{"id":10,"date":"2026-05-25T17:11:49","date_gmt":"2026-05-25T17:11:49","guid":{"rendered":"https:\/\/texasmedicalmarijuanadoctors.org\/booking\/?page_id=10"},"modified":"2026-06-16T22:28:40","modified_gmt":"2026-06-16T22:28:40","slug":"home","status":"publish","type":"page","link":"https:\/\/texasmedicalmarijuanadoctors.org\/booking\/","title":{"rendered":"Home"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"10\" class=\"elementor elementor-10\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e3ad36a e-flex e-con-boxed e-con e-parent\" data-id=\"e3ad36a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-276f4d2 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"276f4d2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t\t        <input type=\"hidden\" class=\"conditional_logic_data_js hidden\" data-form-id=\"Texas Medical Form\" value=\"{&quot;field_852be78&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Chronic Pain&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_2c3fe9c&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Chronic Pain&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_b42e1ca&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Chronic Pain&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_cb4f0c8&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Chronic Pain&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_ddc32b8&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Chronic Pain&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_151013c&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;PTSD&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_f280538&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;PTSD&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_bdb410c&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;PTSD&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_af57a03&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;PTSD&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_26c55c9&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;PTSD&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_6288f76&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Cancer&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_9c363b4&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Cancer&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_9d515bc&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Cancer&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_bd4591d&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Cancer&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_e65d46a&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Cancer&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_67130f6&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Seizures&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_0356edf&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Seizures&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_5ff8187&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Seizures&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_5839180&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Seizures&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_b34a679&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Arthritis&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_5b43700&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Arthritis&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_a53ec9b&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Arthritis&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_e4e7875&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Arthritis&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_81c6765&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_06a5888&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Other&quot;,&quot;_id&quot;:&quot;c1b7c3b&quot;}]},&quot;field_07528de&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_46b54d1&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;13ead54&quot;}]},&quot;field_673ea27&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_46b54d1&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;2bb7998&quot;}]},&quot;field_15fb092&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_46b54d1&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;No&quot;,&quot;_id&quot;:&quot;2bb7998&quot;}]},&quot;field_7f173cc&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_81f6425&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;2bb7998&quot;}]},&quot;field_7add37c&quot;:{&quot;display&quot;:&quot;show&quot;,&quot;trigger&quot;:&quot;ALL&quot;,&quot;datas&quot;:[{&quot;conditional_logic_id&quot;:&quot;field_7f173cc&quot;,&quot;conditional_logic_operator&quot;:&quot;==&quot;,&quot;conditional_logic_value&quot;:&quot;Patient&quot;,&quot;_id&quot;:&quot;2bb7998&quot;}]}}\" \/>\r\n\t\t<form class=\"elementor-form\" method=\"post\" name=\"Texas Medical Form\" aria-label=\"Texas Medical Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"10\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"276f4d2\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_6cedf6e elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html1 elementor-field-group elementor-column elementor-field-group-field_55ddd02 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-html-type\" id=\"form-field-field_55ddd02\">\r\n\t\t\t<h2 class=spcl--head>1. Patient Information Section<\/h2>\t\t<\/div>\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEnter Your Full Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Name\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_755ecc8 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_755ecc8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_755ecc8]\" id=\"form-field-field_755ecc8\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field\" placeholder=\"YYY\/MM\/DD\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-message elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-message\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[message]\" id=\"form-field-message\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"123 456 789\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"john@example.com\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4330e07 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4330e07\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tResidency\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_4330e07]\" id=\"form-field-field_4330e07\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Please Select<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Texan\">Texan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Non-Texan\">Non-Texan<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_570127c elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_570127c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tValid DL or ID Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_570127c]\" id=\"form-field-field_570127c\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Enter valid driver license or ID\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_d8bb619 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_cafd157 elementor-col-100\">\n\t\t\t\t\t<h2 class=spcl--head>2. Qualifying Condition Selection<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_06a5888 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_06a5888\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tQualifying Conditions (Please upload valid documentation)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Chronic Pain\" id=\"form-field-field_06a5888-0\" name=\"form_fields[field_06a5888]\" required=\"required\"> <label for=\"form-field-field_06a5888-0\">Chronic Pain<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"PTSD\" id=\"form-field-field_06a5888-1\" name=\"form_fields[field_06a5888]\" required=\"required\"> <label for=\"form-field-field_06a5888-1\">PTSD<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Cancer\" id=\"form-field-field_06a5888-2\" name=\"form_fields[field_06a5888]\" required=\"required\"> <label