{"id":2430,"date":"2020-06-29T13:16:02","date_gmt":"2020-06-29T13:16:02","guid":{"rendered":"https:\/\/www.toplinemd.com\/comprehensive-ob-gyn\/?page_id=2430"},"modified":"2023-03-17T14:09:42","modified_gmt":"2023-03-17T14:09:42","slug":"request-an-appointment","status":"publish","type":"page","link":"https:\/\/www.toplinemd.com\/comprehensive-ob-gyn\/request-an-appointment\/","title":{"rendered":"Request an Appointment"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-parallax-none nonhundred-percent-fullwidth non-hundred-percent-height-scrolling PC2-title-sep-section\" style=\"--awb-background-position:center bottom;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:45px;--awb-background-color:#eeeeee;--awb-background-image:linear-gradient(180deg, rgba(0,0,0,0.2) 0%,rgba(0,0,0,0.2) 100%),url(https:\/\/www.toplinemd.com\/comprehensive-ob-gyn\/wp-content\/uploads\/sites\/104\/2020\/06\/15-Contact-header.jpg);;--awb-background-size:cover;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_6 1_6 fusion-one-sixth fusion-column-first fusion-no-small-visibility\" style=\"--awb-bg-size:cover;--awb-margin-top:0px;--awb-margin-bottom:0px;width:16.6666666667%;width:calc(16.6666666667% - ( ( 0 + 0 ) * 0.166666666667 ) );margin-right: 0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_2_3 2_3 fusion-two-third fusion-animated hero-header\" style=\"--awb-bg-size:cover;--awb-margin-top:45px;--awb-margin-bottom:45px;width:66.6666666667%;width:calc(66.6666666667% - ( ( 0 + 0 ) * 0.666666666667 ) );margin-right: 0px;\" data-animationType=\"zoomIn\" data-animationDuration=\"0.9\" data-animationOffset=\"top-into-view\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-1\"><h1 class=\"title-h2\" style=\"text-align: center;color: #fff;margin-bottom: 0\">REQUEST AN APPOINTMENT<\/h1>\n<\/div><div class=\"title-sep-custom\"><hr><i class=\"fa-heart fas\" style=\"color:#ffffff;\"><\/i><hr><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_6 1_6 fusion-one-sixth fusion-column-last fusion-no-small-visibility\" style=\"--awb-bg-size:cover;--awb-margin-top:0px;--awb-margin-bottom:0px;width:16.6666666667%;width:calc(16.6666666667% - ( ( 0 + 0 ) * 0.166666666667 ) );\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"--awb-padding-top:0px;--awb-padding-right:0px;--awb-padding-bottom:0px;--awb-padding-left:0px;--awb-bg-size:cover;--awb-margin-top:0px;--awb-margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-section-separator section-separator big-half-circle fusion-section-separator-1\" style=\"--awb-spacer-height:99px;--awb-svg-margin-left:0;--awb-svg-margin-right:0;--awb-divider-height:99px;--awb-spacer-padding-top:inherit;--awb-sep-padding:0;--awb-svg-padding:0;\"><div class=\"fusion-section-separator-svg\"><svg class=\"fusion-big-half-circle-candy\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" version=\"1.1\" width=\"100%\" height=\"100\" viewBox=\"0 0 100 100\" preserveAspectRatio=\"none\" fill=\"rgba(246,248,251,1)\"><path d=\"M0 100 C40 0 60 0 100 100 Z\"><\/path><\/svg><\/div><div class=\"fusion-section-separator-spacer\"><div class=\"fusion-section-separator-spacer-height\"><\/div><\/div><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling PC2-contact-sec\" style=\"--awb-background-repeat:repeat-x;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:10px;--awb-padding-bottom:0px;--awb-background-color:#f6f8fb;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last fusion-animated\" style=\"--awb-bg-size:cover;--awb-margin-top:60px;\" data-animationType=\"zoomIn\" data-animationDuration=\"0.9\" data-animationOffset=\"top-into-view\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-2\"><h2 class=\"title-h2\" style=\"text-align: center\">Request an Appointment<\/h2>\n<\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator PC2-title-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:15px;margin-bottom:50px;width:100%;max-width:18%;\"><div class=\"fusion-separator-border sep-single\" style=\"--awb-height:20px;--awb-amount:20px;--awb-sep-color:#3c3f47;border-color:#3c3f47;border-top-width:2px;\"><\/div><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-3 hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-equal-height-columns fusion-no-small-visibility fusion-no-medium-visibility PC2-home-sec2\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-background-color:#f6f8fb;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_3 1_3 fusion-one-third fusion-column-first fusion-animated\" style=\"--awb-padding-top:30px;--awb-padding-bottom:25px;--awb-bg-position:right center;--awb-bg-repeat:repeat-y;--awb-border-color:#ccd2dc;--awb-border-right:1px;--awb-border-style:solid;--awb-margin-top:30px;--awb-margin-bottom:30px;width:33.3333333333%;width:calc(33.3333333333% - ( ( 0px + 0px ) * 0.333333333333 ) );margin-right: 0px;\" data-animationType=\"fadeInRight\" data-animationDuration=\"1.0\" data-animationOffset=\"top-into-view\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-column-content-centered\"><div class=\"fusion-column-content\"><div class=\"fusion-text fusion-text-3\"><h6 style=\"text-align: center;letter-spacing: 1px\">OFFICE LINE<\/h6>\n<\/div><div