{"id":31605,"date":"2019-07-19T13:04:37","date_gmt":"2019-07-19T13:04:37","guid":{"rendered":"http:\/\/alfa-diagnostic.com\/?page_id=31605"},"modified":"2019-07-19T20:09:14","modified_gmt":"2019-07-19T20:09:14","slug":"request-an-appointment","status":"publish","type":"page","link":"https:\/\/alfa-diagnostic.com\/request-an-appointment\/","title":{"rendered":"Request an appointment"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;section&#8221; _builder_version=&#8221;3.26.3&#8243; background_enable_image=&#8221;off&#8221; custom_padding=&#8221;13px||13px|&#8221; custom_padding_tablet=&#8221;13px||13px|&#8221; padding_mobile=&#8221;on&#8221; locked=&#8221;off&#8221;][et_pb_row custom_padding=&#8221;20px|0px|0px|0px&#8221; padding_mobile=&#8221;off&#8221; column_padding_mobile=&#8221;on&#8221; _builder_version=&#8221;3.26.3&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; width=&#8221;90%&#8221; max_width=&#8221;1920px&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.25&#8243; custom_padding=&#8221;|||&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text _builder_version=&#8221;3.26.3&#8243; header_font_size=&#8221;52px&#8221; border_style=&#8221;solid&#8221;]<\/p>\n<h1 style=\"text-align: center;\">Request an Appointment<\/h1>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;section&#8221; _builder_version=&#8221;3.26.3&#8243; background_image=&#8221;http:\/\/alfa-diagnostic.com\/wp-content\/uploads\/2019\/07\/2595-bg.jpg&#8221; custom_padding=&#8221;13px||13px|&#8221; custom_padding_tablet=&#8221;13px||13px|&#8221; padding_mobile=&#8221;on&#8221; locked=&#8221;off&#8221;][et_pb_row column_structure=&#8221;1_5,3_5,1_5&#8243; custom_padding=&#8221;20px|0px|0px|0px&#8221; padding_mobile=&#8221;off&#8221; column_padding_mobile=&#8221;on&#8221; _builder_version=&#8221;3.26.3&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; width=&#8221;90%&#8221; max_width=&#8221;1920px&#8221;][et_pb_column type=&#8221;1_5&#8243; _builder_version=&#8221;3.25&#8243; custom_padding=&#8221;|||&#8221; custom_padding__hover=&#8221;|||&#8221;][\/et_pb_column][et_pb_column type=&#8221;3_5&#8243; _builder_version=&#8221;3.25&#8243; custom_padding=&#8221;|||&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text _builder_version=&#8221;3.26.3&#8243;]<div class=\"caldera-grid\" id=\"caldera_form_1\" data-cf-ver=\"1.9.7\" data-cf-form-id=\"CF5d31ec396e605\"><div id=\"caldera_notices_1\" data-spinner=\"https:\/\/alfa-diagnostic.com\/wp-admin\/images\/spinner.gif\"><\/div><form data-instance=\"1\" class=\"CF5d31ec396e605 caldera_forms_form cfajax-trigger\" method=\"POST\" enctype=\"multipart\/form-data\" id=\"CF5d31ec396e605_1\" data-form-id=\"CF5d31ec396e605\" aria-label=\"Request an appointment\" data-target=\"#caldera_notices_1\" data-template=\"#cfajax_CF5d31ec396e605-tmpl\" data-cfajax=\"CF5d31ec396e605\" data-load-element=\"_parent\" data-load-class=\"cf_processing\" data-post-disable=\"0\" data-action=\"cf_process_ajax_submit\" data-request=\"https:\/\/alfa-diagnostic.com\/cf-api\/CF5d31ec396e605\" data-hiderows=\"true\">\r\n<input type=\"hidden\" id=\"_cf_verify_CF5d31ec396e605\" name=\"_cf_verify\" value=\"20c2da933c\"  data-nonce-time=\"1714975977\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/31605\" \/><div id=\"cf2-CF5d31ec396e605_1\"><\/div><input type=\"hidden\" name=\"_cf_frm_id\" value=\"CF5d31ec396e605\">\r\n<input type=\"hidden\" name=\"_cf_frm_ct\" value=\"1\">\r\n<input type=\"hidden\" name=\"cfajax\" value=\"CF5d31ec396e605\">\r\n<input type=\"hidden\" name=\"_cf_cr_pst\" value=\"31605\">\r\n<div class=\"hide\" style=\"display:none; overflow:hidden;height:0;width:0;\">\r\n<label>Order Number<\/label><input