for=\"form-field-field_06a5888-2\">Cancer<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Seizures\" id=\"form-field-field_06a5888-3\" name=\"form_fields[field_06a5888]\" required=\"required\"> <label for=\"form-field-field_06a5888-3\">Seizures<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Arthritis\" id=\"form-field-field_06a5888-4\" name=\"form_fields[field_06a5888]\" required=\"required\"> <label for=\"form-field-field_06a5888-4\">Arthritis<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Other\" id=\"form-field-field_06a5888-5\" name=\"form_fields[field_06a5888]\" required=\"required\"> <label for=\"form-field-field_06a5888-5\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_852be78 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_852be78\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDescribe incident\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_852be78]\" id=\"form-field-field_852be78\" rows=\"4\" placeholder=\"Describe incident (What caused your pain?) \" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2c3fe9c elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2c3fe9c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName of hospital\/PCP\/Urgent care\/ Physical Therapist Or where did you receive the treatment? \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2c3fe9c]\" id=\"form-field-field_2c3fe9c\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Name of hospital\/PCP\/Urgent care\/ Physical Therapist (Who treated you for your pain?)\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b42e1ca elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b42e1ca\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b42e1ca]\" id=\"form-field-field_b42e1ca\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"City, State\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_cb4f0c8 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cb4f0c8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_cb4f0c8]\" id=\"form-field-field_cb4f0c8\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Phone number\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_ddc32b8 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ddc32b8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMonth\/Year of visit\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_ddc32b8]\" id=\"form-field-field_ddc32b8\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field\" placeholder=\"YYY\/MM\/DD\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_151013c elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_151013c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tYear Diagnosed\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_151013c]\" id=\"form-field-field_151013c\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field\" placeholder=\"YYY\/MM\/DD\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-field_f280538 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f280538\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tUpload diagnosis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[field_f280538]\" id=\"form-field-field_f280538\" class=\"elementor-field elementor-size-md  elementor-upload-field\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bdb410c elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bdb410c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName of Provider\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bdb410c]\" id=\"form-field-field_bdb410c\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Name of Provider\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_af57a03 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_af57a03\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_af57a03]\" id=\"form-field-field_af57a03\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"City, State\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_26c55c9 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_26c55c9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_26c55c9]\" id=\"form-field-field_26c55c9\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Phone Number\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_6288f76 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6288f76\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tYear Diagnosed\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_6288f76]\" id=\"form-field-field_6288f76\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field\" placeholder=\"YYY\/MM\/DD\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-field_9c363b4 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9c363b4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tUpload diagnosis\/my chart\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[field_9c363b4]\" id=\"form-field-field_9c363b4\" class=\"elementor-field elementor-size-md  elementor-upload-field\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9d515bc elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9d515bc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName of Provider\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9d515bc]\" id=\"form-field-field_9d515bc\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Name of Provider\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bd4591d elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bd4591d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bd4591d]\" id=\"form-field-field_bd4591d\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"City, State\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_e65d46a elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e65d46a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_e65d46a]\" id=\"form-field-field_e65d46a\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Phone Number\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_67130f6 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_67130f6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName of Provider\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_67130f6]\" id=\"form-field-field_67130f6\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Name of Provider\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0356edf elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0356edf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0356edf]\" id=\"form-field-field_0356edf\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"City, State\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_5ff8187 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5ff8187\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_5ff8187]\" id=\"form-field-field_5ff8187\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Phone Number\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-field_5839180 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5839180\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tUpload Medications\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[field_5839180]\" id=\"form-field-field_5839180\" class=\"elementor-field elementor-size-md  elementor-upload-field\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b34a679 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b34a679\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName of Provider\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b34a679]\" id=\"form-field-field_b34a679\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Name of Provider\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5b43700 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5b43700\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5b43700]\" id=\"form-field-field_5b43700\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"City, State\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_a53ec9b elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a53ec9b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_a53ec9b]\" id=\"form-field-field_a53ec9b\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Phone Number\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-field_e4e7875 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e4e7875\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tUpload medications\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[field_e4e7875]\" id=\"form-field-field_e4e7875\" class=\"elementor-field elementor-size-md  elementor-upload-field\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html1 elementor-field-group elementor-column elementor-field-group-field_81c6765 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_81c6765\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOther\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-html-type\" id=\"form-field-field_81c6765\">\r\n\t\t\t<h6>Please Call Our Office <a href=\"tel:1 (844) 832-4367\">1 (844) 832-4367<\/a> to speak to a medical professional.