class=\"fusion-text fusion-text-4\"><h5 style=\"text-align: center;margin: 0px\"><a href=\"tel:9547532411\">954-753-2411<\/a><\/h5>\n<\/div><div class=\"fusion-text fusion-text-5\"><h6 style=\"text-align: center;letter-spacing: 1px;margin-top: 20px\">FAX LINE<\/h6>\n<\/div><div class=\"fusion-text fusion-text-6\"><h5 style=\"text-align: center;margin: 0px\"><a href=\"fax:9547531176\">954-753-1176<\/a><\/h5>\n<\/div><\/div><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_3 1_3 fusion-one-third fusion-animated\" style=\"--awb-padding-top:30px;--awb-padding-bottom:25px;--awb-bg-size:cover;--awb-border-color:#ccd2dc;--awb-border-right:1px;--awb-border-style:solid;--awb-margin-top:30px;--awb-margin-bottom:30px;width:33.3333333333%;width:calc(33.3333333333% - ( ( 0px + 0px ) * 0.333333333333 ) );margin-right: 0px;\" data-animationType=\"fadeInUp\" data-animationDuration=\"1.0\" data-animationOffset=\"top-into-view\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-column-content-centered\"><div class=\"fusion-column-content\"><div class=\"fusion-text fusion-text-7\"><h6 style=\"text-align: center;letter-spacing: 1px\">ADDRESS<\/h6>\n<\/div><div class=\"fusion-text fusion-text-8\"><h5 style=\"text-align: center;margin: 0px;color: #52a8ff\"><a href=\"https:\/\/goo.gl\/maps\/wWSyyTzKxsznh8zX8\" target=\"_blank\" rel=\"noopener noreferrer\">8880 Royal Palm Blvd STE 100,<br \/>\nCoral Springs, FL 33065, USA<\/a><\/h5>\n<\/div><\/div><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_3 1_3 fusion-one-third fusion-column-last fusion-animated\" style=\"--awb-padding-top:30px;--awb-padding-bottom:25px;--awb-bg-position:left center;--awb-bg-repeat:repeat-y;--awb-margin-top:30px;--awb-margin-bottom:30px;width:33.3333333333%;width:calc(33.3333333333% - ( ( 0px + 0px ) * 0.333333333333 ) );\" data-animationType=\"fadeInLeft\" data-animationDuration=\"1.0\" data-animationOffset=\"top-into-view\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-column-content-centered\"><div class=\"fusion-column-content\"><div class=\"fusion-text fusion-text-9\"><h6 style=\"text-align: center;letter-spacing: 1px\">OFFICE HOURS<\/h6>\n<\/div><div class=\"fusion-text fusion-text-10\"><p style=\"text-align: center;font-size: 16px;font-weight: 400;margin-bottom: 0;line-height: 1.5\">Mon &#8211; Fri 8:30am &#8211; 5:00pm<br \/>\nSat &#8211; Sun &#8211; Closed<\/p>\n<\/div><\/div><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-4 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-no-large-visibility\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-bottom:0px;--awb-background-color:#f6f8fb;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_3 1_3 fusion-one-third fusion-column-first\" style=\"--awb-padding-top:35px;--awb-padding-bottom:35px;--awb-bg-position:right center;--awb-bg-repeat:repeat-y;--awb-border-color:#ccd2dc;--awb-border-bottom:1px;--awb-border-style:solid;--awb-margin-top:0px;--awb-margin-bottom:0px;width:33.3333333333%;width:calc(33.3333333333% - ( ( 0px + 0px ) * 0.333333333333 ) );margin-right: 0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-11\"><h6 style=\"text-align: center;letter-spacing: 1px\">OFFICE LINE<\/h6>\n<\/div><div class=\"fusion-text fusion-text-12\"><h5 style=\"text-align: center;margin: 0px\"><a href=\"tel:9547532411\">954-753-2411<\/a><\/h5>\n<\/div><div class=\"fusion-text fusion-text-13\"><h6 style=\"text-align: center;letter-spacing: 1px;margin-top: 20px\">FAX LINE<\/h6>\n<\/div><div class=\"fusion-text fusion-text-14\"><h5 style=\"text-align: center;margin: 0px\"><a href=\"fax:9547531176\">954-753-1176<\/a><\/h5>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_3 1_3 fusion-one-third\" style=\"--awb-padding-top:35px;--awb-padding-bottom:35px;--awb-bg-size:cover;--awb-border-color:#ccd2dc;--awb-border-bottom:1px;--awb-border-style:solid;--awb-margin-top:0px;--awb-margin-bottom:0px;width:33.3333333333%;width:calc(33.3333333333% - ( ( 0px + 0px ) * 0.333333333333 ) );margin-right: 0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-15\"><h6 style=\"text-align: center;letter-spacing: 1px\">ADDRESS<\/h6>\n<\/div><div class=\"fusion-text fusion-text-16\"><h5 style=\"text-align: center;margin: 0px;color: #52a8ff\"><a href=\"https:\/\/goo.gl\/maps\/wWSyyTzKxsznh8zX8\" target=\"_blank\" rel=\"noopener noreferrer\">8880 Royal Palm Blvd STE 100,<br \/>\nCoral Springs, FL 33065, USA<\/a><\/h5>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_3 1_3 fusion-one-third fusion-column-last\" style=\"--awb-padding-top:35px;--awb-padding-bottom:35px;--awb-bg-position:left center;--awb-bg-repeat:repeat-y;--awb-border-color:#ccd2dc;--awb-border-bottom:1px;--awb-border-style:solid;--awb-margin-top:0px;--awb-margin-bottom:0px;width:33.3333333333%;width:calc(33.3333333333% - ( ( 0px + 0px ) * 0.333333333333 ) );\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-17\"><h6 style=\"text-align: center;letter-spacing: 1px\">OFFICE HOURS<\/h6>\n<\/div><div class=\"fusion-text fusion-text-18\"><p style=\"text-align: center;font-size: 16px;font-weight: 400;margin-bottom: 0;line-height: 1.5\">Mon &#8211; Fri 8:30am &#8211; 5:00pm<br \/>\nSat &#8211; Sun &#8211; Closed<\/p>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-5 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling PC2-contact-sec\" style=\"--awb-background-repeat:repeat-x;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:10px;--awb-padding-bottom:0px;--awb-background-color:#f6f8fb;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-11 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last fusion-animated\" style=\"--awb-bg-size:cover;--awb-margin-top:60px;--awb-margin-bottom:55px;\" data-animationType=\"zoomIn\" data-animationDuration=\"0.9\" data-animationOffset=\"top-into-view\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-19\"><p style=\"text-align: center\">This appointment request form is NOT intended for emergency appointments. If this is a medical emergency call 911 or head to your nearest emergency room. Do not submit appointment requests for medical emergencies, these requests are not monitored 24\/7, please allow up to 72 hours for a response. If your matter requires attention before the allotted response time, please call our main number 954-753-2411 to speak with a staff member or the on-call physician. Date selection and time is not a guarantee of a scheduled appointment. A staff member will call you back to confirm the appointment. Please be sure to include your FULL NAME, DATE OF BIRTH, CONTACT PHONE NUMBER, EMAIL, REASON FOR APPOINTMENT, AND INSURANCE INFORMATION when submitting your request.<\/p>\n<\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:40px;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div>\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f4-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"4\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/comprehensive-ob-gyn\/wp-json\/wp\/v2\/pages\/2430#wpcf7-f4-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"4\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div class=\"app-form\">\n\t<div class=\"section1\">\n\t\t<div class=\"app cf7-patient third\">\n\t\t\t<p><label> New Patient? * <span class=\"wpcf7-form-control-wrap\" data-name=\"new-patient\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"new-patient\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app cf7-first-name third\">\n\t\t\t<p><label> First Name: * <span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name *\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app cf7-last-name third\">\n\t\t\t<p><label> Last Name: * <span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name *\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"section2\">\n\t\t<div class=\"app cf7-phone half left\">\n\t\t\t<p><label> Phone: * <span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone *\" value=\"\" type=\"tel\" name=\"your-phone\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app cf7-email half right\">\n\t\t\t<p><label> Email: * <span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email *\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"section3\">\n\t\t<div class=\"app cf7-phone half left\">\n\t\t\t<p><label> Preferred Time: <span class=\"wpcf7-form-control-wrap\" data-name=\"preferred-time\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"preferred-time\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"ASAP\">ASAP<\/option><option value=\"AM\">AM<\/option><option value=\"PM\">PM<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app cf7-phone half right\">\n\t\t\t<p><label> Preferred Date Selection: <span class=\"wpcf7-form-control-wrap\" data-name=\"select-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" placeholder=\"Select Date\" value=\"\" type=\"date\" name=\"select-date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"section4\">\n\t\t<div class=\"app cf7-phone third\">\n\t\t\t<p><label> Insurance: * <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Insurance\" value=\"\" type=\"text\" name=\"insurance\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app cf7-phone third\">\n\t\t\t<p><label> Gender: <span class=\"wpcf7-form-control-wrap\" data-name=\"gender\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"gender\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"M\">M<\/option><option value=\"F\">F<\/option><option value=\"Prefer not to share\">Prefer not to share<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app cf7-phone third\">\n\t\t\t<p><label> Date of Birth * <span class=\"wpcf7-form-control-wrap\" data-name=\"birth-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Select Date\" value=\"\" type=\"date\" name=\"birth-date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"app cf7-comment\">\n\t\t<p><label> Comments: * <span class=\"wpcf7-form-control-wrap\" data-name=\"comment\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Describe the reason for your appointment\" name=\"comment\"><\/textarea><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n\t<\/p>\n<\/div><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"194\"\/><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n\/* ]]> *\/\n<\/script>\n<\/p><input type='hidden' class='wpcf7-pum' 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