Patient Enrollment Form<\/title>\r\n<style>\r\n @import url('https:\/\/fonts.googleapis.com\/css2?family=Open+Sans:wght@400;600&display=swap');\r\n\r\n body {\r\n font-family: 'Open Sans', sans-serif;\r\n background-color: #f3f7fb;\r\n margin: 0;\r\n padding: 40px 20px;\r\n color: #344054;\r\n }\r\n\r\n .form-container {\r\n max-width: 800px;\r\n margin: 0 auto;\r\n background-color: white;\r\n border-radius: 14px;\r\n padding: 40px 36px;\r\n box-shadow: 0 4px 15px rgba(0,0,0,0.1);\r\n }\r\n\r\n h1 {\r\n text-align: center;\r\n font-weight: 600;\r\n margin-bottom: 30px;\r\n color: #1e293b;\r\n }\r\n\r\n .section {\r\n margin-bottom: 30px;\r\n border-bottom: 1px solid #e2e8f0;\r\n padding-bottom: 20px;\r\n }\r\n\r\n .section:last-child {\r\n border-bottom: none;\r\n }\r\n\r\n .section-title {\r\n font-size: 1.3rem;\r\n font-weight: 600;\r\n color: #0f172a;\r\n margin-bottom: 20px;\r\n }\r\n\r\n label {\r\n display: block;\r\n font-weight: 600;\r\n margin-bottom: 8px;\r\n }\r\n\r\n input[type=\"text\"],\r\n input[type=\"email\"],\r\n input[type=\"tel\"],\r\n input[type=\"date\"],\r\n select,\r\n textarea {\r\n width: 100%;\r\n padding: 12px 14px;\r\n border: 1.6px solid #cbd5e1;\r\n border-radius: 10px;\r\n font-size: 1rem;\r\n color: #334155;\r\n font-family: 'Open Sans', sans-serif;\r\n resize: vertical;\r\n }\r\n\r\n input[type=\"text\"]:focus,\r\n input[type=\"email\"]:focus,\r\n input[type=\"tel\"]:focus,\r\n input[type=\"date\"]:focus,\r\n select:focus,\r\n textarea:focus {\r\n outline: none;\r\n border-color: #2563eb;\r\n box-shadow: 0 0 6px #93c5fd;\r\n }\r\n\r\n .form-row {\r\n display: grid;\r\n grid-template-columns: 1fr 1fr;\r\n gap: 24px;\r\n }\r\n\r\n .full-width {\r\n grid-column: 1 \/ -1;\r\n }\r\n\r\n .checkbox-group,\r\n .radio-group {\r\n display: flex;\r\n flex-wrap: wrap;\r\n gap: 20px;\r\n margin-top: 10px;\r\n }\r\n\r\n .checkbox-item,\r\n .radio-item {\r\n display: flex;\r\n align-items: center;\r\n gap: 8px;\r\n }\r\n\r\n input[type=\"checkbox\"],\r\n input[type=\"radio\"] {\r\n width: 18px;\r\n height: 18px;\r\n cursor: pointer;\r\n }\r\n\r\n .submit-btn {\r\n margin-top: 30px;\r\n display: block;\r\n width: 100%;\r\n padding: 16px 0;\r\n font-size: 1.15rem;\r\n font-weight: 600;\r\n color: white;\r\n background-color: #2563eb;\r\n border: none;\r\n border-radius: 12px;\r\n cursor: pointer;\r\n transition: background 0.3s ease;\r\n }\r\n\r\n .submit-btn:hover {\r\n background-color: #1e40af;\r\n }\r\n\r\n .required {\r\n color: #dc2626;\r\n }\r\n\r\n @media (max-width: 700px) {\r\n .form-row {\r\n grid-template-columns: 1fr;\r\n }\r\n }\r\n<\/style>\r\n<\/head>\r\n<body>\r\n\r\n<div class=\"form-container\">\r\n <h1>Patient Enrollment Form<\/h1>\r\n\r\n <form action=\"mailto:info@linn.telehealthpractices.com\" method=\"post\" enctype=\"text\/plain\">\r\n \r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">I. Patient Information<\/h2>\r\n\r\n <label for=\"full_name\">Full Name <span class=\"required\">*<\/span><\/label>\r\n <input type=\"text\" id=\"full_name\" name=\"Full Name\" required>\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <label for=\"dob\">Date of Birth <span class=\"required\">*<\/span><\/label>\r\n <input type=\"date\" id=\"dob\" name=\"Date of Birth\" required>\r\n <\/div>\r\n <div>\r\n <label for=\"gender\">Gender Identity<\/label>\r\n <select id=\"gender\" name=\"Gender Identity\">\r\n <option value=\"\">Select...