{"id":544,"date":"2017-10-25T21:55:23","date_gmt":"2017-10-25T21:55:23","guid":{"rendered":"https:\/\/radiologyassist.com\/forms\/?page_id=544"},"modified":"2019-09-12T03:05:47","modified_gmt":"2019-09-12T03:05:47","slug":"cancelmyrequest","status":"publish","type":"page","link":"https:\/\/radiologyassist.com\/forms\/cancelmyrequest\/","title":{"rendered":"Cancel My Request"},"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:0px;padding-bottom:0px;padding-left:0px;margin-bottom: 0px;margin-top: 0px;border-width: 0px 0px 0px 0px;border-color:#eae9e9;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_2_3 2_3 fusion-two-third fusion-column-first\" style=\"width:65.3333%; margin-right: 4%;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\">\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_13' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_13'  action='\/forms\/wp-json\/wp\/v2\/pages\/544'>\n                        <div class='gform_heading'>\n                            <h3 class='gform_title'>Cancel or Reschedule Request<\/h3>\n                        <\/div>\n                        <div class='gform_body'><ul id='gform_fields_13' class='gform_fields top_label form_sublabel_below description_below'><li id='field_13_1'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_13_1' >Patient ID<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_13_1' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_13_3'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_13_3' >First Name<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_13_3' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_13_4'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_13_4' >Last Name<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_13_4' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_13_5'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >What would you like to do?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_5'><li class='gchoice_13_5_0'><input name='input_5' type='radio' value='Cancel Appointment or Close Request' checked='checked' id='choice_13_5_0'    \/><label for='choice_13_5_0' id='label_13_5_0'>Cancel Appointment or Close Request<\/label><\/li><li class='gchoice_13_5_1'><input name='input_5' type='radio' value='Reschedule Appointment'  id='choice_13_5_1'    \/><label for='choice_13_5_1' id='label_13_5_1'>Reschedule Appointment<\/label><\/li><\/ul><\/div><\/li><li id='field_13_2'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_13_2' >Reason for cancellation<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_2' id='input_13_2' class='textarea medium'  aria-describedby=\"gfield_description_13_2\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_13_2'>If there is something we can improve please do let us know. It allows us to create a program that is beneficial and relevant for all.<\/div><\/li><li id='field_13_6'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_13_6' >Reschedule Instructions<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_6' id='input_13_6' class='textarea medium'  aria-describedby=\"gfield_description_13_6\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_13_6'>Please enter when to reschedule for.<\/div><\/li><li id='field_13_7'  class='gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_13_7' >Name<\/label><div class='ginput_container'><input name='input_7' id='input_13_7' type='text' value='' \/><\/div><div class='gfield_description' id='gfield_description__7'>This field is for validation purposes and should be left unchanged.<\/div><\/li>\n                            <\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_13' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_13\"]){return false;}  window[\"gf_submitting_13\"]=true; 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background:#f1f1f1; text-align: center;\">\r\n<h2 style=\"padding-top: 20px; padding-bottom: 0px; margin: 0px;\">Prefer a live person?<\/h2>\r\n<h1 style=\"color: black; padding: 0px; margin: 0px;\">1-855-346-5152<\/h1>\r\n<p style=\"padding-top: 0px; padding-bottom: 4px; margin: 0px;\">Mon-Fri 8-5:00pm (CST)<br>\r\nInstant Nationwide scheduling<\/p>\r\n<\/div><\/div><\/div><div class=\"fusion-additional-widget-content\"><\/div><\/div><div class=\"fusion-widget-area fusion-widget-area-2 fusion-content-widget-area\"><style type=\"text\/css\">.fusion-widget-area-2 {padding:0px 0px 0px 0px;}.fusion-widget-area-2 .widget h4 {color:#000000;}.fusion-widget-area-2 .widget .heading h4 {color:#000000;}.fusion-widget-area-2 .widget h4 {font-size:14px;}.fusion-widget-area-2 .widget .heading h4 {font-size:14px;}<\/style><div id=\"custom_html-12\" class=\"widget_text widget widget_custom_html\" style=\"border-style: solid;border-color: #a8a8a8;border-width:0px;\"><div class=\"heading\"><h4 class=\"widget-title\">Contact Us<\/h4><\/div><div class=\"textwidget custom-html-widget\"><div style=\"font-size:14px;\">\r\n<b>Radiology Assist<\/b><br>\r\n2100 Valley View Lnr<br>\r\nSuite #490<br>\r\nFarmers Branch TX 75234<br>\r\n<br>\r\n<br>\r\n\r\nPhone\t: <a href=\"tel:\/\/8553465152\">(855) 346 5152<\/a><br>\r\nFax\t: (855) 345-5222<br>\r\nHours : Mon-Fri 8-5pm (CST)<br>\r\n<br>\r\n<a href=\"https:\/\/radiologyassist.com\/contact-us\/\">More Contact Information \u00bb<\/a>\r\n<\/div><\/div><\/div><div class=\"fusion-additional-widget-content\"><\/div><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":24,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/radiologyassist.com\/forms\/wp-json\/wp\/v2\/pages\/544"}],"collection":[{"href":"https:\/\/radiologyassist.com\/forms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/radiologyassist.com\/forms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/radiologyassist.com\/forms\/wp-json\/wp\/v2\/users\/24"}],"replies":[{"embeddable":true,"href":"https:\/\/radiologyassist.com\/forms\/wp-json\/wp\/v2\/comments?post=544"}],"version-history":[{"count":3,"href":"https:\/\/radiologyassist.com\/forms\/wp-json\/wp\/v2\/pages\/544\/revisions"}],"predecessor-version":[{"id":25191,"href":"https:\/\/radiologyassist.com\/forms\/wp-json\/wp\/v2\/pages\/544\/revisions\/25191"}],"wp:attachment":[{"href":"https:\/\/radiologyassist.com\/forms\/wp-json\/wp\/v2\/media?parent=544"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}