{"id":5389,"date":"2024-03-18T07:28:53","date_gmt":"2024-03-18T07:28:53","guid":{"rendered":"https:\/\/optimaafyaclinic.com\/?page_id=5389"},"modified":"2024-03-18T07:36:39","modified_gmt":"2024-03-18T07:36:39","slug":"make-a-referral","status":"publish","type":"page","link":"https:\/\/optimaafyaclinic.com\/?page_id=5389","title":{"rendered":"Make a referral"},"content":{"rendered":"<p>[et_pb_section admin_label=&#8221;section&#8221;]<br \/>\n\t\t\t[et_pb_row admin_label=&#8221;row&#8221;]<br \/>\n\t\t\t\t[et_pb_column type=&#8221;4_4&#8243;][et_pb_text admin_label=&#8221;Text&#8221;]<style id=\"wpforms-css-vars-5391\">\n\t\t\t\t#wpforms-5391 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-5391\"><form id=\"wpforms-form-5391\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"5391\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F5389\" data-token=\"aedefeea123b9ddb208204373592bab9\" data-token-time=\"1784607437\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-5391-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_3\">Enter referring agency\/Individual here <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-5391-field_3-error\" required><\/div><div id=\"wpforms-5391-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-5391-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-5391-field_0-error\" required><label for=\"wpforms-5391-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-5391-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-5391-field_0-last-error\" required><label for=\"wpforms-5391-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-5391-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_1\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-5391-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" aria-errormessage=\"wpforms-5391-field_1-error\" required><\/div><div id=\"wpforms-5391-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_2\">Message <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-5391-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-5391-field_2-error\" required><\/textarea><\/div><div id=\"wpforms-5391-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_4\">Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-5391-field_4-error\" required><\/div><div id=\"wpforms-5391-field_5-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Gender<\/legend><ul id=\"wpforms-5391-field_5\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-5391-field_5_1\" name=\"wpforms[fields][5]\" value=\"Male\" aria-errormessage=\"wpforms-5391-field_5_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5391-field_5_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-5391-field_5_2\" name=\"wpforms[fields][5]\" value=\"Female\" aria-errormessage=\"wpforms-5391-field_5_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5391-field_5_2\">Female<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-5391-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_6\">Home Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-5391-field_6-error\" required><\/div><div id=\"wpforms-5391-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_7\">City <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-5391-field_7-error\" required><\/div><div id=\"wpforms-5391-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_8\">State <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-5391-field_8-error\" required><\/div><div id=\"wpforms-5391-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_9\">SSN <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-5391-field_9-error\" required><\/div><div id=\"wpforms-5391-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_10\">ZIP Postal Code <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-5391-field_10-error\" required><\/div><div id=\"wpforms-5391-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_11\">Family\/Emergency Phone number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-5391-field_11-error\" required><\/div><div id=\"wpforms-5391-field_12-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-5391-field_12\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][12][first]\" aria-errormessage=\"wpforms-5391-field_12-error\" required><label for=\"wpforms-5391-field_12\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-5391-field_12-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][12][last]\" aria-errormessage=\"wpforms-5391-field_12-last-error\" required><label for=\"wpforms-5391-field_12-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-5391-field_13-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_13\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-5391-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" spellcheck=\"false\" aria-errormessage=\"wpforms-5391-field_13-error\" required><\/div><div id=\"wpforms-5391-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_14\">Insurance<\/label><select id=\"wpforms-5391-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\"><option value=\"Medicad\"  class=\"choice-1 depth-1\"  >Medicad<\/option><option value=\"Molina\"  class=\"choice-2 depth-1\"  >Molina<\/option><option value=\"Superior\"  class=\"choice-3 depth-1\"  >Superior<\/option><option value=\"BCBS of TX\"  class=\"choice-4 depth-1\"  >BCBS of TX<\/option><option value=\"Other\"  class=\"choice-5 depth-1\"  >Other<\/option><\/select><\/div><div id=\"wpforms-5391-field_16-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_16\">Any known Medical Conditions <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-5391-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-5391-field_16-error\" required><\/textarea><\/div><div id=\"wpforms-5391-field_17-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_17\">Reason Of referral <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-5391-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-5391-field_17-error\" required><\/textarea><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"5391\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/optimaafyaclinic.com\/index.php?rest_route=\/wp\/v2\/pages\/5389\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-5391\" class=\"wpforms-submit\" data-alt-text=\"Sending\u2026\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/optimaafyaclinic.