<\/option>\r\n <option value=\"Female\">Female<\/option>\r\n <option value=\"Male\">Male<\/option>\r\n <option value=\"Non-binary\">Non-binary<\/option>\r\n <option value=\"Other\">Other<\/option>\r\n <\/select>\r\n <\/div>\r\n <\/div>\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <label for=\"pronouns\">Preferred Pronouns<\/label>\r\n <input type=\"text\" id=\"pronouns\" name=\"Preferred Pronouns\">\r\n <\/div>\r\n <div>\r\n <label for=\"marital_status\">Marital Status<\/label>\r\n <select id=\"marital_status\" name=\"Marital Status\">\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 <\/div>\r\n <\/div>\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <label for=\"occupation\">Occupation<\/label>\r\n <input type=\"text\" id=\"occupation\" name=\"Occupation\">\r\n <\/div>\r\n <div>\r\n <label for=\"employer\">Employer<\/label>\r\n <input type=\"text\" id=\"employer\" name=\"Employer\">\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">II. Contact Details<\/h2>\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <label for=\"phone\">Primary Phone Number <span class=\"required\">*<\/span><\/label>\r\n <input type=\"tel\" id=\"phone\" name=\"Primary Phone Number\" required>\r\n <\/div>\r\n <div>\r\n <label for=\"email\">Email Address <span class=\"required\">*<\/span><\/label>\r\n <input type=\"email\" id=\"email\" name=\"Email Address\" required>\r\n <\/div>\r\n <\/div>\r\n\r\n <label for=\"address\">Mailing Address<\/label>\r\n <input type=\"text\" id=\"address\" name=\"Mailing Address\">\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <input type=\"text\" id=\"city\" name=\"City\" placeholder=\"City\">\r\n <\/div>\r\n <div>\r\n <input type=\"text\" id=\"state\" name=\"State\" placeholder=\"State\">\r\n <\/div>\r\n <\/div>\r\n\r\n <label for=\"zip\" style=\"max-width: 200px;\">Zip Code<\/label>\r\n <input type=\"text\" id=\"zip\" name=\"Zip Code\" style=\"max-width: 200px;\">\r\n\r\n <label>Preferred Contact Method<\/label>\r\n <div class=\"radio-group\">\r\n <label class=\"radio-item\">\r\n <input type=\"radio\" name=\"Preferred Contact Method\" value=\"Phone\"> Phone\r\n <\/label>\r\n <label class=\"radio-item\">\r\n <input type=\"radio\" name=\"Preferred Contact Method\" value=\"Text\"> Text\r\n <\/label>\r\n <label class=\"radio-item\">\r\n <input type=\"radio\" name=\"Preferred Contact Method\" value=\"Email\"> Email\r\n <\/label>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">III. Emergency Contact<\/h2>\r\n\r\n <label for=\"emergency_name\">Full Name<\/label>\r\n <input type=\"text\" id=\"emergency_name\" name=\"Emergency Contact Full Name\">\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <label for=\"emergency_relationship\">Relationship<\/label>\r\n <input type=\"text\" id=\"emergency_relationship\" name=\"Emergency Contact Relationship\">\r\n <\/div>\r\n <div>\r\n <label for=\"emergency_phone\">Phone Number<\/label>\r\n <input type=\"tel\" id=\"emergency_phone\" name=\"Emergency Contact Phone Number\">\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">IV. Referral Information<\/h2>\r\n\r\n <label>How did you hear about us?<\/label>\r\n <div class=\"checkbox-group\">\r\n <label class=\"checkbox-item\">\r\n <input type=\"checkbox\" name=\"Referral - Website\" value=\"Website\"> Website\r\n <\/label>\r\n <label class=\"checkbox-item\">\r\n <input type=\"checkbox\" name=\"Referral - Social Media\" value=\"Social Media\"> Social Media\r\n <\/label>\r\n <label class=\"checkbox-item\">\r\n <input type=\"checkbox\" name=\"Referral - Friend\/Family\" value=\"Friend\/Family\"> Friend\/Family\r\n <\/label>\r\n <label class=\"checkbox-item\">\r\n <input type=\"checkbox\" name=\"Referral - Practitioner\" value=\"Practitioner\"> Practitioner\r\n <\/label>\r\n <label class=\"checkbox-item\">\r\n <input type=\"checkbox\" name=\"Referral - Event\" value=\"Event\"> Event\r\n <\/label>\r\n <\/div>\r\n <input type=\"text\" name=\"Referral - Other\" placeholder=\"Other (please specify)\" style=\"margin-top: 10px;\">\r\n <\/div>\r\n\r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">V. Health Information<\/h2>\r\n\r\n <label>Are you currently under the care of a physician or mental health professional?<\/label>\r\n <div class=\"radio-group\">\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Under Care\" value=\"Yes\"> Yes<\/label>\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Under Care\" value=\"No\"> No<\/label>\r\n <\/div>\r\n <textarea name=\"Care Explanation\" placeholder=\"If yes, please explain...