{"id":10269,"date":"2022-01-13T07:24:16","date_gmt":"2022-01-13T12:24:16","guid":{"rendered":"https:\/\/586d3263a6.nxcli.net\/?page_id=234"},"modified":"2025-01-23T13:41:18","modified_gmt":"2025-01-23T13:41:18","slug":"physical-therapist-appointment","status":"publish","type":"page","link":"https:\/\/mainstreetpt.net\/sternen-physical-therapy\/physical-therapist-appointment\/","title":{"rendered":"Request Appointment"},"content":{"rendered":"\n<h2 class=\"wp-block-heading has-text-align-center\" id=\"request-appointment\"><strong>Request Appointment<\/strong><\/h2>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\">Once you submit the form below, a team member will contact you to schedule an appointment that best fits your needs.<\/p>\n\n\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1' class='appointment-form' action='\/sternen-physical-therapy\/wp-json\/wp\/v2\/pages\/10269' data-formid='1' novalidate>\t\t\t\t\t<div style=\"display: none !important;\" class=\"akismet-fields-container gf_invisible\" data-prefix=\"ak_\">\n\t\t\t\t\t\t<label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label>\n\t\t\t\t\t\t<input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"125\" \/>\n\t\t\t\t\t\t<script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n\n\t\t\t\t\t<\/div><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeW0OQeAAAAAIK2dfIXf7axEqQ3AuPB71QPfdxv' data-tabindex='0'><input id=\"input_9e4ac593f2b5cde8e633ad1c4ff5c880\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_9e4ac593f2b5cde8e633ad1c4ff5c880\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_11\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Company<\/label><div class='ginput_container'><input name='input_11' id='input_1_11' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_11'>This field is for validation purposes and should be left unchanged.<\/div><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label 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gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_1_4' type='tel' value='' class='large'  placeholder='Phone *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_1_3' type='email' value='' class='large'   placeholder='Email *' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half disable-gravity-pastdate gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_1_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Preferred Date *' aria-describedby=\"input_1_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                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<span id='input_1_9_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_9' class='gform_hidden' value='https:\/\/mainstreetpt.net\/sternen-physical-therapy\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>Briefly describe your reason for requesting an appointment.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_1_8' class='textarea large'    placeholder='Briefly describe your reason for requesting an appointment.'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_10\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_10.1' id='input_1_10_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_10_1' >By opting into SMS from a web form or other medium, you are agreeing to receive SMS messages from Sternen Physical Therapy. This includes SMS messages for customer care, marketing. Message frequency varies. Message and data rates may apply. See privacy policy at https:\/\/mainstreetpt.net\/sternen-physical-therapy\/privacy-policy\/. Message HELP for help. Reply STOP to any message to opt out.<\/label><input type='hidden' name='input_10.2' value='By opting into SMS from a web form or other medium, you are agreeing to receive SMS messages from Sternen Physical Therapy. This includes SMS messages for customer care, marketing. Message frequency varies. Message and data rates may apply. See privacy policy at https:\/\/mainstreetpt.net\/sternen-physical-therapy\/privacy-policy\/. Message HELP for help. 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