type=\"text\" name=\"order_number\" value=\"\" autocomplete=\"off\">\r\n<\/div><div id=\"CF5d31ec396e605_1-row-1\"  class=\"row  first_row\"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_468081\" class=\"form-group\" id=\"fld_468081_1-wrap\">\r\n\t<label id=\"fld_468081Label\" for=\"fld_468081_1\" class=\"control-label\">First Name <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_468081\" class=\" form-control\" id=\"fld_468081_1\" name=\"fld_468081\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_468081Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_140211\" class=\"form-group\" id=\"fld_140211_1-wrap\">\r\n\t<label id=\"fld_140211Label\" for=\"fld_140211_1\" class=\"control-label\">Last Name <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_140211\" class=\" form-control\" id=\"fld_140211_1\" name=\"fld_140211\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_140211Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_1-row-2\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4116538\" class=\"form-group\" id=\"fld_4116538_1-wrap\">\r\n\t<label id=\"fld_4116538Label\" for=\"fld_4116538_1\" class=\"control-label\">Your E-mail <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"email\" data-field=\"fld_4116538\" class=\" form-control\" id=\"fld_4116538_1\" name=\"fld_4116538\" value=\"\" data-type=\"email\" aria-required=\"true\"   aria-labelledby=\"fld_4116538Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_9993056\" class=\"form-group\" id=\"fld_9993056_1-wrap\">\r\n\t<label id=\"fld_9993056Label\" for=\"fld_9993056_1\" class=\"control-label\">Phone <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9993056\" class=\" form-control\" id=\"fld_9993056_1\" name=\"fld_9993056\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9993056Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_1-row-3\"  class=\"row \"><div  class=\"col-sm-6  first_col\">\n<div data-field-wrapper=\"fld_5792986\" class=\"form-group\" id=\"fld_5792986_1-wrap\">\r\n\t<label id=\"fld_5792986Label\" for=\"fld_5792986_1\" class=\"control-label\">Birthdate <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input  type=\"text\" data-provide=\"cfdatepicker\" name=\"fld_5792986\" value=\"\" id=\"fld_5792986_1\" data-field=\"fld_5792986\" class=\"form-control cfdatepicker is-cfdatepicker\" data-date-format=\"yyyy-mm-dd\" required=\"1\" data-date-start-view=\"month\"   aria-labelledby=\"fld_5792986Label\" required  \/>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_3372234\" class=\"form-group\" id=\"fld_3372234_1-wrap\">\r\n\t<label id=\"fld_3372234Label\" for=\"fld_3372234_1\" class=\"control-label\">Diagnosis (if available)<\/label>\r\n\t<div class=\"\">\r\n\t\t<input    type=\"text\" data-field=\"fld_3372234\" class=\" form-control\" id=\"fld_3372234_1\" name=\"fld_3372234\" value=\"\" data-type=\"text\"   aria-labelledby=\"fld_3372234Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_1-row-4\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div class=\"\"><p>Doctor\u2019s Name (if available)<\/p>\n<\/div><\/div><div  class=\"col-sm-3 \"><\/div><div  class=\"col-sm-3  last_col\"><\/div><\/div><div id=\"CF5d31ec396e605_1-row-5\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5179508\" class=\"form-group\" id=\"fld_5179508_1-wrap\">\r\n\t<label id=\"fld_5179508Label\" for=\"fld_5179508_1\" class=\"control-label screen-reader-text sr-only\">(Last)<\/label>\r\n\t<div class=\"\">\r\n\t\t<input placeholder=\"(Last)\"   type=\"text\" data-field=\"fld_5179508\" class=\" form-control\" id=\"fld_5179508_1\" name=\"fld_5179508\" value=\"\" data-type=\"text\"   aria-labelledby=\"fld_5179508Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_1933656\" class=\"form-group\" id=\"fld_1933656_1-wrap\">\r\n\t<label