{"id":147,"date":"2022-09-21T17:55:01","date_gmt":"2022-09-21T17:55:01","guid":{"rendered":"https:\/\/uabmedicine.org\/blogs\/greyform\/?page_id=147"},"modified":"2022-10-21T13:53:12","modified_gmt":"2022-10-21T13:53:12","slug":"oncc-new-patient-appt-request","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/oncc-new-patient-appt-request\/","title":{"rendered":"O&#8217;Neal Comprehensive Cancer Center New Patient Appt Request"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var 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 gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_18' style='display:none'><div id='gf_18' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_18' id='gform_18'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/147#gf_18' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_18' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_18_18\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Please choose which best applies to you<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_18_18'>\n\t\t\t<div class='gchoice gchoice_18_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='I am a patient'  id='choice_18_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_18_0' id='label_18_18_0'>I am a patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='I am a referring physician'  id='choice_18_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_18_1' id='label_18_18_1'>I am a referring physician<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_18_17\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p class=\"lead\">Please submit this form to request an appointment.<\/p><\/div><div id=\"field_18_3\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_18_3' >Referring Provider 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_3' id='input_18_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_18_21\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Referring Provider Point of Contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_18_21'>\n                            \n                            <span id='input_18_21_3_container' class='name_first' >\n                                                    <input type='text' name='input_21.3' id='input_18_21_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_18_21_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_18_21_6_container' class='name_last' >\n                                                    <input type='text' name='input_21.6' id='input_18_21_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_18_21_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_18_22\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_18_22' >Referring Provider Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_18_22' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_18_23\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_18_23' >Referring Provider Phone #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_23' id='input_18_23' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_24\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_18_24' >Referring Provider Fax #<\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_18_24' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_26\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_18_26' >Reason for Referral<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_26' id='input_18_26' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_18_4\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_18_4' >Does your patient have a cancer diagnosis?<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_4' id='input_18_4' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='No Diagnosis' >No Diagnosis<\/option><option value='Unknown' >Unknown<\/option><option value='Other' >Other<\/option><option value='Adrenal Carcinoma' >Adrenal Carcinoma<\/option><option value='Adrenal nodules\/adrenal mass' >Adrenal nodules\/adrenal mass<\/option><option value='Anal Cancer' >Anal Cancer<\/option><option value='Appendix Cancer' >Appendix Cancer<\/option><option value='Basal Cell Carcinoma' >Basal Cell Carcinoma<\/option><option value='Bladder Cancer' >Bladder Cancer<\/option><option value='Brain Cancer' >Brain Cancer<\/option><option value='Breast Cancer' >Breast Cancer<\/option><option value='Cervical Cancer' >Cervical Cancer<\/option><option value='Cholangiocarcinoma (Bile Duct Cancer)' >Cholangiocarcinoma (Bile Duct Cancer)<\/option><option value='Colon Cancer' >Colon Cancer<\/option><option value='Colorectal Cancer' >Colorectal Cancer<\/option><option value='Ductal Carcinoma In Situ' >Ductal Carcinoma In Situ<\/option><option value='Esophageal Cancer' >Esophageal Cancer<\/option><option value='Gall Bladder Cancer' >Gall Bladder Cancer<\/option><option value='GI Carcinoid Tumor' >GI Carcinoid Tumor<\/option><option value='GIST (GI Stromal Tumor)' >GIST (GI Stromal Tumor)<\/option><option value='Glioblastoma' >Glioblastoma<\/option><option value='Head and Neck Cancer' >Head and Neck Cancer<\/option><option value='Hodgkin Lymphoma' >Hodgkin Lymphoma<\/option><option value='Inflammatory Breast Cancer' >Inflammatory Breast Cancer<\/option><option value='Invasive Ductal Carcinoma' >Invasive Ductal Carcinoma<\/option><option value='Kidney (Renal Vell) Cancer' >Kidney (Renal Vell) Cancer<\/option><option value='Leukemia' >Leukemia<\/option><option value='Liver Cancer' >Liver Cancer<\/option><option value='Lung Cancer' >Lung Cancer<\/option><option value='Lymphoma (Hodgkin\/Non-Hodgkin)' >Lymphoma (Hodgkin\/Non-Hodgkin)<\/option><option value='Melanoma' >Melanoma<\/option><option value='Meningioma' >Meningioma<\/option><option value='Merkel Cell Carcinoma' >Merkel Cell Carcinoma<\/option><option value='Multiple Myeloma' >Multiple Myeloma<\/option><option value='Myelodysplastic Syndromes (MDS)' >Myelodysplastic Syndromes (MDS)<\/option><option value='Neuroendocrine Tumor' >Neuroendocrine Tumor<\/option><option value='Neurofibromatosis' >Neurofibromatosis<\/option><option value='Non-Hodgkin Lymphoma' >Non-Hodgkin Lymphoma<\/option><option value='Osteosarcoma' >Osteosarcoma<\/option><option value='Ovarian' >Ovarian<\/option><option value='Pancoast Tumor' >Pancoast Tumor<\/option><option value='Penile Cancer' >Penile Cancer<\/option><option value='Pituitary Macroadenoma' >Pituitary Macroadenoma<\/option><option value='Pituitary Microadenoma' >Pituitary Microadenoma<\/option><option value='Pituitary neoplasm' >Pituitary neoplasm<\/option><option value='Prostate Cancer' >Prostate Cancer<\/option><option value='Rectal Cancer' >Rectal Cancer<\/option><option value='Sarcoma' >Sarcoma<\/option><option value='Skin Cancer (Nonmelanoma)' >Skin Cancer (Nonmelanoma)<\/option><option