Patient Enrollment Form<\/title>\r\n<style>\r\n body {\r\n font-family: 'Segoe UI', Tahoma, Geneva, Verdana, sans-serif;\r\n background: #eef4fb;\r\n margin: 0; \r\n padding: 20px;\r\n }\r\n .form-wrapper {\r\n max-width: 720px;\r\n background: white;\r\n margin: auto;\r\n padding: 25px 30px;\r\n border-radius: 12px;\r\n box-shadow: 0 0 15px #b1c9e9cc;\r\n }\r\n h1 {\r\n text-align: center;\r\n color: #224b73;\r\n font-weight: 700;\r\n margin-bottom: 20px;\r\n }\r\n .section-title {\r\n color: #3269b0;\r\n font-weight: 600;\r\n margin-top: 28px;\r\n margin-bottom: 12px;\r\n font-size: 1.15rem;\r\n border-bottom: 1.5px solid #a9c0e3;\r\n padding-bottom: 5px;\r\n }\r\n label {\r\n display: block;\r\n margin-top: 12px;\r\n font-weight: 600;\r\n color: #33475b;\r\n }\r\n input[type=\"text\"], input[type=\"email\"], input[type=\"tel\"], input[type=\"date\"], textarea, select {\r\n width: 100%;\r\n padding: 10px 12px;\r\n margin-top: 4px;\r\n border-radius: 6px;\r\n border: 1.8px solid #cbd7ee;\r\n background: #f9fbfe;\r\n font-size: 1rem;\r\n font-weight: 400;\r\n color: #33475b;\r\n resize: vertical;\r\n }\r\n textarea {\r\n min-height: 70px;\r\n }\r\n .inline-group {\r\n display: flex;\r\n flex-wrap: wrap;\r\n gap: 18px;\r\n margin-top: 6px;\r\n }\r\n .inline-group label {\r\n font-weight: normal;\r\n color: #415a7f;\r\n display: flex;\r\n align-items: center;\r\n }\r\n input[type=\"radio\"], input[type=\"checkbox\"] {\r\n margin-right: 7px;\r\n width: 18px;\r\n height: 18px;\r\n }\r\n button[type=\"submit\"] {\r\n margin-top: 25px;\r\n background-color: #325ea8;\r\n color: white;\r\n border: none;\r\n border-radius: 8px;\r\n padding: 15px 40px;\r\n font-size: 1.1rem;\r\n font-weight: 700;\r\n cursor: pointer;\r\n transition: background-color 0.25s ease;\r\n }\r\n button[type=\"submit\"]:hover {\r\n background-color: #1c3a6d;\r\n }\r\n .consent-text {\r\n font-size: 0.95rem;\r\n color: #2a456f;\r\n margin-top: 15px;\r\n line-height: 1.3;\r\n }\r\n<\/style>\r\n<\/head>\r\n<body>\r\n\r\n<form class=\"form-wrapper\" action=\"mailto:inffo@tiffany.telehealthpractices.com\" method=\"post\" enctype=\"text\/plain\" >\r\n <h1>Patient Enrollment Form<\/h1>\r\n\r\n <div class=\"section-title\">I. Patient Information<\/div>\r\n <label for=\"fullname\">Full Name<\/label>\r\n <input type=\"text\" id=\"fullname\" name=\"Full Name\" required \/>\r\n\r\n <label for=\"dob\">Date of Birth<\/label>\r\n <input type=\"date\" id=\"dob\" name=\"Date of Birth\" required \/>\r\n\r\n <label>Gender Identity<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"Gender Identity\" value=\"Female\" required \/> Female<\/label>\r\n <label><input type=\"radio\" name=\"Gender Identity\" value=\"Male\" \/> Male<\/label>\r\n <label><input type=\"radio\" name=\"Gender Identity\" value=\"Non-binary\" \/> Non-binary<\/label>\r\n <label><input type=\"radio\" name=\"Gender Identity\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n\r\n <label for=\"pronouns\">Preferred Pronouns<\/label>\r\n <input type=\"text\" id=\"pronouns\" name=\"Preferred Pronouns\" \/>\r\n\r\n <label for=\"marital\">Marital Status<\/label>\r\n <select id=\"marital\" name=\"Marital Status\" required>\r\n <option value=\"\">Select<\/option>\r\n <option value=\"Single\">Single<\/option>\r\n <option value=\"Married\">Married<\/option>\r\n <option value=\"Divorced\">Divorced<\/option>\r\n <option value=\"Widowed\">Widowed<\/option>\r\n <\/select>\r\n\r\n <label for=\"occupation\">Occupation<\/label>\r\n <input type=\"text\" id=\"occupation\" name=\"Occupation\" \/>\r\n\r\n <label for=\"employer\">Employer<\/label>\r\n <input type=\"text\" id=\"employer\" name=\"Employer\" \/>\r\n\r\n <div class=\"section-title\">II. Contact Details<\/div>\r\n <label for=\"phone\">Primary Phone Number<\/label>\r\n <input type=\"tel\" id=\"phone\" name=\"Primary Phone Number\" required \/>\r\n\r\n <label for=\"email\">Email Address<\/label>\r\n <input type=\"email\" id=\"email\" name=\"Email Address\" required \/>\r\n\r\n <label for=\"address\">Mailing