\" style=\"margin-top:10px;\"><\/textarea>\r\n\r\n <label>Are you taking any medications or supplements?<\/label>\r\n <div class=\"radio-group\">\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Taking Medications\" value=\"Yes\"> Yes<\/label>\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Taking Medications\" value=\"No\"> No<\/label>\r\n <\/div>\r\n <textarea name=\"Medication List\" placeholder=\"If yes, please list...\" style=\"margin-top:10px;\"><\/textarea>\r\n\r\n <label>Have you had any recent surgeries, diagnoses, or major health concerns?<\/label>\r\n <div class=\"radio-group\">\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Recent Health\" value=\"Yes\"> Yes<\/label>\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Recent Health\" value=\"No\"> No<\/label>\r\n <\/div>\r\n <textarea name=\"Health Description\" placeholder=\"If yes, please describe...\" style=\"margin-top:10px;\"><\/textarea>\r\n\r\n <label>Are you currently pregnant?<\/label>\r\n <div class=\"radio-group\">\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Pregnant\" value=\"Yes\"> Yes<\/label>\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Pregnant\" value=\"No\"> No<\/label>\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Pregnant\" value=\"N\/A\"> 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=\"checkbox-group\" style=\"flex-wrap: wrap;\">\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - Chronic Pain\" value=\"Yes\"> Chronic Pain<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - Anxiety\" value=\"Yes\"> Anxiety<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - Depression\" value=\"Yes\"> Depression<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - High Blood Pressure\" value=\"Yes\"> High Blood Pressure<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - PTSD\" value=\"Yes\"> PTSD<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - Autoimmune Disorder\" value=\"Yes\"> Autoimmune Disorder<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - Cancer\" value=\"Yes\"> Cancer<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - Diabetes\" value=\"Yes\"> Diabetes<\/label>\r\n <\/div>\r\n <input type=\"text\" name=\"History - Other\" placeholder=\"Other (please specify)\" style=\"margin-top: 10px;\">\r\n <\/div>\r\n\r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">VI. Wellness Goals & Intentions<\/h2>\r\n\r\n <label for=\"reason\">What brings you in today? (Optional)<\/label>\r\n <textarea name=\"Reason\" id=\"reason\" placeholder=\"Please explain your goals or concerns\"><\/textarea>\r\n\r\n <label>Primary goals for our sessions (check all that apply):<\/label>\r\n <div class=\"checkbox-group\" style=\"flex-wrap: wrap;\">\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Stress Relief\" value=\"Yes\"> Stress Relief<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Emotional Healing\" value=\"Yes\"> Emotional Healing<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Pain Management\" value=\"Yes\"> Pain Management<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Spiritual Connection\" value=\"Yes\"> Spiritual Connection<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Chakra Balancing\" value=\"Yes\"> Chakra Balancing<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Energy Clearing\" value=\"Yes\"> Energy Clearing<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Chronic Disease Management\" value=\"Yes\"> Chronic Dis-Ease Management<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Autoimmune Relief\" value=\"Yes\"> Autoimmune Dis-Ease Relief<\/label>\r\n <\/div>\r\n <input type=\"text\" name=\"Goals - Other\" placeholder=\"Other (please specify)\" style=\"margin-top: 10px;\">\r\n <\/div>\r\n\r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">VII. Consent & Acknowledgement<\/h2>\r\n\r\n <p style=\"font-size: 0.95rem; color: #475569; line-height: 1.5;\">\r\n I acknowledge that the services provided are not a substitute for medical care and do not diagnose, treat, or cure disease.