value='Small Intestine Cancer' >Small Intestine Cancer<\/option><option value='Spinal Tumor' >Spinal Tumor<\/option><option value='Squamous Cell Carcinoma' >Squamous Cell Carcinoma<\/option><option value='Stomach (Gastric) Cancer' >Stomach (Gastric) Cancer<\/option><option value='Testicular Cancer' >Testicular Cancer<\/option><option value='Thymoma' >Thymoma<\/option><option value='Thyroid Cancer' >Thyroid Cancer<\/option><option value='Thyroid Nodules' >Thyroid Nodules<\/option><option value='Triple Negative Breast Cancer' >Triple Negative Breast Cancer<\/option><option value='Vaginal Cancer' >Vaginal Cancer<\/option><option value='Vulvar Cancer' >Vulvar Cancer<\/option><\/select><\/div><\/div><fieldset id=\"field_18_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_18_5'>\n                            \n                            <span id='input_18_5_3_container' class='name_first' >\n                                                    <input type='text' name='input_5.3' id='input_18_5_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_18_5_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_18_5_6_container' class='name_last' >\n                                                    <input type='text' name='input_5.6' id='input_18_5_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_18_5_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_18_7\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_18_7' >Patient&#039;s Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_18_7' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_8\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_18_8' >Patient&#039;s Alternate Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_18_8' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_18_9\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Patient&#039;s Mailing Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_18_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_18_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_18_9_1' value=''    aria-required='false'    \/>\n                                        <label for='input_18_9_1' id='input_18_9_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_18_9_2_container' >\n                                        <input type='text' name='input_9.2' id='input_18_9_2' value=''     aria-required='false'   \/>\n                                        <label for='input_18_9_2' id='input_18_9_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_18_9_3_container' >\n                                    <input type='text' name='input_9.3' id='input_18_9_3' value=''    aria-required='false'    \/>\n                                    <label for='input_18_9_3' id='input_18_9_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_18_9_4_container' >\n                                        <select name='input_9.4' id='input_18_9_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_18_9_4' id='input_18_9_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_18_9_5_container' >\n                                    <input type='text' name='input_9.5' id='input_18_9_5' value=''    aria-required='false'    \/>\n                                    <label for='input_18_9_5' id='input_18_9_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_9.6' id='input_18_9_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_18_10\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_18_10' >Patient&#039;s Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_10' id='input_18_10' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_18_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_18_10_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_18_10' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_18_20\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_18_20' >Patient&#039;s Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_20' id='input_18_20' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_18_20_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_18_20_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_18_20' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_18_11\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_18_11' >Primary Insurance Type<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_18_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_18_14\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_18_14' >Primary Insurance Policy Number<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_18_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_18_13\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Does your patient have Secondary Insurance?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_13'>\n\t\t\t<div class='gchoice gchoice_18_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes'  id='choice_18_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_13_0' id='label_18_13_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_18_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_13_1' id='label_18_13_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_18_16\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='gform_browse_button_18_16' >You may upload patient\u2019s records and insurance card to help ease the appointment process<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_18_16' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_18_16&quot;,&quot;container&quot;:&quot;gform_multifile_upload_18_16&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_18_16&quot;,&quot;filelist&quot;:&quot;gform_preview_18_16&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/uabforms.hs.uab.edu\\\/blogs\\\/greyform\\\/?gf_page=d61af79efd0b180&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/uabforms.hs.uab.edu\\\/blogs\\\/greyform\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/uabforms.hs.uab.edu\\\/blogs\\\/greyform\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed 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class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button id='gform_browse_button_18_16' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_18_16\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gform_fileupload_rules' id='gfield_upload_rules_18_16'>Accepted file types: doc, pdf, jpg, gif, png, txt, Max. file size: 8 MB.<\/span><ul class='validation_message validation_message--hidden-on-empty gfield_validation_message gform-ul-reset' id='gform_multifile_messages_18_16'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_18_16'><\/div><\/div><div id=\"field_18_25\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>If you need assistance making a referral, please call <a 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