{"id":22,"date":"2022-01-06T00:11:20","date_gmt":"2022-01-06T00:11:20","guid":{"rendered":"https:\/\/pentadocs.fm1.dev\/request-appointment\/"},"modified":"2023-07-06T14:34:29","modified_gmt":"2023-07-06T18:34:29","slug":"request-appointment","status":"publish","type":"page","link":"https:\/\/pentadocs.com\/request-appointment\/","title":{"rendered":"Request Appointment"},"content":{"rendered":"\n<div class=\"request-appt-wrap\">\n\t<div class=\"request-img-left\"><\/div>\n\t<p class=\"above-form\">To request an appointment at one of our 10 convenient locations, please fill out the form below. Our office will follow up with you regarding a date and time for your appointment.<\/p>\n\t<p class=\"above-form\"><strong>If you are experiencing a medical emergency, please call 911.<\/strong><\/p>\n\t<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return 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)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_2' style='display:none'><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='\/wp-json\/wp\/v2\/pages\/22\/#gf_2' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_1\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\" ><label class='gfield_label gform-field-label' for='input_2_1'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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><\/div><div id=\"field_2_3\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\" ><label class='gfield_label gform-field-label' for='input_2_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_2_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_4\" ><label class='gfield_label gform-field-label' for='input_2_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_2_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\" ><legend class='gfield_label gform-field-label' >Select One:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_5'>\n\t\t\t<div class='gchoice gchoice_2_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='New Patient' checked='checked' id='choice_2_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_5_0' id='label_2_5_0' class='gform-field-label gform-field-label--type-inline'>New Patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Existing Patient'  id='choice_2_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_5_1' id='label_2_5_1' class='gform-field-label gform-field-label--type-inline'>Existing Patient<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_10\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\" ><label class='gfield_label gform-field-label' for='input_2_10'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-select populate-locations gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\" ><label class='gfield_label gform-field-label' for='input_2_6'>Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_2_6' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select a Location<\/option><option value='1784' >Exton, PA<\/option><option value='1803' >Kennett Square, PA<\/option><option value='1833' >West Chester, PA<\/option><option value='1839' >West Grove, PA<\/option><option value='30479' >Doylestown, PA<\/option><option value='1788' >Havertown, PA<\/option><option value='1821' >Paoli, PA<\/option><option value='1816' >Limerick, PA<\/option><option value='1773' >Blue Bell, PA<\/option><option value='1829' >Spring House, PA<\/option><\/select><\/div><\/div><div id=\"field_2_7\" class=\"gfield gfield--type-select populate-physicians gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\" ><label class='gfield_label gform-field-label' for='input_2_7'>Physician<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_2_7' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select a Provider<\/option><option value='No Preference' >No Preference<\/option><option value='Joseph Ardito, MD' >Joseph Ardito, MD<\/option><option value='Andrew V. Chuma, MD, FAAOA' >Andrew V. Chuma, MD, FAAOA<\/option><option value='Timothy J. Downey, MD' >Timothy J. Downey, MD<\/option><option value='Larry Feiner, MD, FACS' >Larry Feiner, MD, FACS<\/option><option value='Michael A. Hoffmann, MD' >Michael A. Hoffmann, MD<\/option><option value='Raymond Lesser, MD' >Raymond Lesser, MD<\/option><option value='Jenny F. Ma, MD' >Jenny F. Ma, MD<\/option><option value='Jillian Mattioni, DO' >Jillian Mattioni, DO<\/option><option value='Daniel P. Nadeau, MD' >Daniel P. Nadeau, MD<\/option><option value='Douglas Nadel, MD' >Douglas Nadel, MD<\/option><option value='Marc A. Stiefel, MD' >Marc A. Stiefel, MD<\/option><option value='Satyen Undavia, MD' >Satyen Undavia, MD<\/option><option value='Michael J. Ward, MD' >Michael J. Ward, MD<\/option><option value='Warren H. Zager, MD, FACS' >Warren H. Zager, MD, FACS<\/option><option value='Jillian Groman, PA-C' >Jillian Groman, PA-C<\/option><\/select><\/div><\/div><div id=\"field_2_8\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\" ><label class='gfield_label gform-field-label' for='input_2_8'>Appointment Time Preference<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_8' id='input_2_8' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='First Available' >First Available<\/option><option value='Morning' >Morning<\/option><option value='Afternoon' >Afternoon<\/option><option value='Evening' >Evening<\/option><\/select><\/div><\/div><div id=\"field_2_9\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\" ><label class='gfield_label gform-field-label' for='input_2_9'>Reason for Appointment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_2_9' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Allergy' >Allergy<\/option><option value='Balance' >Balance<\/option><option value='Ear' >Ear<\/option><option value='Facial Plastic Surgery' >Facial Plastic Surgery<\/option><option value='Hearing Aids' >Hearing Aids<\/option><option value='Hearing Loss' >Hearing Loss<\/option><option value='Nose &amp; Sinus' >Nose &amp; Sinus<\/option><option value='Pediatric Audiology' >Pediatric Audiology<\/option><option value='Pediatric ENT' >Pediatric ENT<\/option><option value='Throat' >Throat<\/option><option value='Sleep' >Sleep<\/option><option value='Voice &amp; Swallowing' >Voice &amp; Swallowing<\/option><\/select><\/div><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-fuelCAPTCHA field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible fuelCAPTCHA\"  data-field-class=\"fuelCAPTCHA\" data-js-reload=\"field_2_11\" ><label class='gfield_label gform-field-label screen-reader-text' for='input_2_11'><\/label><label>Name 2<input type=\"text\" name=\"name-2\" id=\"name-2\" value=\"John Doe\"><\/label><label>Email 2<input type=\"email\" name=\"email-2\" id=\"email-2\" value=\"\"><\/label><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button class=\"button gform_button\" id=\"gform_submit_button_2\">Submit<\/button> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme' \/>\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='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='WyJ7XCI1XCI6W1wiN2JhYTdkNGQxYmI3MTcxMmQ1NmY1NzQ3MmI3MjlmMzRcIixcIjUwYjM2MzliNDgzNjcxMGViOTgxNTQ4NjA5Y2Y4YjgwXCJdfSIsIjQyNTY0MWRlMDNhMWExMjhhY2Q1MTg2OTVjZTE5ZTllIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' 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                        <\/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>\ngform.initializeOnLoaded( function() {gformInitSpinner( 2, 'data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7', 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){form_content.find('form').css('opacity', 0);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); 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