Address<\/label>\r\n <input type=\"text\" id=\"address\" name=\"Mailing Address\" \/>\r\n\r\n <label for=\"city\">City<\/label>\r\n <input type=\"text\" id=\"city\" name=\"City\" \/>\r\n\r\n <label for=\"state\">State<\/label>\r\n <input type=\"text\" id=\"state\" name=\"State\" \/>\r\n\r\n <label for=\"zip\">Zip Code<\/label>\r\n <input type=\"text\" id=\"zip\" name=\"Zip Code\" \/>\r\n\r\n <label>Preferred Contact Method<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"checkbox\" name=\"Preferred Contact Method\" value=\"Phone\" \/> Phone<\/label>\r\n <label><input type=\"checkbox\" name=\"Preferred Contact Method\" value=\"Text\" \/> Text<\/label>\r\n <label><input type=\"checkbox\" name=\"Preferred Contact Method\" value=\"Email\" \/> Email<\/label>\r\n <\/div>\r\n\r\n <div class=\"section-title\">III. Emergency Contact<\/div>\r\n <label for=\"emergency-name\">Full Name<\/label>\r\n <input type=\"text\" id=\"emergency-name\" name=\"Emergency Contact Name\" required \/>\r\n\r\n <label for=\"emergency-relationship\">Relationship<\/label>\r\n <input type=\"text\" id=\"emergency-relationship\" name=\"Emergency Contact Relationship\" required \/>\r\n\r\n <label for=\"emergency-phone\">Phone Number<\/label>\r\n <input type=\"tel\" id=\"emergency-phone\" name=\"Emergency Contact Phone\" required \/>\r\n\r\n <div class=\"section-title\">IV. Referral Information<\/div>\r\n <label>How did you hear about us?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"checkbox\" name=\"Referral Information\" value=\"Website\" \/> Website<\/label>\r\n <label><input type=\"checkbox\" name=\"Referral Information\" value=\"Social Media\" \/> Social Media<\/label>\r\n <label><input type=\"checkbox\" name=\"Referral Information\" value=\"FriendFamily\" \/> Friend\/Family<\/label>\r\n <label><input type=\"checkbox\" name=\"Referral Information\" value=\"Practitioner\" \/> Practitioner<\/label>\r\n <label><input type=\"checkbox\" name=\"Referral Information\" value=\"Event\" \/> Event<\/label>\r\n <label><input type=\"checkbox\" name=\"Referral Information\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n\r\n <div class=\"section-title\">V. Health Information<\/div>\r\n <label>Are you currently under the care of a physician or mental health professional?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"Physician Care\" value=\"Yes\" required \/> Yes<\/label>\r\n <label><input type=\"radio\" name=\"Physician Care\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n\r\n <label for=\"care-explain\">If yes, please explain<\/label>\r\n <textarea id=\"care-explain\" name=\"Care Explanation\"><\/textarea>\r\n\r\n <label>Are you taking any medications or supplements?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"Taking Medications\" value=\"Yes\" required \/> Yes<\/label>\r\n <label><input type=\"radio\" name=\"Taking Medications\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n\r\n <label for=\"med-list\">If yes, please list<\/label>\r\n <textarea id=\"med-list\" name=\"Medication List\"><\/textarea>\r\n\r\n <label>Have you had any recent surgeries, diagnoses, or major health concerns?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"Recent Health Issues\" value=\"Yes\" required \/> Yes<\/label>\r\n <label><input type=\"radio\" name=\"Recent Health Issues\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n\r\n <label for=\"health-desc\">If yes, please describe<\/label>\r\n <textarea id=\"health-desc\" name=\"Health Description\"><\/textarea>\r\n\r\n <label>Are you currently pregnant?