id=\"fld_1933656Label\" for=\"fld_1933656_1\" class=\"control-label screen-reader-text sr-only\">(First)<\/label>\r\n\t<div class=\"\">\r\n\t\t<input placeholder=\"(First)\"   type=\"text\" data-field=\"fld_1933656\" class=\" form-control\" id=\"fld_1933656_1\" name=\"fld_1933656\" value=\"\" data-type=\"text\"   aria-labelledby=\"fld_1933656Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_1-row-6\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div class=\"\"><p>New Patient<\/p>\n<\/div><div data-field-wrapper=\"fld_1969276\" class=\"form-group\" id=\"fld_1969276_1-wrap\">\r\n<label id=\"fld_1969276Label\" for=\"fld_1969276_1\" class=\"control-label screen-reader-text sr-only\">No<\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"Yes\" for=\"fld_1969276_1_opt1954443\"><input type=\"radio\" id=\"fld_1969276_1_opt1954443\" data-field=\"fld_1969276\" class=\"fld_1969276_1\" name=\"fld_1969276\" value=\"Yes\"    data-radio-field=\"fld_1969276_1\" data-type=\"radio\" data-calc-value=\"Yes\" \/>\n\t\t\tYes\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"No\" for=\"fld_1969276_1_opt1683918\"><input type=\"radio\" id=\"fld_1969276_1_opt1683918\" data-field=\"fld_1969276\" class=\"fld_1969276_1\" name=\"fld_1969276\" value=\"No\"    data-radio-field=\"fld_1969276_1\" data-type=\"radio\" data-calc-value=\"No\" \/>\n\t\t\tNo\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_115758\" class=\"form-group\" id=\"fld_115758_1-wrap\">\r\n\t<label id=\"fld_115758Label\" for=\"fld_115758_1\" class=\"control-label\">Promo Code<\/label>\r\n\t<div class=\"\">\r\n\t\t<input    type=\"text\" data-field=\"fld_115758\" class=\" form-control\" id=\"fld_115758_1\" name=\"fld_115758\" value=\"\" data-type=\"text\"   aria-labelledby=\"fld_115758Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_1-row-7\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div class=\"\"><p>Do you have insurance?<\/p>\n<\/div><div data-field-wrapper=\"fld_1896172\" class=\"form-group\" id=\"fld_1896172_1-wrap\">\r\n<label id=\"fld_1896172Label\" for=\"fld_1896172_1\" class=\"control-label screen-reader-text sr-only\">No<\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"Yes\" for=\"fld_1896172_1_opt1954443\"><input type=\"radio\" id=\"fld_1896172_1_opt1954443\" data-field=\"fld_1896172\" class=\"fld_1896172_1\" name=\"fld_1896172\" value=\"Yes\"    data-radio-field=\"fld_1896172_1\" data-type=\"radio\" data-calc-value=\"Yes\" \/>\n\t\t\tYes\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"No\" for=\"fld_1896172_1_opt1683918\"><input type=\"radio\" id=\"fld_1896172_1_opt1683918\" data-field=\"fld_1896172\" class=\"fld_1896172_1\" name=\"fld_1896172\" value=\"No\"    data-radio-field=\"fld_1896172_1\" data-type=\"radio\" data-calc-value=\"No\" \/>\n\t\t\tNo\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6455173\" class=\"form-group\" id=\"fld_6455173_1-wrap\">\r\n\t<label id=\"fld_6455173Label\" for=\"fld_6455173_1\" class=\"control-label\">Insurance Provider<\/label>\r\n\t<div class=\"\">\r\n\t\t<input    type=\"text\" data-field=\"fld_6455173\" class=\" form-control\" id=\"fld_6455173_1\" name=\"fld_6455173\" value=\"\" data-type=\"text\"   aria-labelledby=\"fld_6455173Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_1-row-8\"  class=\"row \"><div  class=\"col-sm-12  single\"><div class=\"\"><h3 style=\"text-align:center;padding: 35px 0px;\">We will attempt to accommodate the following:<\/h3>\n<\/div><\/div><\/div><div id=\"CF5d31ec396e605_1-row-9\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><\/div><div  class=\"col-sm-6  last_col\"><\/div><\/div><div