\r\n I understand that I should consult with my healthcare provider for any medical concerns.<br><br>\r\n I give permission to be contacted for appointment reminders, wellness updates, or follow-ups.\r\n <\/p>\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <label for=\"signature\">Signature <span class=\"required\">*<\/span><\/label>\r\n <input type=\"text\" id=\"signature\" name=\"Signature\" placeholder=\"Type your full name\" required>\r\n <\/div>\r\n <div>\r\n <label for=\"consent_date\">Date <span class=\"required\">*<\/span><\/label>\r\n <input type=\"date\" id=\"consent_date\" name=\"Date\" required>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n <button type=\"submit\" class=\"submit-btn\">Submit Enrollment Form<\/button>\r\n\r\n <\/form>\r\n<\/div>\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 Select…FemaleMaleNon-binaryOther Preferred Pronouns Marital Status Select…SingleMarriedDivorcedWidowed Occupation Employer II. Contact Details Primary Phone Number * Email Address * Mailing Address Zip Code Preferred Contact Method Phone Text Email III. Emergency Contact Full Name Relationship Phone Number IV. […]<\/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-1127","page","type-page","status-publish","hentry"],"blocksy_meta":[],"_links":{"self":[{"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/1127","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1127"}],"version-history":[{"count":7,"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/1127\/revisions"}],"predecessor-version":[{"id":1355,"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/1127\/revisions\/1355"}],"wp:attachment":[{"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1127"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}

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\n\t\t\t\t\t\r\n\r\n\r\n\r\n\r\nPatient Enrollment Form<\/title>\r\n<style>\r\n @import url('https:\/\/fonts.googleapis.com\/css2?family=Open+Sans:wght@400;600&display=swap');\r\n\r\n body {\r\n font-family: 'Open Sans', sans-serif;\r\n background-color: #f3f7fb;\r\n margin: 0;\r\n padding: 40px 20px;\r\n color: #344054;\r\n }\r\n\r\n .form-container {\r\n max-width: 800px;\r\n margin: 0 auto;\r\n background-color: white;\r\n border-radius: 14px;\r\n padding: 40px 36px;\r\n box-shadow: 0 4px 15px rgba(0,0,0,0.1);\r\n }\r\n\r\n h1 {\r\n text-align: center;\r\n font-weight: 600;\r\n margin-bottom: 30px;\r\n color: #1e293b;\r\n }\r\n\r\n .section {\r\n margin-bottom: 30px;\r\n border-bottom: 1px solid #e2e8f0;\r\n padding-bottom: 20px;\r\n }\r\n\r\n .section:last-child {\r\n border-bottom: none;\r\n }\r\n\r\n .section-title {\r\n font-size: 1.3rem;\r\n font-weight: 600;\r\n color: #0f172a;\r\n margin-bottom: 20px;\r\n }\r\n\r\n label {\r\n display: block;\r\n font-weight: 600;\r\n margin-bottom: 8px;\r\n }\r\n\r\n input[type=\"text\"],\r\n input[type=\"email\"],\r\n input[type=\"tel\"],\r\n input[type=\"date\"],\r\n select,\r\n textarea {\r\n width: 100%;\r\n padding: 12px 14px;\r\n border: 1.6px solid #cbd5e1;\r\n border-radius: 10px;\r\n font-size: 1rem;\r\n color: #334155;\r\n font-family: 'Open Sans', sans-serif;\r\n resize: vertical;\r\n }\r\n\r\n input[type=\"text\"]:focus,\r\n input[type=\"email\"]:focus,\r\n input[type=\"tel\"]:focus,\r\n input[type=\"date\"]:focus,\r\n select:focus,\r\n textarea:focus {\r\n outline: none;\r\n border-color: #2563eb;\r\n box-shadow: 0 0 6px #93c5fd;\r\n }\r\n\r\n .form-row {\r\n display: grid;\r\n grid-template-columns: 1fr 1fr;\r\n gap: 24px;\r\n }\r\n\r\n .full-width {\r\n grid-column: 1 \/ -1;\r\n }\r\n\r\n .checkbox-group,\r\n .radio-group {\r\n display: flex;\r\n flex-wrap: wrap;\r\n gap: 20px;\r\n margin-top: 10px;\r\n }\r\n\r\n .checkbox-item,\r\n .radio-item {\r\n display: flex;\r\n align-items: center;\r\n gap: 8px;\r\n }\r\n\r\n input[type=\"checkbox\"],\r\n input[type=\"radio\"] {\r\n width: 18px;\r\n height: 18px;\r\n cursor: pointer;\r\n }\r\n\r\n .submit-btn {\r\n margin-top: 30px;\r\n display: block;\r\n width: 100%;\r\n padding: 16px 0;\r\n font-size: 1.15rem;\r\n font-weight: 600;\r\n color: white;\r\n background-color: #2563eb;\r\n border: none;\r\n border-radius: 12px;\r\n cursor: pointer;\r\n transition: background 0.3s ease;\r\n }\r\n\r\n .submit-btn:hover {\r\n background-color: #1e40af;\r\n }\r\n\r\n .required {\r\n color: #dc2626;\r\n }\r\n\r\n @media (max-width: 700px) {\r\n .form-row {\r\n grid-template-columns: 1fr;\r\n }\r\n }\r\n<\/style>\r\n<\/head>\r\n<body>\r\n\r\n<div class=\"form-container\">\r\n <h1>Patient Enrollment Form<\/h1>\r\n\r\n <form action=\"mailto:info@linn.telehealthpractices.com\" method=\"post\" enctype=\"text\/plain\">\r\n \r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">I. Patient Information<\/h2>\r\n\r\n <label for=\"full_name\">Full Name <span class=\"required\">*<\/span><\/label>\r\n <input type=\"text\" id=\"full_name\" name=\"Full Name\" required>\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <label for=\"dob\">Date of Birth <span class=\"required\">*<\/span><\/label>\r\n <input type=\"date\" id=\"dob\" name=\"Date of Birth\" required>\r\n <\/div>\r\n <div>\r\n <label for=\"gender\">Gender Identity<\/label>\r\n <select id=\"gender\" name=\"Gender Identity\">\r\n <option value=\"\">Select...<\/option>\r\n <option value=\"Female\">Female<\/option>\r\n <option value=\"Male\">Male<\/option>\r\n <option value=\"Non-binary\">Non-binary<\/option>\r\n <option value=\"Other\">Other<\/option>\r\n <\/select>\r\n <\/div>\r\n <\/div>\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <label for=\"pronouns\">Preferred Pronouns<\/label>\r\n <input type=\"text\" id=\"pronouns\" name=\"Preferred Pronouns\">\r\n <\/div>\r\n <div>\r\n <label for=\"marital_status\">Marital Status<\/label>\r\n <select id=\"marital_status\" name=\"Marital Status\">\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 <\/div>\r\n <\/div>\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <label for=\"occupation\">Occupation<\/label>\r\n <input type=\"text\" id=\"occupation\" name=\"Occupation\">\r\n <\/div>\r\n <div>\r\n <label for=\"employer\">Employer<\/label>\r\n <input type=\"text\" id=\"employer\" name=\"Employer\">\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">II. Contact Details<\/h2>\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <label for=\"phone\">Primary Phone Number <span class=\"required\">*<\/span><\/label>\r\n <input type=\"tel\" id=\"phone\" name=\"Primary Phone Number\" required>\r\n <\/div>\r\n <div>\r\n <label for=\"email\">Email Address <span class=\"required\">*<\/span><\/label>\r\n <input type=\"email\" id=\"email\" name=\"Email Address\" required>\r\n <\/div>\r\n <\/div>\r\n\r\n <label for=\"address\">Mailing Address<\/label>\r\n <input type=\"text\" id=\"address\" name=\"Mailing Address\">\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <input type=\"text\" id=\"city\" name=\"City\" placeholder=\"City\">\r\n <\/div>\r\n <div>\r\n <input type=\"text\" id=\"state\" name=\"State\" placeholder=\"State\">\r\n <\/div>\r\n <\/div>\r\n\r\n <label for=\"zip\" style=\"max-width: 200px;\">Zip Code<\/label>\r\n <input type=\"text\" id=\"zip\" name=\"Zip Code\" style=\"max-width: 200px;\">\r\n\r\n <label>Preferred Contact Method<\/label>\r\n <div class=\"radio-group\">\r\n <label class=\"radio-item\">\r\n <input type=\"radio\" name=\"Preferred Contact Method\" value=\"Phone\"> Phone\r\n <\/label>\r\n <label class=\"radio-item\">\r\n <input type=\"radio\" name=\"Preferred Contact Method\" value=\"Text\"> Text\r\n <\/label>\r\n <label class=\"radio-item\">\r\n <input type=\"radio\" name=\"Preferred Contact Method\" value=\"Email\"> Email\r\n <\/label>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">III. Emergency Contact<\/h2>\r\n\r\n <label for=\"emergency_name\">Full Name<\/label>\r\n <input type=\"text\" id=\"emergency_name\" name=\"Emergency Contact Full Name\">\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <label for=\"emergency_relationship\">Relationship<\/label>\r\n <input type=\"text\" id=\"emergency_relationship\" name=\"Emergency Contact Relationship\">\r\n <\/div>\r\n <div>\r\n <label for=\"emergency_phone\">Phone Number<\/label>\r\n <input type=\"tel\" id=\"emergency_phone\" name=\"Emergency Contact Phone Number\">\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">IV. Referral Information<\/h2>\r\n\r\n <label>How did you hear about us?<\/label>\r\n <div class=\"checkbox-group\">\r\n <label class=\"checkbox-item\">\r\n <input type=\"checkbox\" name=\"Referral - Website\" value=\"Website\"> Website\r\n <\/label>\r\n <label class=\"checkbox-item\">\r\n <input type=\"checkbox\" name=\"Referral - Social Media\" value=\"Social Media\"> Social Media\r\n <\/label>\r\n <label class=\"checkbox-item\">\r\n <input type=\"checkbox\" name=\"Referral - Friend\/Family\" value=\"Friend\/Family\"> Friend\/Family\r\n <\/label>\r\n <label class=\"checkbox-item\">\r\n <input type=\"checkbox\" name=\"Referral - Practitioner\" value=\"Practitioner\"> Practitioner\r\n <\/label>\r\n <label class=\"checkbox-item\">\r\n <input type=\"checkbox\" name=\"Referral - Event\" value=\"Event\"> Event\r\n <\/label>\r\n <\/div>\r\n <input type=\"text\" name=\"Referral - Other\" placeholder=\"Other (please specify)\" style=\"margin-top: 10px;\">\r\n <\/div>\r\n\r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">V. Health Information<\/h2>\r\n\r\n <label>Are you currently under the care of a physician or mental health professional?<\/label>\r\n <div class=\"radio-group\">\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Under Care\" value=\"Yes\"> Yes<\/label>\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Under Care\" value=\"No\"> No<\/label>\r\n <\/div>\r\n <textarea name=\"Care Explanation\" placeholder=\"If yes, please explain...\" style=\"margin-top:10px;\"><\/textarea>\r\n\r\n <label>Are you taking any medications or supplements?<\/label>\r\n <div class=\"radio-group\">\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Taking Medications\" value=\"Yes\"> Yes<\/label>\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Taking Medications\" value=\"No\"> No<\/label>\r\n <\/div>\r\n <textarea name=\"Medication List\" placeholder=\"If yes, please list...\" style=\"margin-top:10px;\"><\/textarea>\r\n\r\n <label>Have you had any recent surgeries, diagnoses, or major health concerns?<\/label>\r\n <div class=\"radio-group\">\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Recent Health\" value=\"Yes\"> Yes<\/label>\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Recent Health\" value=\"No\"> No<\/label>\r\n <\/div>\r\n <textarea name=\"Health Description\" placeholder=\"If yes, please describe...\" style=\"margin-top:10px;\"><\/textarea>\r\n\r\n <label>Are you currently pregnant?<\/label>\r\n <div class=\"radio-group\">\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Pregnant\" value=\"Yes\"> Yes<\/label>\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Pregnant\" value=\"No\"> No<\/label>\r\n <label class=\"radio-item\"><input type=\"radio\" name=\"Pregnant\" value=\"N\/A\"> 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=\"checkbox-group\" style=\"flex-wrap: wrap;\">\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - Chronic Pain\" value=\"Yes\"> Chronic Pain<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - Anxiety\" value=\"Yes\"> Anxiety<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - Depression\" value=\"Yes\"> Depression<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - High Blood Pressure\" value=\"Yes\"> High Blood Pressure<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - PTSD\" value=\"Yes\"> PTSD<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - Autoimmune