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"Pregnant\" value=\"Yes\" \/> Yes<\/label>\r\n <label><input type=\"radio\" name=\"Pregnant\" value=\"No\" \/> No<\/label>\r\n <label><input type=\"radio\" name=\"Pregnant\" value=\"NA\" \/> N\/A<\/label>\r\n <\/div>\r\n\r\n <label>Do you have a history of (check all that apply):<\/label>\r\n <div class=\"inline-group\" style=\"flex-wrap: wrap;\">\r\n <label><input type=\"checkbox\" name=\"History\" value=\"Chronic Pain\" \/> Chronic Pain<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"Anxiety\" \/> Anxiety<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"Depression\" \/> Depression<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"High Blood Pressure\" \/> High Blood Pressure<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"PTSD\" \/> PTSD<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"Autoimmune Disorder\" \/> Autoimmune Disorder<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"Cancer\" \/> Cancer<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"Diabetes\" \/> Diabetes<\/label>\r\n <\/div>\r\n\r\n <label for=\"other-history\">Other<\/label>\r\n <input type=\"text\" id=\"other-history\" name=\"Other History\" \/>\r\n\r\n <div class=\"section-title\">VI. Wellness Goals & Intentions<\/div>\r\n <label for=\"reason\">What brings you in today? Feel free to be as detailed as you'd like<\/label>\r\n <textarea id=\"reason\" name=\"Reason\" rows=\"4\"><\/textarea>\r\n\r\n <label>Primary goals for our sessions (check all):<\/label>\r\n <div class=\"inline-group\" style=\"flex-wrap: wrap;\">\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Stress Relief\" \/> Stress Relief<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Emotional Healing\" \/> Emotional Healing<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Pain Management\" \/> Pain Management<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Spiritual Connection\" \/> Spiritual Connection<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Chakra Balancing\" \/> Chakra Balancing<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Energy Clearing\" \/> Energy Clearing<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Chronic Dis-Ease Management\" \/> Chronic Dis-Ease Management<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Autoimmune Dis-Ease Relief\" \/> Autoimmune Dis-Ease Relief<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n\r\n <div class=\"section-title\">VII. Consent & Acknowledgement<\/div>\r\n <p class=\"consent-text\">\r\n I acknowledge that the services provided are not a substitute for medical care and do not diagnose, treat, or cure disease. I understand that I should consult with my healthcare provider for any medical concerns.<br \/>\r\n I give permission to be contacted for appointment reminders, wellness updates, or follow-ups.\r\n <\/p>\r\n\r\n <label for=\"signature\">Signature<\/label>\r\n <input type=\"text\" id=\"signature\" name=\"Signature\" required \/>\r\n\r\n <label for=\"consent-date\">Date<\/label>\r\n <input type=\"date\" id=\"consent-date\" name=\"Date\" required \/>\r\n\r\n <button type=\"submit\">Submit<\/button>\r\n<\/form>\r\n\r\n<\/body>\r\n<\/html>\r\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Patient Enrollment Form Patient Enrollment Form I. Patient Information Full Name Date of Birth Gender Identity Female Male Non-binary Other Preferred Pronouns Marital Status SelectSingleMarriedDivorcedWidowed Occupation Employer II. Contact Details Primary Phone Number Email Address Mailing Address City State Zip Code Preferred Contact Method Phone Text Email III. Emergency Contact Full Name Relationship Phone Number […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"content-type":"","footnotes":""},"class_list":["post-1393","page","type-page","status-publish","hentry"],"blocksy_meta":[],"_hostinger_reach_plugin_has_subscription_block":false,"_hostinger_reach_plugin_is_elementor":false,"_links":{"self":[{"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/1393","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1393"}],"version-history":[{"count":4,"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/1393\/revisions"}],"predecessor-version":[{"id":1397,"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/1393\/revisions\/1397"}],"wp:attachment":[{"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1393"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}

\n\t\t\t\t

\n\t\t\t\t\t

\n\t\t\t\t

