Patient Enrollment Form<\/title>\r\n <link href=\"https:\/\/fonts.googleapis.com\/css?family=Nunito:400,700&display=swap\" rel=\"stylesheet\">\r\n <style>\r\n body {\r\n background: #f6f9fb;\r\n font-family: 'Nunito', Arial, sans-serif;\r\n padding: 0;\r\n margin: 0;\r\n }\r\n .form-container {\r\n max-width: 700px;\r\n margin: 40px auto;\r\n background: #fff;\r\n border-radius: 10px;\r\n box-shadow: 0 4px 20px #0001;\r\n padding: 30px 40px;\r\n }\r\n h2 {\r\n text-align: center;\r\n color: #375a7f;\r\n font-weight: 700;\r\n margin-bottom: 25px;\r\n letter-spacing: 1px;\r\n }\r\n label {\r\n display: block;\r\n margin: 12px 0 5px;\r\n font-weight: 600;\r\n color: #415b7a;\r\n }\r\n input, select, textarea {\r\n width: 100%;\r\n padding: 9px 12px;\r\n border: 1px solid #bbe1fa;\r\n border-radius: 6px;\r\n background: #fafcff;\r\n margin-bottom: 15px;\r\n font-size: 1rem;\r\n }\r\n input[type=\"radio\"], input[type=\"checkbox\"] {\r\n width: auto;\r\n margin-right: 8px;\r\n }\r\n .section-title {\r\n margin-top: 32px;\r\n font-size: 1.2em;\r\n color: #3282b8;\r\n font-weight: 700;\r\n }\r\n .inline-group {\r\n display: flex;\r\n flex-wrap: wrap;\r\n gap: 18px;\r\n }\r\n .inline-group label {\r\n font-weight: normal;\r\n margin: 0 9px 0 0;\r\n display: flex;\r\n align-items: center;\r\n }\r\n button[type=\"submit\"] {\r\n background: #3282b8;\r\n color: #fff;\r\n border: none;\r\n font-size: 1.1rem;\r\n padding: 12px 32px;\r\n border-radius: 6px;\r\n cursor: pointer;\r\n letter-spacing: .5px;\r\n margin-top: 10px;\r\n box-shadow: 0 2px 8px #0001;\r\n font-weight: 700;\r\n transition: background .18s;\r\n }\r\n button[type=\"submit\"]:hover {\r\n background: #375a7f;\r\n }\r\n .consent {\r\n font-size: .98em;\r\n color: #183656;\r\n margin-bottom: 14px;\r\n }\r\n <\/style>\r\n<\/head>\r\n<body>\r\n <form class=\"form-container\" action=\"mailto:info@kencare.telehealthpractices.com\" method=\"post\" enctype=\"text\/plain\">\r\n <h2>Patient Enrollment Form<\/h2>\r\n\r\n <div class=\"section-title\">I. Patient Information<\/div>\r\n <label>Full Name<\/label>\r\n <input type=\"text\" name=\"full_name\" required>\r\n <label>Date of Birth<\/label>\r\n <input type=\"date\" name=\"dob\" required>\r\n <label>Gender Identity<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"gender_identity\" value=\"Female\">Female<\/label>\r\n <label><input type=\"radio\" name=\"gender_identity\" value=\"Male\">Male<\/label>\r\n <label><input type=\"radio\" name=\"gender_identity\" value=\"Non-binary\">Non-binary<\/label>\r\n <label><input type=\"radio\" name=\"gender_identity\" value=\"Other\">Other<\/label>\r\n <\/div>\r\n <label>Preferred Pronouns<\/label>\r\n <input type=\"text\" name=\"pronouns\">\r\n <label>Marital Status<\/label>\r\n <select name=\"marital_status\">\r\n <option value=\"Single\">Single<\/option>\r\n <option value=\"Married\">Married<\/option>\r\n <option value=\"Divorced\">Divorced<\/option>\r\n <option value=\"Widowed\">Widowed<\/option>\r\n <\/select>\r\n <label>Occupation<\/label>\r\n <input type=\"text\" name=\"occupation\">\r\n <label>Employer<\/label>\r\n <input type=\"text\" name=\"employer\">\r\n\r\n <div class=\"section-title\">II. Contact Details<\/div>\r\n <label>Primary Phone Number<\/label>\r\n <input type=\"tel\" name=\"phone\" required>\r\n <label>Email Address<\/label>\r\n <input type=\"email\" name=\"email\" required>\r\n <label>Mailing Address<\/label>\r\n <input type=\"text\" name=\"address\">\r\n <label>City<\/label>\r\n <input type=\"text\" name=\"city\">\r\n <label>State<\/label>\r\n <input type=\"text\" name=\"state\">\r\n <label>Zip Code<\/label>\r\n <input type=\"text\" name=\"zip\">\r\n <label>Preferred Contact Method<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"checkbox\" name=\"contact_method\" value=\"Phone\">Phone<\/label>\r\n <label><input type=\"checkbox\" name=\"contact_method\" value=\"Text\">Text<\/label>\r\n <label><input type=\"checkbox\" name=\"contact_method\" value=\"Email\">Email<\/label>\r\n <\/div>\r\n\r\n <div class=\"section-title\">III. Emergency Contact<\/div>\r\n <label>Full Name<\/label>\r\n <input type=\"text\" name=\"emergency_name\" required>\r\n <label>Relationship<\/label>\r\n <input type=\"text\" name=\"emergency_relationship\" required>\r\n <label>Phone Number<\/label>\r\n <input type=\"tel\" name=\"emergency_phone\" required>\r\n\r\n <div class=\"section-title\">IV. Referral Information<\/div>\r\n <label>How did you hear about us?