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->[\/et_pb_text][\/et_pb_column]<br \/>\n\t\t\t[\/et_pb_row]<br \/>\n\t\t[\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<style id=\"wpforms-css-vars-5391\">\n\t\t\t\t#wpforms-5391 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-5391\"><form id=\"wpforms-form-5391\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"5391\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F5389\" data-token=\"aedefeea123b9ddb208204373592bab9\" data-token-time=\"1784607437\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-5391-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_3\">Enter referring agency\/Individual here <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-5391-field_3-error\" required><\/div><div id=\"wpforms-5391-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-5391-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-5391-field_0-error\" required><label for=\"wpforms-5391-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-5391-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-5391-field_0-last-error\" required><label for=\"wpforms-5391-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-5391-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_1\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-5391-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" aria-errormessage=\"wpforms-5391-field_1-error\" required><\/div><div id=\"wpforms-5391-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_2\">Message <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-5391-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-5391-field_2-error\" required><\/textarea><\/div><div id=\"wpforms-5391-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_4\">Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-5391-field_4-error\" required><\/div><div id=\"wpforms-5391-field_5-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Gender<\/legend><ul id=\"wpforms-5391-field_5\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-5391-field_5_1\" name=\"wpforms[fields][5]\" value=\"Male\" aria-errormessage=\"wpforms-5391-field_5_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5391-field_5_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-5391-field_5_2\" name=\"wpforms[fields][5]\" value=\"Female\" aria-errormessage=\"wpforms-5391-field_5_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5391-field_5_2\">Female<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-5391-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_6\">Home Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-5391-field_6-error\" required><\/div><div id=\"wpforms-5391-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_7\">City <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-5391-field_7-error\" required><\/div><div id=\"wpforms-5391-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_8\">State <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-5391-field_8-error\" required><\/div><div id=\"wpforms-5391-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_9\">SSN <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-5391-field_9-error\" required><\/div><div id=\"wpforms-5391-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_10\">ZIP Postal Code <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-5391-field_10-error\" required><\/div><div id=\"wpforms-5391-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_11\">Family\/Emergency Phone number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5391-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-5391-field_11-error\" required><\/div><div id=\"wpforms-5391-field_12-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-5391-field_12\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][12][first]\" aria-errormessage=\"wpforms-5391-field_12-error\" required><label for=\"wpforms-5391-field_12\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-5391-field_12-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][12][last]\" aria-errormessage=\"wpforms-5391-field_12-last-error\" required><label for=\"wpforms-5391-field_12-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-5391-field_13-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_13\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-5391-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" spellcheck=\"false\" aria-errormessage=\"wpforms-5391-field_13-error\" required><\/div><div id=\"wpforms-5391-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_14\">Insurance<\/label><select id=\"wpforms-5391-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\"><option value=\"Medicad\"  class=\"choice-1 depth-1\"  >Medicad<\/option><option value=\"Molina\"  class=\"choice-2 depth-1\"  >Molina<\/option><option value=\"Superior\"  class=\"choice-3 depth-1\"  >Superior<\/option><option value=\"BCBS of TX\"  class=\"choice-4 depth-1\"  >BCBS of TX<\/option><option value=\"Other\"  class=\"choice-5 depth-1\"  >Other<\/option><\/select><\/div><div id=\"wpforms-5391-field_16-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_16\">Any known Medical Conditions <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-5391-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-5391-field_16-error\" required><\/textarea><\/div><div id=\"wpforms-5391-field_17-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-5391-field_17\">Reason Of referral <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-5391-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-5391-field_17-error\" required><\/textarea><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" 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