{"id":275,"date":"2020-04-23T18:01:04","date_gmt":"2020-04-23T18:01:04","guid":{"rendered":"https:\/\/www.angelscarehospice.com\/?page_id=275"},"modified":"2023-05-09T19:23:39","modified_gmt":"2023-05-09T19:23:39","slug":"community-referral-form","status":"publish","type":"page","link":"https:\/\/www.angelscarehospice.com\/community\/community-referral-form\/","title":{"rendered":"Community Referral Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"275\" class=\"elementor elementor-275\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2eca9fc elementor-section-height-min-height elementor-section-stretched elementor-section-full_width elementor-section-height-default elementor-section-items-middle\" data-id=\"2eca9fc\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-f2c036e\" data-id=\"f2c036e\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4e2808a elementor-widget elementor-widget-heading\" data-id=\"4e2808a\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Community Referral Form<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-eda772e\" data-id=\"eda772e\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-61f34514 elementor-section-stretched elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"61f34514\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-74a8cc9c\" data-id=\"74a8cc9c\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-13297cb elementor-widget elementor-widget-shortcode\" data-id=\"13297cb\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><div class='fluentform ff-default fluentform_wrapper_3 ffs_default_wrap'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-top ff_form_instance_3_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Community Referral Form<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='275' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"dd686e4931\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/275\" \/><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_Office_Location' aria-label=\"Office Location\">Office Location<\/label><\/div><div class='ff-el-input--content'><select name=\"Office_Location\" id=\"ff_3_Office_Location\" class=\"ff-el-form-control\" data-name=\"Office_Location\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Select A Office Location -<\/option><option value=\"Bay City, TX\"  >Bay City, TX<\/option><option value=\"Broken Arrow, OK\"  >Broken Arrow, OK<\/option><option value=\"Emporia, KS\"  >Emporia, KS<\/option><option value=\"Midland, TX\"  >Midland, TX<\/option><option value=\"Omaha, NE\"  >Omaha, NE<\/option><option value=\"Prescott, AZ\"  >Prescott, AZ<\/option><option value=\"San Angelo, TX\"  >San Angelo, TX<\/option><option value=\"Wichita, KS\"  >Wichita, KS<\/option><option value=\"Wichita Falls, TX\"  >Wichita Falls, TX<\/option><\/select><\/div><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_first_name_' aria-label=\"First Name\">First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_3_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"First Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_last_name_' aria-label=\"Last Name\">Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_3_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Last Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_3_email\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_Phone_Number' aria-label=\"Phone Number\">Phone Number<\/label><\/div><div class='ff-el-input--content'><input name=\"Phone_Number\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"Phone_Number\" id=\"ff_3_Phone_Number\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--label'><label aria-label=Address>Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_1_address_line_1_' aria-label=\"Address Line 1\">Address Line 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_3_address_1_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Address Line 1\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_1_address_line_2_' aria-label=\"Address Line 2\">Address Line 2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_2]\" id=\"ff_3_address_1_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Address Line 2\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_3_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_1_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[state]\" id=\"ff_3_address_1_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_1_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_3_address_1_zip_\" class=\"ff-el-form-control\" placeholder=\"Zip\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Are You A\">Are You A<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for=Are_You_A_88fdbda86f3f5e272e56c9ef078d5ee5><input  type=\"checkbox\" name=\"Are_You_A[]\" data-name=\"Are_You_A\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" checked=\"1\" value=\"Patient\"  id='Are_You_A_88fdbda86f3f5e272e56c9ef078d5ee5' aria-label='Patient' aria-invalid='false' aria-required=false> <span>Patient<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=Are_You_A_fa37130b6dd1ed439810dd5c8e7fcbcb><input  type=\"checkbox\" name=\"Are_You_A[]\" data-name=\"Are_You_A\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Caregiver\"  id='Are_You_A_fa37130b6dd1ed439810dd5c8e7fcbcb' aria-label='Caregiver' aria-invalid='false' aria-required=false> <span>Caregiver<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=Are_You_A_e51c2f1544043dd09064d6d052121a16><input  type=\"checkbox\" name=\"Are_You_A[]\" data-name=\"Are_You_A\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Family \/ Friend\"  id='Are_You_A_e51c2f1544043dd09064d6d052121a16' aria-label='Family \/ Friend' aria-invalid='false' aria-required=false> <span>Family \/ Friend<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_description' aria-label=\"Message\">Message<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=true name=\"description\" id=\"ff_3_description\" class=\"ff-el-form-control\" rows=\"5\" cols=\"2\" data-name=\"description\" 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<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Community Referral 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