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"checkbox\" name=\"referral\" value=\"Website\">Website<\/label>\r\n <label><input type=\"checkbox\" name=\"referral\" value=\"Social Media\">Social Media<\/label>\r\n <label><input type=\"checkbox\" name=\"referral\" value=\"Friend\/Family\">Friend\/Family<\/label>\r\n <label><input type=\"checkbox\" name=\"referral\" value=\"Practitioner\">Practitioner<\/label>\r\n <label><input type=\"checkbox\" name=\"referral\" value=\"Event\">Event<\/label>\r\n <label><input type=\"checkbox\" name=\"referral\" value=\"Other\">Other<\/label>\r\n <\/div>\r\n\r\n <div class=\"section-title\">V. Health Information<\/div>\r\n <label>Currently under physician or mental health care?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"health_care\" value=\"Yes\">Yes<\/label>\r\n <label><input type=\"radio\" name=\"health_care\" value=\"No\">No<\/label>\r\n <\/div>\r\n <label>If yes, please explain<\/label>\r\n <textarea name=\"health_care_explain\"><\/textarea>\r\n <label>Taking any medications or supplements?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"medications\" value=\"Yes\">Yes<\/label>\r\n <label><input type=\"radio\" name=\"medications\" value=\"No\">No<\/label>\r\n <\/div>\r\n <label>If yes, please list<\/label>\r\n <textarea name=\"medication_list\"><\/textarea>\r\n <label>Recent surgeries, diagnoses, or major health concerns?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"recent_health\" value=\"Yes\">Yes<\/label>\r\n <label><input type=\"radio\" name=\"recent_health\" value=\"No\">No<\/label>\r\n <\/div>\r\n <label>If yes, please describe<\/label>\r\n <textarea name=\"recent_health_desc\"><\/textarea>\r\n <label>Currently pregnant?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"pregnant\" value=\"Yes\">Yes<\/label>\r\n <label><input type=\"radio\" name=\"pregnant\" value=\"No\">No<\/label>\r\n <label><input type=\"radio\" name=\"pregnant\" value=\"NA\">N\/A<\/label>\r\n <\/div>\r\n <label>History of (check all that apply):<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"Chronic Pain\">Chronic Pain<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"Anxiety\">Anxiety<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"Depression\">Depression<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"High Blood Pressure\">High Blood Pressure<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"PTSD\">PTSD<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"Autoimmune Disorder\">Autoimmune Disorder<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"Cancer\">Cancer<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"Diabetes\">Diabetes<\/label>\r\n <\/div>\r\n <label>Other<\/label>\r\n <input type=\"text\" name=\"history_other\">\r\n\r\n <div class=\"section-title\">VI. Wellness Goals & Intentions<\/div>\r\n <label>What brings you in today?<\/label>\r\n <textarea name=\"reason\" rows=\"3\"><\/textarea>\r\n <label>Primary goals for our sessions (check all):<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Stress Relief\">Stress Relief<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Emotional Healing\">Emotional Healing<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Pain Management\">Pain Management<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Spiritual Connection\">Spiritual Connection<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Chakra Balancing\">Chakra Balancing<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Energy Clearing\">Energy Clearing<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Chronic Dis-Ease Management\">Chronic Dis-Ease Management<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Autoimmune Dis-Ease Relief\">Autoimmune Dis-Ease Relief<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Other\">Other<\/label>\r\n <\/div>\r\n\r\n <div class=\"section-title\">VII. Consent & Acknowledgement<\/div>\r\n <div class=\"consent\">\r\n I acknowledge that the services provided are not a substitute for medical care and do not diagnose, treat, or cure disease. I understand that I should consult with my healthcare provider for any medical concerns.