\n\t\t\t\t\t\r\n\r\n\r\n\r\n\r\nPatient Enrollment Form<\/title>\r\n<style>\r\n body {\r\n font-family: 'Segoe UI', Tahoma, Geneva, Verdana, sans-serif;\r\n background: #eef4fb;\r\n margin: 0; \r\n padding: 20px;\r\n }\r\n .form-wrapper {\r\n max-width: 720px;\r\n background: white;\r\n margin: auto;\r\n padding: 25px 30px;\r\n border-radius: 12px;\r\n box-shadow: 0 0 15px #b1c9e9cc;\r\n }\r\n h1 {\r\n text-align: center;\r\n color: #224b73;\r\n font-weight: 700;\r\n margin-bottom: 20px;\r\n }\r\n .section-title {\r\n color: #3269b0;\r\n font-weight: 600;\r\n margin-top: 28px;\r\n margin-bottom: 12px;\r\n font-size: 1.15rem;\r\n border-bottom: 1.5px solid #a9c0e3;\r\n padding-bottom: 5px;\r\n }\r\n label {\r\n display: block;\r\n margin-top: 12px;\r\n font-weight: 600;\r\n color: #33475b;\r\n }\r\n input[type=\"text\"], input[type=\"email\"], input[type=\"tel\"], input[type=\"date\"], textarea, select {\r\n width: 100%;\r\n padding: 10px 12px;\r\n margin-top: 4px;\r\n border-radius: 6px;\r\n border: 1.8px solid #cbd7ee;\r\n background: #f9fbfe;\r\n font-size: 1rem;\r\n font-weight: 400;\r\n color: #33475b;\r\n resize: vertical;\r\n }\r\n textarea {\r\n min-height: 70px;\r\n }\r\n .inline-group {\r\n display: flex;\r\n flex-wrap: wrap;\r\n gap: 18px;\r\n margin-top: 6px;\r\n }\r\n .inline-group label {\r\n font-weight: normal;\r\n color: #415a7f;\r\n display: flex;\r\n align-items: center;\r\n }\r\n input[type=\"radio\"], input[type=\"checkbox\"] {\r\n margin-right: 7px;\r\n width: 18px;\r\n height: 18px;\r\n }\r\n button[type=\"submit\"] {\r\n margin-top: 25px;\r\n background-color: #325ea8;\r\n color: white;\r\n border: none;\r\n border-radius: 8px;\r\n padding: 15px 40px;\r\n font-size: 1.1rem;\r\n font-weight: 700;\r\n cursor: pointer;\r\n transition: background-color 0.25s ease;\r\n }\r\n button[type=\"submit\"]:hover {\r\n background-color: #1c3a6d;\r\n }\r\n .consent-text {\r\n font-size: 0.95rem;\r\n color: #2a456f;\r\n margin-top: 15px;\r\n line-height: 1.3;\r\n }\r\n<\/style>\r\n<\/head>\r\n<body>\r\n\r\n<form class=\"form-wrapper\" action=\"mailto:inffo@tiffany.telehealthpractices.com\" method=\"post\" enctype=\"text\/plain\" >\r\n <h1>Patient Enrollment Form<\/h1>\r\n\r\n <div class=\"section-title\">I. Patient Information<\/div>\r\n <label for=\"fullname\">Full Name<\/label>\r\n <input type=\"text\" id=\"fullname\" name=\"Full Name\" required \/>\r\n\r\n <label for=\"dob\">Date of Birth<\/label>\r\n <input type=\"date\" id=\"dob\" name=\"Date of Birth\" required \/>\r\n\r\n <label>Gender Identity<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"Gender Identity\" value=\"Female\" required \/> Female<\/label>\r\n <label><input type=\"radio\" name=\"Gender Identity\" value=\"Male\" \/> Male<\/label>\r\n <label><input type=\"radio\" name=\"Gender Identity\" value=\"Non-binary\" \/> Non-binary<\/label>\r\n <label><input type=\"radio\" name=\"Gender Identity\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n\r\n <label for=\"pronouns\">Preferred Pronouns<\/label>\r\n <input type=\"text\" id=\"pronouns\" name=\"Preferred Pronouns\" \/>\r\n\r\n <label for=\"marital\">Marital Status<\/label>\r\n <select id=\"marital\" name=\"Marital Status\" required>\r\n <option value=\"\">Select<\/option>\r\n <option value=\"Single\">Single<\/option>\r\n <option value=\"Married\">Married<\/option>\r\n <option value=\"Divorced\">Divorced<\/option>\r\n <option value=\"Widowed\">Widowed<\/option>\r\n <\/select>\r\n\r\n <label for=\"occupation\">Occupation<\/label>\r\n <input type=\"text\" id=\"occupation\" name=\"Occupation\" \/>\r\n\r\n <label for=\"employer\">Employer<\/label>\r\n <input type=\"text\" id=\"employer\" name=\"Employer\" \/>\r\n\r\n <div class=\"section-title\">II. Contact Details<\/div>\r\n <label for=\"phone\">Primary Phone Number<\/label>\r\n <input type=\"tel\" id=\"phone\" name=\"Primary Phone Number\" required \/>\r\n\r\n <label for=\"email\">Email Address<\/label>\r\n <input type=\"email\" id=\"email\" name=\"Email Address\" required \/>\r\n\r\n <label for=\"address\">Mailing Address<\/label>\r\n <input type=\"text\" id=\"address\" name=\"Mailing Address\" \/>\r\n\r\n <label for=\"city\">City<\/label>\r\n <input type=\"text\" id=\"city\" name=\"City\" \/>\r\n\r\n <label for=\"state\">State<\/label>\r\n <input type=\"text\" id=\"state\" name=\"State\" \/>\r\n\r\n <label for=\"zip\">Zip Code<\/label>\r\n <input type=\"text\" id=\"zip\" name=\"Zip Code\" \/>\r\n\r\n <label>Preferred Contact Method<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"checkbox\" name=\"Preferred Contact Method\" value=\"Phone\" \/> Phone<\/label>\r\n <label><input type=\"checkbox\" name=\"Preferred Contact Method\" value=\"Text\" \/> Text<\/label>\r\n <label><input type=\"checkbox\" name=\"Preferred Contact Method\" value=\"Email\" \/> Email<\/label>\r\n <\/div>\r\n\r\n <div class=\"section-title\">III. Emergency Contact<\/div>\r\n <label for=\"emergency-name\">Full Name<\/label>\r\n <input type=\"text\" id=\"emergency-name\" name=\"Emergency Contact Name\" required \/>\r\n\r\n <label for=\"emergency-relationship\">Relationship<\/label>\r\n <input type=\"text\" id=\"emergency-relationship\" name=\"Emergency Contact Relationship\" required \/>\r\n\r\n <label for=\"emergency-phone\">Phone Number<\/label>\r\n <input type=\"tel\" id=\"emergency-phone\" name=\"Emergency Contact Phone\" required \/>\r\n\r\n <div class=\"section-title\">IV. Referral Information<\/div>\r\n <label>How did you hear about us?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"checkbox\" name=\"Referral Information\" value=\"Website\" \/> Website<\/label>\r\n <label><input type=\"checkbox\" name=\"Referral Information\" value=\"Social Media\" \/> Social Media<\/label>\r\n <label><input type=\"checkbox\" name=\"Referral Information\" value=\"FriendFamily\" \/> Friend\/Family<\/label>\r\n <label><input type=\"checkbox\" name=\"Referral Information\" value=\"Practitioner\" \/> Practitioner<\/label>\r\n <label><input type=\"checkbox\" name=\"Referral Information\" value=\"Event\" \/> Event<\/label>\r\n <label><input type=\"checkbox\" name=\"Referral Information\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n\r\n <div class=\"section-title\">V. Health Information<\/div>\r\n <label>Are you currently under the care of a physician or mental health professional?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"Physician Care\" value=\"Yes\" required \/> Yes<\/label>\r\n <label><input type=\"radio\" name=\"Physician Care\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n\r\n <label for=\"care-explain\">If yes, please explain<\/label>\r\n <textarea id=\"care-explain\" name=\"Care Explanation\"><\/textarea>\r\n\r\n <label>Are you taking any medications or supplements?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"Taking Medications\" value=\"Yes\" required \/> Yes<\/label>\r\n <label><input type=\"radio\" name=\"Taking Medications\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n\r\n <label for=\"med-list\">If yes, please list<\/label>\r\n <textarea id=\"med-list\" name=\"Medication List\"><\/textarea>\r\n\r\n <label>Have you had any recent surgeries, diagnoses, or major health concerns?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"Recent Health Issues\" value=\"Yes\" required \/> Yes<\/label>\r\n <label><input type=\"radio\" name=\"Recent Health Issues\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n\r\n <label for=\"health-desc\">If yes, please describe<\/label>\r\n <textarea id=\"health-desc\" name=\"Health Description\"><\/textarea>\r\n\r\n <label>Are you currently pregnant?