{"id":17,"date":"2020-05-14T15:35:04","date_gmt":"2020-05-14T19:35:04","guid":{"rendered":"https:\/\/woundmd.local\/?page_id=17"},"modified":"2024-02-22T16:49:39","modified_gmt":"2024-02-22T21:49:39","slug":"contact-us","status":"publish","type":"page","link":"https:\/\/personichealth.com\/contact-us\/","title":{"rendered":"Contact us"},"content":{"rendered":"\n<h1>\n\t\tContact Advanced Mobile Wound Care Experts\n\t<\/h1>\n\t<p>Our team of advanced wound care specialists are ready to provide hands-on medical service and support in the comfort of your patients&#8217; own home.<\/p>\n\t<h2><strong>Referral Form<\/strong><\/h2>\n\t\t<nav>\n\t\t\t<ul>\n\t\t\t\t\t\t\t\t<li data-index=\"0\" tabindex=\"0\">\n\t\t\t\t\t<h4>\n\t\t\t\t\t\t<a href=\"javascript:void(0);\" tabindex=\"-1\">Schedule a Consultation\n\t\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h4>\n\t\t\t\t<\/li>\n\t\t\t\t\t\t\t<\/ul>\n\t\t<\/nav>\n\t\t\t\t\t<p>No need to wait any longer. Schedule a visit and we&#8217;ll come to you!<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return 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gform-theme--orbital contact-form_wrapper' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_5' ><style>#gform_wrapper_5[data-form-index=\"0\"].gform-theme,[data-parent-form=\"5_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 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fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5' class='contact-form' action='\/wp-json\/wp\/v2\/pages\/17' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_1\" ><label class='gfield_label gform-field-label' for='input_5_1'>Patient First 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_5_1' type='text' value='' class='large'    placeholder='Enter Patient First Name *' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_12\" ><label class='gfield_label gform-field-label' for='input_5_12'>Patient Last 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_12' id='input_5_12' type='text' value='' class='large'    placeholder='Enter Patient Last Name *' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_36\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_36\" ><label class='gfield_label gform-field-label' for='input_5_36'>Patient Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_36' id='input_5_36' type='email' value='' class='large'   placeholder='Enter Patient Email *' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_38\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_38\" ><label class='gfield_label gform-field-label' for='input_5_38'>Patient DOB<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_38' id='input_5_38' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Enter Patient DOB *' aria-describedby=\"input_5_38_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_38_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_38' class='gform_hidden' value='https:\/\/personichealth.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_42\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_42\" ><label class='gfield_label gform-field-label' for='input_5_42'>Patient 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_42' id='input_5_42' type='tel' value='' class='large'  placeholder='Enter Patient Phone *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_23\" ><label class='gfield_label gform-field-label' for='input_5_23'>Patient Street Address<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_5_23' type='text' value='' class='large'    placeholder='Enter Patient Street Address'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_22\" ><label class='gfield_label gform-field-label' for='input_5_22'>Patient City<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_5_22' type='text' value='' class='large'    placeholder='Enter Patient City'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_21\" ><label class='gfield_label gform-field-label' for='input_5_21'>Patient State<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_5_21' type='text' value='' class='large'    placeholder='Enter Patient State'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_20\" ><label class='gfield_label gform-field-label' for='input_5_20'>Patient ZIP Code<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_5_20' type='text' value='' class='large'    placeholder='Enter Patient ZIP Code'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_19\" ><label class='gfield_label gform-field-label' for='input_5_19'>Patient Primary Care Provider<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_5_19' type='text' value='' class='large'    placeholder='Enter Patient Primary Care Provider'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_24\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_24\" ><label class='gfield_label gform-field-label' for='input_5_24'>Power of Attorney<\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_5_24' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Power of Attorney<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_5_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_43\" ><label class='gfield_label gform-field-label' for='input_5_43'>Power of Attorney<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_5_43' type='text' value='' class='large'    placeholder='Power of Attorney Name *' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_39\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_39\" ><label class='gfield_label gform-field-label' for='input_5_39'>Power of Attorney Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_39' id='input_5_39' type='email' value='' class='large'   placeholder='Enter Power of Attorney Email'  aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_44\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_44\" ><label class='gfield_label gform-field-label' for='input_5_44'>Power of Attorney 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_44' id='input_5_44' type='tel' value='' class='large'  placeholder='Power of Attorney Phone Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_17\" ><label class='gfield_label gform-field-label' for='input_5_17'>Patient Insurance Provider<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_5_17' type='text' value='' class='large'    placeholder='Enter Patient Insurance Provider'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_16\" ><label class='gfield_label gform-field-label' for='input_5_16'>Patient Insurance\/Medicare ID Number<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_5_16' type='text' value='' class='large'    placeholder='Primary Insurance\/Medicare ID Number'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\" ><label class='gfield_label gform-field-label' for='input_5_15'>Secondary Insurance ID Number<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_5_15' type='text' value='' class='large'    placeholder='Secondary Insurance ID Number'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\" ><label class='gfield_label gform-field-label' for='input_5_14'>Diagnosis<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_5_14' type='text' value='' class='large'    placeholder='Enter Diagnosis'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_28\" ><label class='gfield_label gform-field-label' for='input_5_28'>Duration of Wound<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_5_28' type='text' value='' class='large'    placeholder='Enter Duration of Wound'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_27\" ><label class='gfield_label gform-field-label' for='input_5_27'>Medical Provider Company Name\/Provider<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_5_27' type='text' value='' class='large'    placeholder='Referring Medical Provider Practice\/Company Name'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_26\" ><label class='gfield_label gform-field-label' for='input_5_26'>Medical Provider First Name<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_5_26' type='text' value='' class='large'    placeholder='Enter Medical Provider First Name'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_25\" ><label class='gfield_label gform-field-label' for='input_5_25'>Medical Provider Last Name<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_5_25' type='text' value='' class='large'    placeholder='Enter Medical Provider Last Name'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_40\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_40\" ><label class='gfield_label gform-field-label' for='input_5_40'>Medical Provider Contact Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_5_40' type='email' value='' class='large'   placeholder='Enter Medical Provider Contact Email'  aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_41\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_41\" ><label class='gfield_label gform-field-label' for='input_5_41'>Medical Provider Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_41' id='input_5_41' type='tel' 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