<br>\r\n I give permission to be contacted for appointment reminders, wellness updates, or follow-ups.\r\n <\/div>\r\n <label>Signature<\/label>\r\n <input type=\"text\" name=\"signature\" required>\r\n <label>Date<\/label>\r\n <input type=\"date\" name=\"consent_date\" required>\r\n <button type=\"submit\">Submit<\/button>\r\n <\/form>\r\n<\/body>\r\n<\/html>\r\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Patient Enrollment Form Patient Enrollment Form I. Patient Information Full Name Date of Birth Gender Identity Female Male Non-binary Other Preferred Pronouns Marital Status SingleMarriedDivorcedWidowed Occupation Employer II. Contact Details Primary Phone Number Email Address Mailing Address City State Zip Code Preferred Contact Method Phone Text Email III. Emergency Contact Full Name Relationship Phone Number […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"content-type":"","footnotes":""},"class_list":["post-439","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/439","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=439"}],"version-history":[{"count":4,"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/439\/revisions"}],"predecessor-version":[{"id":443,"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/439\/revisions\/443"}],"wp:attachment":[{"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=439"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}

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\n\t\t\t\t\t\r\n\r\n\r\n \r\n Patient Enrollment Form<\/title>\r\n <link href=\"https:\/\/fonts.googleapis.com\/css?family=Nunito:400,700&display=swap\" rel=\"stylesheet\">\r\n <style>\r\n body {\r\n background: #f6f9fb;\r\n font-family: 'Nunito', Arial, sans-serif;\r\n padding: 0;\r\n margin: 0;\r\n }\r\n .form-container {\r\n max-width: 700px;\r\n margin: 40px auto;\r\n background: #fff;\r\n border-radius: 10px;\r\n box-shadow: 0 4px 20px #0001;\r\n padding: 30px 40px;\r\n }\r\n h2 {\r\n text-align: center;\r\n color: #375a7f;\r\n font-weight: 700;\r\n margin-bottom: 25px;\r\n letter-spacing: 1px;\r\n }\r\n label {\r\n display: block;\r\n margin: 12px 0 5px;\r\n font-weight: 600;\r\n color: #415b7a;\r\n }\r\n input, select, textarea {\r\n width: 100%;\r\n padding: 9px 12px;\r\n border: 1px solid #bbe1fa;\r\n border-radius: 6px;\r\n background: #fafcff;\r\n margin-bottom: 15px;\r\n font-size: 1rem;\r\n }\r\n input[type=\"radio\"], input[type=\"checkbox\"] {\r\n width: auto;\r\n margin-right: 8px;\r\n }\r\n .section-title {\r\n margin-top: 32px;\r\n font-size: 1.2em;\r\n color: #3282b8;\r\n font-weight: 700;\r\n }\r\n .inline-group {\r\n display: flex;\r\n flex-wrap: wrap;\r\n gap: 18px;\r\n }\r\n .inline-group label {\r\n font-weight: normal;\r\n margin: 0 9px 0 0;\r\n display: flex;\r\n align-items: center;\r\n }\r\n button[type=\"submit\"] {\r\n background: #3282b8;\r\n color: #fff;\r\n border: none;\r\n font-size: 1.1rem;\r\n padding: 12px 32px;\r\n border-radius: 6px;\r\n cursor: pointer;\r\n letter-spacing: .5px;\r\n margin-top: 10px;\r\n box-shadow: 0 2px 8px #0001;\r\n font-weight: 700;\r\n transition: background .18s;\r\n }\r\n button[type=\"submit\"]:hover {\r\n background: #375a7f;\r\n }\r\n .consent {\r\n font-size: .98em;\r\n color: #183656;\r\n margin-bottom: 14px;\r\n }\r\n <\/style>\r\n<\/head>\r\n<body>\r\n <form class=\"form-container\" action=\"mailto:info@kencare.telehealthpractices.com\" method=\"post\" enctype=\"text\/plain\">\r\n <h2>Patient Enrollment Form<\/h2>\r\n\r\n <div class=\"section-title\">I. Patient