id=\"CF5d31ec396e605_1-row-10\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4456150\" class=\"form-group\" id=\"fld_4456150_1-wrap\">\r\n\t<label id=\"fld_4456150Label\" for=\"fld_4456150_1\" class=\"control-label\">Test To Be Ordered <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<select name=\"fld_4456150\" value=\"\" data-field=\"fld_4456150\" class=\"form-control\" id=\"fld_4456150_1\"  required=\"required\"  aria-labelledby=\"fld_4456150Label\" >\n\t\t<option value=\"\" disabled selected>Select<\/option>\t\t\t\t\t<option value=\"DX: X ray\"  data-calc-value=\"DX: X ray\" >\n\t\t\t\t\t\tDX: X ray\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"US: Ultrasound\u00a0\"  data-calc-value=\"US: Ultrasound\u00a0\" >\n\t\t\t\t\t\tUS: Ultrasound\u00a0\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"US: Echocardiogram\u00a0\"  data-calc-value=\"US: Echocardiogram\u00a0\" >\n\t\t\t\t\t\tUS: Echocardiogram\u00a0\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"CT: Computerized Tomography (CAT scan)\"  data-calc-value=\"CT: Computerized Tomography (CAT scan)\" >\n\t\t\t\t\t\tCT: Computerized Tomography (CAT scan)\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"BD: Bone Density\"  data-calc-value=\"BD: Bone Density\" >\n\t\t\t\t\t\tBD: Bone Density\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"MRI: Magnetic resonance tomography\"  data-calc-value=\"MRI: Magnetic resonance tomography\" >\n\t\t\t\t\t\tMRI: Magnetic resonance tomography\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"MG: 3D Mammography\"  data-calc-value=\"MG: 3D Mammography\" >\n\t\t\t\t\t\tMG: 3D Mammography\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><\/div><\/div><div id=\"CF5d31ec396e605_1-row-11\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_750206\" class=\"form-group\" id=\"fld_750206_1-wrap\">\r\n\t<label id=\"fld_750206Label\" for=\"fld_750206_1\" class=\"control-label\">Comments or Questions<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_750206\" value=\"\" data-field=\"fld_750206\" class=\"form-control\" id=\"fld_750206_1\" rows=\"4\"    aria-labelledby=\"fld_750206Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_1-row-12\"  class=\"row  last_row\"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_3371283\" class=\"form-group shedule_custom_btn\" id=\"fld_3371283_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"submit\" name=\"fld_3371283\" id=\"fld_3371283_1\" value=\"Schedule Appointment\" data-field=\"fld_3371283\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_3371283\" id=\"fld_3371283_1_btn\" value=\"\" data-field=\"fld_3371283\"  \/>\n<\/div><\/div><\/form>\r\n<\/div>\r\n[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_5&#8243; _builder_version=&#8221;3.25&#8243; custom_padding=&#8221;|||&#8221; custom_padding__hover=&#8221;|||&#8221;][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Request an Appointment<div class=\"caldera-grid\" id=\"caldera_form_2\" data-cf-ver=\"1.9.7\" data-cf-form-id=\"CF5d31ec396e605\"><div id=\"caldera_notices_2\" data-spinner=\"https:\/\/alfa-diagnostic.com\/wp-admin\/images\/spinner.gif\"><\/div><form data-instance=\"2\" class=\"CF5d31ec396e605 caldera_forms_form cfajax-trigger\" method=\"POST\" enctype=\"multipart\/form-data\" id=\"CF5d31ec396e605_2\" data-form-id=\"CF5d31ec396e605\" aria-label=\"Request an appointment\" data-target=\"#caldera_notices_2\" data-template=\"#cfajax_CF5d31ec396e605-tmpl\" data-cfajax=\"CF5d31ec396e605\" data-load-element=\"_parent\" data-load-class=\"cf_processing\" data-post-disable=\"0\" data-action=\"cf_process_ajax_submit\" data-request=\"https:\/\/alfa-diagnostic.com\/cf-api\/CF5d31ec396e605\" data-hiderows=\"true\">\r\n<input type=\"hidden\" id=\"_cf_verify_CF5d31ec396e605\" name=\"_cf_verify\" value=\"20c2da933c\"  