input_49.12' type='checkbox'  value='Had a creatinine lab test in the last 30 days'  id='choice_52_49_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_49_12' id='label_52_49_12'>Had a creatinine lab test in the last 30 days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_52_49_13'>\n\t\t\t\t\t\t\t\t<input name='input_49.13' type='checkbox'  value='None of the above'  id='choice_52_49_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_49_13' id='label_52_49_13'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_52_53'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Communication<\/h2><\/li><li id='field_52_54'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><p style=\"\n    margin-top: -10px;\n    color: #191818;\n\">RadiologyAssist does not call patients unless requested or if there is a problem with the referral.<\/p><\/li><li id='field_52_86'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Would you like us to call you once your referral is received?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_52_86'><li class='gchoice_52_86_0'><input name='input_86' type='radio' value='No'  id='choice_52_86_0'    \/><label for='choice_52_86_0' id='label_52_86_0'>No. Just schedule my appointment<\/label><\/li><li class='gchoice_52_86_1'><input name='input_86' type='radio' value='Yes'  id='choice_52_86_1'    \/><label for='choice_52_86_1' id='label_52_86_1'>Yes. Please call me once you receive my referral<\/label><\/li><\/ul><\/div><\/li><li id='field_52_56'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Acknowledgements<\/h2><\/li><li id='field_52_12'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><p style=\"color: #191818;font-size:18px;\">By clicking \"Next\" you confirm and acknowledge that you have read, understood and agree to be bound by the Privacy Statement and Terms & Conditions.<\/p><\/li><li id='field_52_57'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label'  >acknow<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_52_57'><li class='gchoice_52_57_1'>\n\t\t\t\t\t\t\t\t<input name='input_57.1' type='checkbox'  value='I authorize RadiologyAssist to make an appointment on my behalf.'  id='choice_52_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_57_1' id='label_52_57_1'>I authorize RadiologyAssist to make an appointment on my behalf.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_52_87'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label'  ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_52_87'><li class='gchoice_52_87_1'>\n\t\t\t\t\t\t\t\t<input name='input_87.1' type='checkbox'  value='I understand that I will be expected to make payment to RadiologyAssist within 24 hours after an appointment is scheduled. (You can always cancel or reschedule)'  id='choice_52_87_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_87_1' id='label_52_87_1'>I understand that I will be expected to make payment to RadiologyAssist within 24 hours after an appointment is scheduled. (You can always cancel or reschedule)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_52_107'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><script>\ndocument.addEventListener('DOMContentLoaded', function () {\n  \/\/ Get raw values\n  let facilityId = sessionStorage.getItem('facility_id');\n  let Services_Renderable = sessionStorage.getItem('Services_Renderable');\n\n  \/\/ Clean outer quotes if present\n  if (facilityId) {\n    facilityId = facilityId.replace(\/^[\"']|[\"']$\/g, '');\n  }\n\n   \/\/ Clean outer quotes if present\n  if (Services_Renderable) {\n    Services_Renderable = Services_Renderable.replace(\/^[\"']|[\"']$\/g, '');\n  }\n\n  \/\/ Set to inputs\n  const facilityInput = document.getElementById('input_52_64');\n  if (facilityInput && facilityId) {\n    facilityInput.value = facilityId;\n  }\n \/\/ Set to inputs\n  const Services_RenderableInput = document.getElementById('input_52_63');\n  if (Services_RenderableInput && Services_Renderable) {\n    Services_RenderableInput.value = Services_Renderable;\n  }\n});\n<\/script>\n<\/li>\n                            <\/ul><\/div>\n        <div class='gform_page_footer '><input type='submit' id='gform_previous_button_52' class='gform_previous_button button' value='Previous'  onclick='if(window[\"gf_submitting_52\"]){return false;}  if( !jQuery(\"#gform_52\")[0].checkValidity || jQuery(\"#gform_52\")[0].checkValidity()){window[\"gf_submitting_52\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_52\"]){return false;} if( !jQuery(\"#gform_52\")[0].checkValidity || jQuery(\"#gform_52\")[0].checkValidity()){window[\"gf_submitting_52\"]=true;}  jQuery(\"#gform_52\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_52' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_52\"]){return false;}  if( 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});\n<\/script>\n<\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":15,"featured_media":0,"parent":0,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"footnotes":""},"class_list":["post-12884","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/pages\/12884","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/users\/15"}],"replies":[{"embeddable":true,"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/comments?post=12884"}],"version-history":[{"count":0,"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/pages\/12884\/revisions"}],"wp:attachment":[{"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/media?parent=12884"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}