Disorder\" value=\"Yes\"> Autoimmune Disorder<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - Cancer\" value=\"Yes\"> Cancer<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"History - Diabetes\" value=\"Yes\"> Diabetes<\/label>\r\n <\/div>\r\n <input type=\"text\" name=\"History - Other\" placeholder=\"Other (please specify)\" style=\"margin-top: 10px;\">\r\n <\/div>\r\n\r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">VI. Wellness Goals & Intentions<\/h2>\r\n\r\n <label for=\"reason\">What brings you in today? (Optional)<\/label>\r\n <textarea name=\"Reason\" id=\"reason\" placeholder=\"Please explain your goals or concerns\"><\/textarea>\r\n\r\n <label>Primary goals for our sessions (check all that apply):<\/label>\r\n <div class=\"checkbox-group\" style=\"flex-wrap: wrap;\">\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Stress Relief\" value=\"Yes\"> Stress Relief<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Emotional Healing\" value=\"Yes\"> Emotional Healing<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Pain Management\" value=\"Yes\"> Pain Management<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Spiritual Connection\" value=\"Yes\"> Spiritual Connection<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Chakra Balancing\" value=\"Yes\"> Chakra Balancing<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Energy Clearing\" value=\"Yes\"> Energy Clearing<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Chronic Disease Management\" value=\"Yes\"> Chronic Dis-Ease Management<\/label>\r\n <label class=\"checkbox-item\"><input type=\"checkbox\" name=\"Goals - Autoimmune Relief\" value=\"Yes\"> Autoimmune Dis-Ease Relief<\/label>\r\n <\/div>\r\n <input type=\"text\" name=\"Goals - Other\" placeholder=\"Other (please specify)\" style=\"margin-top: 10px;\">\r\n <\/div>\r\n\r\n \r\n <div class=\"section\">\r\n <h2 class=\"section-title\">VII. Consent & Acknowledgement<\/h2>\r\n\r\n <p style=\"font-size: 0.95rem; color: #475569; line-height: 1.5;\">\r\n I acknowledge that the services provided are not a substitute for medical care and do not diagnose, treat, or cure disease.\r\n I understand that I should consult with my healthcare provider for any medical concerns.<br><br>\r\n I give permission to be contacted for appointment reminders, wellness updates, or follow-ups.\r\n <\/p>\r\n\r\n <div class=\"form-row\">\r\n <div>\r\n <label for=\"signature\">Signature <span class=\"required\">*<\/span><\/label>\r\n <input type=\"text\" id=\"signature\" name=\"Signature\" placeholder=\"Type your full name\" required>\r\n <\/div>\r\n <div>\r\n <label for=\"consent_date\">Date <span class=\"required\">*<\/span><\/label>\r\n <input type=\"date\" id=\"consent_date\" name=\"Date\" required>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n <button type=\"submit\" class=\"submit-btn\">Submit Enrollment Form<\/button>\r\n\r\n <\/form>\r\n<\/div>\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 Select…FemaleMaleNon-binaryOther Preferred Pronouns Marital Status Select…SingleMarriedDivorcedWidowed Occupation Employer II. Contact Details Primary Phone Number * Email Address * Mailing Address Zip Code Preferred Contact Method Phone Text Email III. Emergency Contact Full Name Relationship Phone Number IV. […]<\/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-1127","page","type-page","status-publish","hentry"],"blocksy_meta":[],"_links":{"self":[{"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/1127","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1127"}],"version-history":[{"count":7,"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/1127\/revisions"}],"predecessor-version":[{"id":1355,"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/1127\/revisions\/1355"}],"wp:attachment":[{"href":"https:\/\/linn.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1127"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}