{"id":385,"date":"2022-09-21T15:39:22","date_gmt":"2022-09-21T15:39:22","guid":{"rendered":"http:\/\/ede.wrq.mybluehost.me\/?page_id=385"},"modified":"2024-12-13T12:26:57","modified_gmt":"2024-12-13T18:26:57","slug":"ckarmout","status":"publish","type":"page","link":"https:\/\/precina.com\/ckarmout\/","title":{"rendered":"Refer a Patient &#8211; Christopher Ivan Karmout"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"385\" class=\"elementor elementor-385\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-64516921 elementor-section-full_width elementor-section-height-min-height elementor-section-stretched elementor-section-height-default elementor-section-items-middle\" data-id=\"64516921\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;,&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\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-69cdcb4a\" data-id=\"69cdcb4a\" 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-287dd9fd elementor-widget elementor-widget-heading\" data-id=\"287dd9fd\" data-element_type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Refer a Patient<\/h2>\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<section class=\"elementor-section elementor-top-section elementor-element elementor-element-315b25fa elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"315b25fa\" data-element_type=\"section\" data-settings=\"{&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\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-467ddb4c\" data-id=\"467ddb4c\" 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-15edbb2a elementor-widget__width-inherit elementor-widget elementor-widget-text-editor\" data-id=\"15edbb2a\" data-element_type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<!-- Video on how to use this template: https:\/\/www.loom.com\/share\/6a968cc7bfae4d38b9ab368fe4358c95\n-->\n\n\n<h1>Refer a Patient: <b>Christopher Karmout<\/b><\/h1>\n<!-- Change the text inside the <b>...<\/b> tag above and replace it with the appropriate title or remove it (and the colon) -->\n\n\n<form action=\"https:\/\/webto.salesforce.com\/servlet\/servlet.WebToLead?encoding=UTF-8&#038;orgId=00DHp000003UrBe\"\n   method=\"POST\"\n   style=\"display: flex; flex-direction: column; gap: 1rem; box-shadow: 5px 5px 56px 0px rgba(0, 0, 0, .25); padding: 2rem\"\n>\n   <!-- Set the 'value' below to the email for the Contact in Salesforce that is referring on this form -->\n   <input\n       value=\"christopherkarmout@web2lead.idp.precina.com\"\n       type=\"hidden\"\n       name=\"00NQQ000007wbw1\"\n   \/>\n   <!-- DO NOT CHANGE THE \"name\" PROPERTY -->\n\n\n   <!-- Don't change anything below here (and don't change the \"name\" above)-->\n   <input type=\"hidden\" name=\"oid\" value=\"00DHp000003UrBe\" \/>\n   <input type=\"hidden\" name=\"retURL\" value=\"https:\/\/precina.com\/patient-referral-thankyou\/\" \/>\n   <div>\n       <label for=\"first_name\">Patient First Name<\/label>\n       <input id=\"first_name\" maxlength=\"40\" name=\"first_name\" size=\"20\" type=\"text\" autofocus \/>\n   <\/div>\n   <div>\n       <label for=\"last_name\">Patient Last Name<\/label>\n       <input id=\"last_name\" maxlength=\"80\" name=\"last_name\" size=\"20\" type=\"text\" \/>\n   <\/div>\n   <div>\n       <label for=\"mobile\">Patient Cell Phone<\/label>\n       <input id=\"mobile\" maxlength=\"40\" name=\"mobile\" size=\"20\" type=\"text\" \/>\n   <\/div>\n   <div>\n       <label for=\"00NQQ0000078UMf2AM\">Comments<\/label>\n       <textarea id=\"00NQQ0000078UMf2AM\" name=\"00NQQ0000078UMf2AM\" type=\"text\" wrap=\"soft\"><\/textarea>\n   <\/div>\n\n\n   <input type=\"submit\" name=\"submit\" \/>\n   <!-- ----------------------------------------------------------------------  -->\n   <!-- NOTE: These fields are optional debugging elements. 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