Information<\/div>\r\n <label>Full Name<\/label>\r\n <input type=\"text\" name=\"full_name\" required>\r\n <label>Date of Birth<\/label>\r\n <input type=\"date\" name=\"dob\" required>\r\n <label>Gender Identity<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"gender_identity\" value=\"Female\">Female<\/label>\r\n <label><input type=\"radio\" name=\"gender_identity\" value=\"Male\">Male<\/label>\r\n <label><input type=\"radio\" name=\"gender_identity\" value=\"Non-binary\">Non-binary<\/label>\r\n <label><input type=\"radio\" name=\"gender_identity\" value=\"Other\">Other<\/label>\r\n <\/div>\r\n <label>Preferred Pronouns<\/label>\r\n <input type=\"text\" name=\"pronouns\">\r\n <label>Marital Status<\/label>\r\n <select name=\"marital_status\">\r\n <option value=\"Single\">Single<\/option>\r\n <option value=\"Married\">Married<\/option>\r\n <option value=\"Divorced\">Divorced<\/option>\r\n <option value=\"Widowed\">Widowed<\/option>\r\n <\/select>\r\n <label>Occupation<\/label>\r\n <input type=\"text\" name=\"occupation\">\r\n <label>Employer<\/label>\r\n <input type=\"text\" name=\"employer\">\r\n\r\n <div class=\"section-title\">II. Contact Details<\/div>\r\n <label>Primary Phone Number<\/label>\r\n <input type=\"tel\" name=\"phone\" required>\r\n <label>Email Address<\/label>\r\n <input type=\"email\" name=\"email\" required>\r\n <label>Mailing Address<\/label>\r\n <input type=\"text\" name=\"address\">\r\n <label>City<\/label>\r\n <input type=\"text\" name=\"city\">\r\n <label>State<\/label>\r\n <input type=\"text\" name=\"state\">\r\n <label>Zip Code<\/label>\r\n <input type=\"text\" name=\"zip\">\r\n <label>Preferred Contact Method<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"checkbox\" name=\"contact_method\" value=\"Phone\">Phone<\/label>\r\n <label><input type=\"checkbox\" name=\"contact_method\" value=\"Text\">Text<\/label>\r\n <label><input type=\"checkbox\" name=\"contact_method\" value=\"Email\">Email<\/label>\r\n <\/div>\r\n\r\n <div class=\"section-title\">III. Emergency Contact<\/div>\r\n <label>Full Name<\/label>\r\n <input type=\"text\" name=\"emergency_name\" required>\r\n <label>Relationship<\/label>\r\n <input type=\"text\" name=\"emergency_relationship\" required>\r\n <label>Phone Number<\/label>\r\n <input type=\"tel\" name=\"emergency_phone\" required>\r\n\r\n <div class=\"section-title\">IV. Referral Information<\/div>\r\n <label>How did you hear about us?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"checkbox\" name=\"referral\" value=\"Website\">Website<\/label>\r\n <label><input type=\"checkbox\" name=\"referral\" value=\"Social Media\">Social Media<\/label>\r\n <label><input type=\"checkbox\" name=\"referral\" value=\"Friend\/Family\">Friend\/Family<\/label>\r\n <label><input type=\"checkbox\" name=\"referral\" value=\"Practitioner\">Practitioner<\/label>\r\n <label><input type=\"checkbox\" name=\"referral\" value=\"Event\">Event<\/label>\r\n <label><input type=\"checkbox\" name=\"referral\" value=\"Other\">Other<\/label>\r\n <\/div>\r\n\r\n <div class=\"section-title\">V. Health Information<\/div>\r\n <label>Currently under physician or mental health care?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"health_care\" value=\"Yes\">Yes<\/label>\r\n <label><input type=\"radio\" name=\"health_care\" value=\"No\">No<\/label>\r\n <\/div>\r\n <label>If yes, please explain<\/label>\r\n <textarea name=\"health_care_explain\"><\/textarea>\r\n <label>Taking any medications or supplements?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"medications\" value=\"Yes\">Yes<\/label>\r\n <label><input type=\"radio\" name=\"medications\" value=\"No\">No<\/label>\r\n <\/div>\r\n <label>If yes, please list<\/label>\r\n <textarea name=\"medication_list\"><\/textarea>\r\n <label>Recent surgeries, diagnoses, or major health concerns?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"recent_health\" value=\"Yes\">Yes<\/label>\r\n <label><input type=\"radio\" name=\"recent_health\" value=\"No\">No<\/label>\r\n <\/div>\r\n <label>If yes, please describe<\/label>\r\n <textarea name=\"recent_health_desc\"><\/textarea>\r\n <label>Currently pregnant?