data-nonce-time=\"1714975977\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/31605\" \/><div id=\"cf2-CF5d31ec396e605_2\"><\/div><input type=\"hidden\" name=\"_cf_frm_id\" value=\"CF5d31ec396e605\">\r\n<input type=\"hidden\" name=\"_cf_frm_ct\" value=\"2\">\r\n<input type=\"hidden\" name=\"cfajax\" value=\"CF5d31ec396e605\">\r\n<input type=\"hidden\" name=\"_cf_cr_pst\" value=\"31605\">\r\n<div class=\"hide\" style=\"display:none; overflow:hidden;height:0;width:0;\">\r\n<label>Url<\/label><input type=\"text\" name=\"url\" value=\"\" autocomplete=\"off\">\r\n<\/div><div id=\"CF5d31ec396e605_2-row-1\"  class=\"row  first_row\"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_468081\" class=\"form-group\" id=\"fld_468081_2-wrap\">\r\n\t<label id=\"fld_468081Label\" for=\"fld_468081_2\" class=\"control-label\">First Name <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_468081\" class=\" form-control\" id=\"fld_468081_2\" name=\"fld_468081\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_468081Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_140211\" class=\"form-group\" id=\"fld_140211_2-wrap\">\r\n\t<label id=\"fld_140211Label\" for=\"fld_140211_2\" class=\"control-label\">Last Name <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_140211\" class=\" form-control\" id=\"fld_140211_2\" name=\"fld_140211\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_140211Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_2-row-2\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4116538\" class=\"form-group\" id=\"fld_4116538_2-wrap\">\r\n\t<label id=\"fld_4116538Label\" for=\"fld_4116538_2\" class=\"control-label\">Your E-mail <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"email\" data-field=\"fld_4116538\" class=\" form-control\" id=\"fld_4116538_2\" name=\"fld_4116538\" value=\"\" data-type=\"email\" aria-required=\"true\"   aria-labelledby=\"fld_4116538Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_9993056\" class=\"form-group\" id=\"fld_9993056_2-wrap\">\r\n\t<label id=\"fld_9993056Label\" for=\"fld_9993056_2\" class=\"control-label\">Phone <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9993056\" class=\" form-control\" id=\"fld_9993056_2\" name=\"fld_9993056\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9993056Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_2-row-3\"  class=\"row \"><div  class=\"col-sm-6  first_col\">\n<div data-field-wrapper=\"fld_5792986\" class=\"form-group\" id=\"fld_5792986_2-wrap\">\r\n\t<label id=\"fld_5792986Label\" for=\"fld_5792986_2\" class=\"control-label\">Birthdate <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input  type=\"text\" data-provide=\"cfdatepicker\" name=\"fld_5792986\" value=\"\" id=\"fld_5792986_2\" data-field=\"fld_5792986\" class=\"form-control cfdatepicker is-cfdatepicker\" data-date-format=\"yyyy-mm-dd\" required=\"1\" data-date-start-view=\"month\"   aria-labelledby=\"fld_5792986Label\" required  \/>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_3372234\" class=\"form-group\" id=\"fld_3372234_2-wrap\">\r\n\t<label id=\"fld_3372234Label\" for=\"fld_3372234_2\" class=\"control-label\">Diagnosis (if available)<\/label>\r\n\t<div class=\"\">\r\n\t\t<input    type=\"text\" data-field=\"fld_3372234\" class=\" form-control\" id=\"fld_3372234_2\" name=\"fld_3372234\" value=\"\" data-type=\"text\"   aria-labelledby=\"fld_3372234Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_2-row-4\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div class=\"\"><p>Doctor\u2019s Name (if available)<\/p>\n<\/div><\/div><div  class=\"col-sm-3 \"><\/div><div  class=\"col-sm-3  last_col\"><\/div><\/div><div