{"id":732,"date":"2020-08-07T19:20:39","date_gmt":"2020-08-07T19:20:39","guid":{"rendered":"http:\/\/happyvalleyhomecare.com\/?page_id=732"},"modified":"2020-08-17T16:14:29","modified_gmt":"2020-08-17T16:14:29","slug":"referral","status":"publish","type":"page","link":"https:\/\/happyvalleyhomecare.com\/es\/referral\/","title":{"rendered":"Forma de Derivaci\u00f3n Pedi\u00e1trica"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"732\" class=\"elementor elementor-732\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e20ba62 elementor-section-boxed elementor-section-height-default elementor-section-height-default parallax_section_no qode_elementor_container_no\" data-id=\"e20ba62\" data-element_type=\"section\" data-e-type=\"section\">\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-092797e\" data-id=\"092797e\" data-element_type=\"column\" data-e-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-0d25fb8 elementor-widget elementor-widget-wp-widget-rev-slider-widget\" data-id=\"0d25fb8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wp-widget-rev-slider-widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n\t\t\t<!-- START Pediatric Referral Form REVOLUTION SLIDER 6.3.5 --><p class=\"rs-p-wp-fix\"><\/p>\n\t\t\t<rs-module-wrap id=\"rev_slider_8_1_wrapper\" data-source=\"gallery\" style=\"background:transparent;padding:0;margin:0px auto;margin-top:0;margin-bottom:0;background-image:url(http:\/\/happyvalleyhomecare.com\/wp-content\/uploads\/revslider\/slider-1\/rev-image-1a1.jpg);background-repeat:no-repeat;background-size:cover;background-position:center center;\">\n\t\t\t\t<rs-module id=\"rev_slider_8_1\" style=\"\" data-version=\"6.3.5\">\n\t\t\t\t\t<rs-slides>\n\t\t\t\t\t\t<rs-slide data-key=\"rs-40\" data-title=\"Slide\" data-anim=\"ei:d;eo:d;s:1000;r:0;t:fade;sl:0;\">\n\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" src=\"\/\/happyvalleyhomecare.com\/wp-content\/uploads\/2020\/08\/pdn-header.jpg\" title=\"pdn-header\" width=\"1800\" height=\"600\" class=\"rev-slidebg\" data-no-retina>\n<!--\n\t\t\t\t\t\t\t--><rs-layer\n\t\t\t\t\t\t\t\tid=\"slider-8-slide-40-layer-4\" \n\t\t\t\t\t\t\t\tdata-type=\"text\"\n\t\t\t\t\t\t\t\tdata-color=\"#889547\"\n\t\t\t\t\t\t\t\tdata-xy=\"xo:110px,75px,43px,32px;y:m;yo:0,10px,10px,-3px;\"\n\t\t\t\t\t\t\t\tdata-text=\"w:normal;s:60,48,48,24;l:73,48,48,32;\"\n\t\t\t\t\t\t\t\tdata-dim=\"w:585px,585px,585px,166px;\"\n\t\t\t\t\t\t\t\tdata-basealign=\"slide\"\n\t\t\t\t\t\t\t\tdata-rsp_o=\"off\"\n\t\t\t\t\t\t\t\tdata-rsp_bd=\"off\"\n\t\t\t\t\t\t\t\tdata-frame_0=\"x:50;\"\n\t\t\t\t\t\t\t\tdata-frame_1=\"e:power2.out;sp:1000;\"\n\t\t\t\t\t\t\t\tdata-frame_999=\"o:0;st:w;sR:8000;\"\n\t\t\t\t\t\t\t\tstyle=\"z-index:8;font-family:Calistoga;\"\n\t\t\t\t\t\t\t>Pediatric Referral Form \n\t\t\t\t\t\t\t<\/rs-layer><!--\n-->\t\t\t\t\t\t<\/rs-slide>\n\t\t\t\t\t<\/rs-slides>\n\t\t\t\t<\/rs-module>\n\t\t\t\t<script type=\"text\/javascript\">\n\t\t\t\t\tsetREVStartSize({c: 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undefined){\n\t\t\t\t\t\t\trevslider_showDoubleJqueryError(\"rev_slider_8_1\");\n\t\t\t\t\t\t}else{\n\t\t\t\t\t\t\trevapi8.revolution({\n\t\t\t\t\t\t\t\tsliderLayout:\"fullwidth\",\n\t\t\t\t\t\t\t\tduration:\"4000ms\",\n\t\t\t\t\t\t\t\tvisibilityLevels:\"1240,1024,778,480\",\n\t\t\t\t\t\t\t\tgridwidth:\"1800,1800,778,480\",\n\t\t\t\t\t\t\t\tgridheight:\"400,600,259,160\",\n\t\t\t\t\t\t\t\tperspective:600,\n\t\t\t\t\t\t\t\tperspectiveType:\"local\",\n\t\t\t\t\t\t\t\teditorheight:\"400,600,259,160\",\n\t\t\t\t\t\t\t\tresponsiveLevels:\"1240,1024,778,480\",\n\t\t\t\t\t\t\t\tprogressBar:{disableProgressBar:true},\n\t\t\t\t\t\t\t\tnavigation: {\n\t\t\t\t\t\t\t\t\tonHoverStop:false\n\t\t\t\t\t\t\t\t},\n\t\t\t\t\t\t\t\tfallbacks: {\n\t\t\t\t\t\t\t\t\tallowHTML5AutoPlayOnAndroid:true\n\t\t\t\t\t\t\t\t},\n\t\t\t\t\t\t\t});\n\t\t\t\t\t\t}\n\t\t\t\t\t\t\n\t\t\t\t\t});\n\t\t\t\t\t} \/\/ End of RevInitScript\n\t\t\t\tvar once_revslider81 = false;\n\t\t\t\tif (document.readyState === \"loading\") 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' ><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/es\/wp-json\/wp\/v2\/pages\/732#gf_2' data-formid='2' novalidate> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_27\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_27'>Referral Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_2_27' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_1\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_1'>Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_2_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_3\" class=\"gfield gfield--type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_2_3' type='text' value='' class='large'    placeholder='Male or Female?' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_4\" class=\"gfield gfield--type-text gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>Physicians Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_2_4' type='text' value='' 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name='input_6' id='input_2_6' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_7\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_7'>Parent Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_2_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_9\" class=\"gfield gfield--type-phone gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_9'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_2_9' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_17\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'>SOC Date<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_16\" class=\"gfield gfield--type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'>Emergency Contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='large'    placeholder='First Name, Last Name, and Phone Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_13\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_13'>Medicaid #<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_2_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_18\" class=\"gfield gfield--type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below 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aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_20\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'>Where<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='large'    placeholder='Hospital Name and City\/State'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_21\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_21'>Surgical Procedure<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_2_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_22\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_22'>Diagnosis<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_2_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_23\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_23'>Other Specific Orders<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_2_23' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_24\" class=\"gfield gfield--type-signature gf_left_half gfield_contains_required 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style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_2_24_data' name='input_2_24_data' value=''><\/div><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_25'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_28\" class=\"gfield gfield--type-captcha 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_2_28'>CAPTCHA<\/label><div id='input_2_28' class='ginput_container ginput_recaptcha' data-sitekey='6Leo89MZAAAAANAidSrTonVZeiNczQoEA3aHnYJ4'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy&amp;styles=[]&amp;hash=d78b6a6628ecf5af0583f4282a3a5075' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='legacy' \/>\n            <input type='hidden' 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name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        \n<script type='text\/javascript'>\n\/* <![CDATA[ *\/\nr3f5x9JS=escape(document['referrer']);\nhf4N='470ad1d9dd7c35868583782f7db70772';\nhf4V='496d935837ce7b7895580f635bb6ec28';\njQuery(document).ready(function($){var e=\"#commentform, .comment-respond form, .comment-form, #lostpasswordform, #registerform, #loginform, #login_form, #wpss_contact_form, .wpcf7-form, .gform_wrapper form\";$(e).submit(function(){$(\"<input>\").attr(\"type\",\"hidden\").attr(\"name\",\"r3f5x9JS\").attr(\"value\",r3f5x9JS).appendTo(e);return true;});var h=\"form[method='post']\";$(h).submit(function(){$(\"<input>\").attr(\"type\",\"hidden\").attr(\"name\",hf4N).attr(\"value\",hf4V).appendTo(h);return true;});});\n\/* ]]> *\/\n<\/script> \n<\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_2' id='gform_ajax_frame_2' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 2, 'https:\/\/happyvalleyhomecare.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_2').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_2').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_2').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_2').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_2').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_2').val();gformInitSpinner( 2, 'https:\/\/happyvalleyhomecare.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [2, current_page]);window['gf_submitting_2'] = false;}else if(!is_redirect){var confirmation_content = 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setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n\t\t\t\t\t\t\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<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"Referral Date*Patient Name*Sex*Physicians Name*Phone*FaxParent Name*Phone*SOC DateEmergency Contact*Medicaid #Date of Birth*Hospitalization*WhereSurgical ProcedureDiagnosisOther Specific OrdersPhysician 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