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"Pregnant\" value=\"Yes\" \/> Yes<\/label>\r\n <label><input type=\"radio\" name=\"Pregnant\" value=\"No\" \/> No<\/label>\r\n <label><input type=\"radio\" name=\"Pregnant\" value=\"NA\" \/> N\/A<\/label>\r\n <\/div>\r\n\r\n <label>Do you have a history of (check all that apply):<\/label>\r\n <div class=\"inline-group\" style=\"flex-wrap: wrap;\">\r\n <label><input type=\"checkbox\" name=\"History\" value=\"Chronic Pain\" \/> Chronic Pain<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"Anxiety\" \/> Anxiety<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"Depression\" \/> Depression<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"High Blood Pressure\" \/> High Blood Pressure<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"PTSD\" \/> PTSD<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"Autoimmune Disorder\" \/> Autoimmune Disorder<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"Cancer\" \/> Cancer<\/label>\r\n <label><input type=\"checkbox\" name=\"History\" value=\"Diabetes\" \/> Diabetes<\/label>\r\n <\/div>\r\n\r\n <label for=\"other-history\">Other<\/label>\r\n <input type=\"text\" id=\"other-history\" name=\"Other History\" \/>\r\n\r\n <div class=\"section-title\">VI. Wellness Goals & Intentions<\/div>\r\n <label for=\"reason\">What brings you in today? Feel free to be as detailed as you'd like<\/label>\r\n <textarea id=\"reason\" name=\"Reason\" rows=\"4\"><\/textarea>\r\n\r\n <label>Primary goals for our sessions (check all):<\/label>\r\n <div class=\"inline-group\" style=\"flex-wrap: wrap;\">\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Stress Relief\" \/> Stress Relief<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Emotional Healing\" \/> Emotional Healing<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Pain Management\" \/> Pain Management<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Spiritual Connection\" \/> Spiritual Connection<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Chakra Balancing\" \/> Chakra Balancing<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Energy Clearing\" \/> Energy Clearing<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Chronic Dis-Ease Management\" \/> Chronic Dis-Ease Management<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Autoimmune Dis-Ease Relief\" \/> Autoimmune Dis-Ease Relief<\/label>\r\n <label><input type=\"checkbox\" name=\"Goals\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n\r\n <div class=\"section-title\">VII. Consent & Acknowledgement<\/div>\r\n <p class=\"consent-text\">\r\n I acknowledge that the services provided are not a substitute for medical care and do not diagnose, treat, or cure disease. I understand that I should consult with my healthcare provider for any medical concerns.<br \/>\r\n I give permission to be contacted for appointment reminders, wellness updates, or follow-ups.\r\n <\/p>\r\n\r\n <label for=\"signature\">Signature<\/label>\r\n <input type=\"text\" id=\"signature\" name=\"Signature\" required \/>\r\n\r\n <label for=\"consent-date\">Date<\/label>\r\n <input type=\"date\" id=\"consent-date\" name=\"Date\" required \/>\r\n\r\n <button type=\"submit\">Submit<\/button>\r\n<\/form>\r\n\r\n<\/body>\r\n<\/html>\r\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Patient Enrollment Form Patient Enrollment Form I. Patient Information Full Name Date of Birth Gender Identity Female Male Non-binary Other Preferred Pronouns Marital Status SelectSingleMarriedDivorcedWidowed Occupation Employer II. Contact Details Primary Phone Number Email Address Mailing Address City State Zip Code Preferred Contact Method Phone Text Email III. Emergency Contact Full Name Relationship Phone Number […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"content-type":"","footnotes":""},"class_list":["post-1393","page","type-page","status-publish","hentry"],"blocksy_meta":[],"_hostinger_reach_plugin_has_subscription_block":false,"_hostinger_reach_plugin_is_elementor":false,"_links":{"self":[{"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/1393","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1393"}],"version-history":[{"count":4,"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/1393\/revisions"}],"predecessor-version":[{"id":1397,"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/1393\/revisions\/1397"}],"wp:attachment":[{"href":"https:\/\/tiffany.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1393"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}