id=\"CF5d31ec396e605_2-row-5\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5179508\" class=\"form-group\" id=\"fld_5179508_2-wrap\">\r\n\t<label id=\"fld_5179508Label\" for=\"fld_5179508_2\" class=\"control-label screen-reader-text sr-only\">(Last)<\/label>\r\n\t<div class=\"\">\r\n\t\t<input placeholder=\"(Last)\"   type=\"text\" data-field=\"fld_5179508\" class=\" form-control\" id=\"fld_5179508_2\" name=\"fld_5179508\" value=\"\" data-type=\"text\"   aria-labelledby=\"fld_5179508Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_1933656\" class=\"form-group\" id=\"fld_1933656_2-wrap\">\r\n\t<label id=\"fld_1933656Label\" for=\"fld_1933656_2\" class=\"control-label screen-reader-text sr-only\">(First)<\/label>\r\n\t<div class=\"\">\r\n\t\t<input placeholder=\"(First)\"   type=\"text\" data-field=\"fld_1933656\" class=\" form-control\" id=\"fld_1933656_2\" name=\"fld_1933656\" value=\"\" data-type=\"text\"   aria-labelledby=\"fld_1933656Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_2-row-6\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div class=\"\"><p>New Patient<\/p>\n<\/div><div data-field-wrapper=\"fld_1969276\" class=\"form-group\" id=\"fld_1969276_2-wrap\">\r\n<label id=\"fld_1969276Label\" for=\"fld_1969276_2\" class=\"control-label screen-reader-text sr-only\">No<\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"Yes\" for=\"fld_1969276_2_opt1954443\"><input type=\"radio\" id=\"fld_1969276_2_opt1954443\" data-field=\"fld_1969276\" class=\"fld_1969276_2\" name=\"fld_1969276\" value=\"Yes\"    data-radio-field=\"fld_1969276_2\" data-type=\"radio\" data-calc-value=\"Yes\" \/>\n\t\t\tYes\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"No\" for=\"fld_1969276_2_opt1683918\"><input type=\"radio\" id=\"fld_1969276_2_opt1683918\" data-field=\"fld_1969276\" class=\"fld_1969276_2\" name=\"fld_1969276\" value=\"No\"    data-radio-field=\"fld_1969276_2\" data-type=\"radio\" data-calc-value=\"No\" \/>\n\t\t\tNo\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_115758\" class=\"form-group\" id=\"fld_115758_2-wrap\">\r\n\t<label id=\"fld_115758Label\" for=\"fld_115758_2\" class=\"control-label\">Promo Code<\/label>\r\n\t<div class=\"\">\r\n\t\t<input    type=\"text\" data-field=\"fld_115758\" class=\" form-control\" id=\"fld_115758_2\" name=\"fld_115758\" value=\"\" data-type=\"text\"   aria-labelledby=\"fld_115758Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_2-row-7\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div class=\"\"><p>Do you have insurance?<\/p>\n<\/div><div data-field-wrapper=\"fld_1896172\" class=\"form-group\" id=\"fld_1896172_2-wrap\">\r\n<label id=\"fld_1896172Label\" for=\"fld_1896172_2\" class=\"control-label screen-reader-text sr-only\">No<\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"Yes\" for=\"fld_1896172_2_opt1954443\"><input type=\"radio\" id=\"fld_1896172_2_opt1954443\" data-field=\"fld_1896172\" class=\"fld_1896172_2\" name=\"fld_1896172\" value=\"Yes\"    data-radio-field=\"fld_1896172_2\" data-type=\"radio\" data-calc-value=\"Yes\" \/>\n\t\t\tYes\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"No\" for=\"fld_1896172_2_opt1683918\"><input type=\"radio\" id=\"fld_1896172_2_opt1683918\" data-field=\"fld_1896172\" class=\"fld_1896172_2\" name=\"fld_1896172\" value=\"No\"    data-radio-field=\"fld_1896172_2\" data-type=\"radio\" data-calc-value=\"No\" \/>\n\t\t\tNo\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6455173\" class=\"form-group\" id=\"fld_6455173_2-wrap\">\r\n\t<label id=\"fld_6455173Label\" for=\"fld_6455173_2\" class=\"control-label\">Insurance Provider<\/label>\r\n\t<div class=\"\">\r\n\t\t<input    type=\"text\" data-field=\"fld_6455173\" class=\" form-control\" id=\"fld_6455173_2\" name=\"fld_6455173\" value=\"\" data-type=\"text\"   