<\/h6>\t\t<\/div>\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_5d6d0c4 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_386e2db elementor-col-100\">\n\t\t\t\t\t<h2 class=spcl--head>3. Additional Qualification Question\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_46b54d1 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_46b54d1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have to submit paperwork or take a drug test for anyone in an official capacity (i.e. lawyer, employer)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_46b54d1-0\" name=\"form_fields[field_46b54d1]\" required=\"required\"> <label for=\"form-field-field_46b54d1-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_46b54d1-1\" name=\"form_fields[field_46b54d1]\" required=\"required\"> <label for=\"form-field-field_46b54d1-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_07528de elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_07528de\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChoose one of the following\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Probation\" id=\"form-field-field_07528de-0\" name=\"form_fields[field_07528de]\"> <label for=\"form-field-field_07528de-0\">Probation<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Parole\" id=\"form-field-field_07528de-1\" name=\"form_fields[field_07528de]\"> <label for=\"form-field-field_07528de-1\">Parole<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Bond\" id=\"form-field-field_07528de-2\" name=\"form_fields[field_07528de]\"> <label for=\"form-field-field_07528de-2\">Bond<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"CPS\" id=\"form-field-field_07528de-3\" name=\"form_fields[field_07528de]\"> <label for=\"form-field-field_07528de-3\">CPS<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Employment Accommodation\" id=\"form-field-field_07528de-4\" name=\"form_fields[field_07528de]\"> <label for=\"form-field-field_07528de-4\">Employment Accommodation<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_673ea27 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_673ea27\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tService option\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_673ea27]\" id=\"form-field-field_673ea27\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Please select<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"$250 &gt; Legal Prescription, CURT registration and additional accommodation letter for one year\">$250 &gt; Legal Prescription, CURT registration and additional accommodation letter for one year<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_15fb092 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_15fb092\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tService option\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_15fb092]\" id=\"form-field-field_15fb092\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Please select<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"$200 &gt; Legal Prescription + CURT registration for one year\">$200 &gt; Legal Prescription + CURT registration for one year<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_81f6425 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_81f6425\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWho were you referred to us by?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_81f6425-0\" name=\"form_fields[field_81f6425]\" required=\"required\"> <label for=\"form-field-field_81f6425-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_81f6425-1\" name=\"form_fields[field_81f6425]\" required=\"required\"> <label for=\"form-field-field_81f6425-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7f173cc elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7f173cc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWho\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7f173cc]\" id=\"form-field-field_7f173cc\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Google\">Google<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Patient\">Patient<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7add37c elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7add37c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7add37c]\" id=\"form-field-field_7add37c\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Patient Name\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_5c9138f elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_4ccfbb2 elementor-col-100\">\n\t\t\t\t\t<h2 class=spcl--head>4. Appointment Section<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7427226 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7427226\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDay\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7427226]\" id=\"form-field-field_7427226\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Please Select<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Monday\">Monday<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tuesday\">Tuesday<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Wednesday\">Wednesday<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Thursday\">Thursday<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Friday\">Friday<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_f4b7aa3 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f4b7aa3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTime\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"8AM-12PM\" id=\"form-field-field_f4b7aa3-0\" name=\"form_fields[field_f4b7aa3]\" required=\"required\"> <label for=\"form-field-field_f4b7aa3-0\">8AM-12PM<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"12PM-5PM\" id=\"form-field-field_f4b7aa3-1\" name=\"form_fields[field_f4b7aa3]\" required=\"required\"> <label for=\"form-field-field_f4b7aa3-1\">12PM-5PM<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_cc8e835 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cc8e835\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tType of Appointment\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_cc8e835]\" id=\"form-field-field_cc8e835\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Please Select<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"In-person\">In-person<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Virtual\">Virtual<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-md\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">SUBMIT<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\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":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"footnotes":""},"class_list":["post-10","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/texasmedicalmarijuanadoctors.org\/booking\/index.php\/wp-json\/wp\/v2\/pages\/10","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/texasmedicalmarijuanadoctors.org\/booking\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/texasmedicalmarijuanadoctors.org\/booking\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/texasmedicalmarijuanadoctors.org\/booking\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/texasmedicalmarijuanadoctors.org\/booking\/index.php\/wp-json\/wp\/v2\/comments?post=10"}],"version-history":[{"count":322,"href":"https:\/\/texasmedicalmarijuanadoctors.org\/booking\/index.php\/wp-json\/wp\/v2\/pages\/10\/revisions"}],"predecessor-version":[{"id":354,"href":"https:\/\/texasmedicalmarijuanadoctors.org\/booking\/index.php\/wp-json\/wp\/v2\/pages\/10\/revisions\/354"}],"wp:attachment":[{"href":"https:\/\/texasmedicalmarijuanadoctors.org\/booking\/index.php\/wp-json\/wp\/v2\/media?parent=10"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}