<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"radio\" name=\"pregnant\" value=\"Yes\">Yes<\/label>\r\n <label><input type=\"radio\" name=\"pregnant\" value=\"No\">No<\/label>\r\n <label><input type=\"radio\" name=\"pregnant\" value=\"NA\">N\/A<\/label>\r\n <\/div>\r\n <label>History of (check all that apply):<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"Chronic Pain\">Chronic Pain<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"Anxiety\">Anxiety<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"Depression\">Depression<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"High Blood Pressure\">High Blood Pressure<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"PTSD\">PTSD<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"Autoimmune Disorder\">Autoimmune Disorder<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"Cancer\">Cancer<\/label>\r\n <label><input type=\"checkbox\" name=\"history[]\" value=\"Diabetes\">Diabetes<\/label>\r\n <\/div>\r\n <label>Other<\/label>\r\n <input type=\"text\" name=\"history_other\">\r\n\r\n <div class=\"section-title\">VI. Wellness Goals & Intentions<\/div>\r\n <label>What brings you in today?<\/label>\r\n <textarea name=\"reason\" rows=\"3\"><\/textarea>\r\n <label>Primary goals for our sessions (check all):<\/label>\r\n <div class=\"inline-group\">\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Stress Relief\">Stress Relief<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Emotional Healing\">Emotional Healing<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Pain Management\">Pain Management<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Spiritual Connection\">Spiritual Connection<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Chakra Balancing\">Chakra Balancing<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Energy Clearing\">Energy Clearing<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Chronic Dis-Ease Management\">Chronic Dis-Ease Management<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Autoimmune Dis-Ease Relief\">Autoimmune Dis-Ease Relief<\/label>\r\n <label><input type=\"checkbox\" name=\"goals[]\" value=\"Other\">Other<\/label>\r\n <\/div>\r\n\r\n <div class=\"section-title\">VII. Consent & Acknowledgement<\/div>\r\n <div class=\"consent\">\r\n I acknowledge that the services provided are not a substitute for medical care and do not diagnose, treat, or cure disease. I understand that I should consult with my healthcare provider for any medical concerns.<br>\r\n I give permission to be contacted for appointment reminders, wellness updates, or follow-ups.\r\n <\/div>\r\n <label>Signature<\/label>\r\n <input type=\"text\" name=\"signature\" required>\r\n <label>Date<\/label>\r\n <input type=\"date\" name=\"consent_date\" required>\r\n <button type=\"submit\">Submit<\/button>\r\n <\/form>\r\n<\/body>\r\n<\/html>\r\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Patient Enrollment Form Patient Enrollment Form I. Patient Information Full Name Date of Birth Gender Identity Female Male Non-binary Other Preferred Pronouns Marital Status SingleMarriedDivorcedWidowed Occupation Employer II. Contact Details Primary Phone Number Email Address Mailing Address City State Zip Code Preferred Contact Method Phone Text Email III. Emergency Contact Full Name Relationship Phone Number […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"content-type":"","footnotes":""},"class_list":["post-439","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/439","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=439"}],"version-history":[{"count":4,"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/439\/revisions"}],"predecessor-version":[{"id":443,"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/439\/revisions\/443"}],"wp:attachment":[{"href":"https:\/\/kencare.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=439"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}