aria-labelledby=\"fld_6455173Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_2-row-8\"  class=\"row \"><div  class=\"col-sm-12  single\"><div class=\"\"><h3 style=\"text-align:center;padding: 35px 0px;\">We will attempt to accommodate the following:<\/h3>\n<\/div><\/div><\/div><div id=\"CF5d31ec396e605_2-row-9\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><\/div><div  class=\"col-sm-6  last_col\"><\/div><\/div><div id=\"CF5d31ec396e605_2-row-10\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4456150\" class=\"form-group\" id=\"fld_4456150_2-wrap\">\r\n\t<label id=\"fld_4456150Label\" for=\"fld_4456150_2\" class=\"control-label\">Test To Be Ordered <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<select name=\"fld_4456150\" value=\"\" data-field=\"fld_4456150\" class=\"form-control\" id=\"fld_4456150_2\"  required=\"required\"  aria-labelledby=\"fld_4456150Label\" >\n\t\t<option value=\"\" disabled selected>Select<\/option>\t\t\t\t\t<option value=\"DX: X ray\"  data-calc-value=\"DX: X ray\" >\n\t\t\t\t\t\tDX: X ray\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"US: Ultrasound\u00a0\"  data-calc-value=\"US: Ultrasound\u00a0\" >\n\t\t\t\t\t\tUS: Ultrasound\u00a0\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"US: Echocardiogram\u00a0\"  data-calc-value=\"US: Echocardiogram\u00a0\" >\n\t\t\t\t\t\tUS: Echocardiogram\u00a0\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"CT: Computerized Tomography (CAT scan)\"  data-calc-value=\"CT: Computerized Tomography (CAT scan)\" >\n\t\t\t\t\t\tCT: Computerized Tomography (CAT scan)\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"BD: Bone Density\"  data-calc-value=\"BD: Bone Density\" >\n\t\t\t\t\t\tBD: Bone Density\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"MRI: Magnetic resonance tomography\"  data-calc-value=\"MRI: Magnetic resonance tomography\" >\n\t\t\t\t\t\tMRI: Magnetic resonance tomography\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"MG: 3D Mammography\"  data-calc-value=\"MG: 3D Mammography\" >\n\t\t\t\t\t\tMG: 3D Mammography\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><\/div><\/div><div id=\"CF5d31ec396e605_2-row-11\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_750206\" class=\"form-group\" id=\"fld_750206_2-wrap\">\r\n\t<label id=\"fld_750206Label\" for=\"fld_750206_2\" class=\"control-label\">Comments or Questions<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_750206\" value=\"\" data-field=\"fld_750206\" class=\"form-control\" id=\"fld_750206_2\" rows=\"4\"    aria-labelledby=\"fld_750206Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5d31ec396e605_2-row-12\"  class=\"row  last_row\"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_3371283\" class=\"form-group shedule_custom_btn\" id=\"fld_3371283_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"submit\" name=\"fld_3371283\" id=\"fld_3371283_2\" value=\"Schedule Appointment\" data-field=\"fld_3371283\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_3371283\" id=\"fld_3371283_2_btn\" value=\"\" data-field=\"fld_3371283\"  \/>\n<\/div><\/div><\/form>\r\n<\/div>\r\n<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v21.8 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Request an appointment :: Alfa Diagnostic<\/title>\n<meta name=\"description\" content=\"Please complete the patient form on this page to request a medical imaging appointment with Alfa Diagnostic.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/alfa-diagnostic.com\/request-an-appointment\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Request an appointment :: Alfa 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