{"id":98,"date":"2016-09-27T23:57:32","date_gmt":"2016-09-27T23:57:32","guid":{"rendered":"http:\/\/plethorathemes.com\/healthflex\/dentist\/?page_id=98"},"modified":"2022-04-24T01:25:14","modified_gmt":"2022-04-24T01:25:14","slug":"request-an-appointment","status":"publish","type":"page","link":"https:\/\/surediagnosticonline.com\/web\/request-an-appointment\/","title":{"rendered":"Request an Appointment"},"content":{"rendered":"<p>[vc_row color_set=&#8221;skincolored_section&#8221; full_width=&#8221;0&#8243; full_height=&#8221;0&#8243; row_padding=&#8221;no_top_padding&#8221; background=&#8221;bgimage&#8221; parallax=&#8221;0&#8243; animation=&#8221;wow fadeIn&#8221;][vc_column][vc_empty_space]<div class=\"section_header subtitle_bottom   fancy text-center\">\n\n    <h3 style=\"text-align: center;\"><img loading=\"lazy\" class=\"alignnone wp-image-412 size-full\" src=\"https:\/\/surediagnosticonline.com\/web\/wp-content\/uploads\/2022\/04\/ic3.png\" alt=\"\" width=\"128\" height=\"128\" \/><br \/>\nREQUEST AN APPOINTMENT<\/h3>\n\n\n        <p >Fill in the form to request an a appointment!<\/p>\n<\/div>[\/vc_column][vc_column width=&#8221;1\/2&#8243; color_set=&#8221;dark_section&#8221; boxed=&#8221;boxed_plus&#8221;]<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f100-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/web\/wp-json\/wp\/v2\/pages\/98#wpcf7-f100-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"100\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.5.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f100-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<p><span class=\"wpcf7-form-control-wrap Name\"><input type=\"text\" name=\"Name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-form-control form-control wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Full Name\" \/><\/span><\/p>\n<p><span class=\"wpcf7-form-control-wrap sex\"><select name=\"sex\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Sex\">Sex<\/option><option value=\"Female\">Female<\/option><option value=\"Male\">Male<\/option><option value=\"Child\">Child<\/option><\/select><\/span> <\/p>\n<p><span class=\"wpcf7-form-control-wrap telephone\"><input type=\"text\" name=\"telephone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-form-control form-control wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone Number\" \/><\/span><\/p>\n<p><span class=\"wpcf7-form-control-wrap email\"><input type=\"email\" name=\"email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-form-control form-control wpcf7-form-control form-control wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email\" \/><\/span><\/p>\n<p><span class=\"wpcf7-form-control-wrap appointmentdate\"><input type=\"date\" name=\"appointmentdate\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Appointment Date\" \/><\/span><\/p>\n<p>Reason for visit<br \/><span class=\"wpcf7-form-control-wrap reason-for-visit\"><select name=\"reason-for-visit\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Health Check\">Health Check<\/option><option value=\"Medical Diagnostics Services\">Medical Diagnostics Services<\/option><option value=\"PATHOLOGY\">PATHOLOGY<\/option><option value=\"RADIOLOGY\">RADIOLOGY<\/option><option value=\"ECHO &amp; ECG\">ECHO &amp; ECG<\/option><option value=\"Others\">Others<\/option><\/select><\/span><\/p>\n<p><span class=\"wpcf7-form-control-wrap message\"><textarea name=\"message\" cols=\"40\" rows=\"4\" class=\"wpcf7-form-control wpcf7-form-control wpcf7-form-control form-control\" aria-invalid=\"false\" placeholder=\"Message\"><\/textarea><\/span> <\/p>\n<p><input type=\"submit\" value=\"Submit\" class=\"wpcf7-form-control has-spinner wpcf7-submit btn btn-primary\" \/><\/p>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>[\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_empty_space][vc_row_inner content_placement=&#8221;middle&#8221; gap=&#8221;1&#8243;][vc_column_inner width=&#8221;1\/3&#8243; offset=&#8221;vc_col-xs-6&#8243; css=&#8221;.vc_custom_1650763427371{padding-right: 5px !important;}&#8221;][\/vc_column_inner][vc_column_inner width=&#8221;1\/3&#8243; offset=&#8221;vc_col-xs-6&#8243;][vc_single_image image=&#8221;377&#8243; img_size=&#8221;medium&#8221; 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