{"id":39,"date":"2024-08-25T22:49:42","date_gmt":"2024-08-26T01:49:42","guid":{"rendered":"https:\/\/envyfilesolutions.ca\/?page_id=39"},"modified":"2024-08-25T22:49:42","modified_gmt":"2024-08-26T01:49:42","slug":"third-party-request","status":"publish","type":"page","link":"https:\/\/envyfilesolutions.ca\/?page_id=39","title":{"rendered":"Third Party Request"},"content":{"rendered":"\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-38 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-38\" data-uid=\"69dc77dd1112e\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-38\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-38 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"38\"\n\t\t\t\t\n\t\t\t\tdata-design=\"default\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\tenctype=\"multipart\/form-data\"\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"69dc77dd1112e\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69dc77dd1112e\" id=\"forminator-field-name-2_69dc77dd1112e-label\" class=\"forminator-label\">Requesting Party Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-2_69dc77dd1112e\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69dc77dd1112e\" id=\"forminator-field-name-1_69dc77dd1112e-label\" class=\"forminator-label\">Patient Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-1_69dc77dd1112e\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69dc77dd1112e\" id=\"forminator-field-date-1-picker_69dc77dd1112e-label\" class=\"forminator-label\">Date Of Birth <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_69dc77dd1112e\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69dc77dd1112e\" id=\"forminator-field-email-1_69dc77dd1112e-label\" class=\"forminator-label\">Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"E.g. john@doe.com\" id=\"forminator-field-email-1_69dc77dd1112e\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_69dc77dd1112e\" id=\"forminator-field-upload-1_69dc77dd1112e-label\" class=\"forminator-label\">Please Attach Patient Authorization <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-file-upload \" data-element=\"upload-1_69dc77dd1112e\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1_69dc77dd1112e\" class=\"forminator-input-file-required do-validate\" 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value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-39","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/envyfilesolutions.ca\/index.php?rest_route=\/wp\/v2\/pages\/39","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/envyfilesolutions.ca\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/envyfilesolutions.ca\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/envyfilesolutions.ca\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/envyfilesolutions.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=39"}],"version-history":[{"count":1,"href":"https:\/\/envyfilesolutions.ca\/index.php?rest_route=\/wp\/v2\/pages\/39\/revisions"}],"predecessor-version":[{"id":40,"href":"https:\/\/envyfilesolutions.ca\/index.php?rest_route=\/wp\/v2\/pages\/39\/revisions\/40"}],"wp:attachment":[{"href":"https:\/\/envyfilesolutions.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=39"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}