{"id":193,"date":"2022-11-14T18:52:33","date_gmt":"2022-11-14T18:52:33","guid":{"rendered":"https:\/\/uabmedicine.org\/blogs\/greyform\/?page_id=193"},"modified":"2023-02-07T19:12:28","modified_gmt":"2023-02-07T19:12:28","slug":"inflammatory-bowel-disease-clinic-referral","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/inflammatory-bowel-disease-clinic-referral\/","title":{"rendered":"Inflammatory Bowel Disease Clinic Referral"},"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 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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_26' style='display:none'><div id='gf_26' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_26' id='gform_26'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/193#gf_26' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_26' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_26_1\" class=\"gfield 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class='name_last' >\n                                                    <input type='text' name='input_1.6' id='input_26_1_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_26_1_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_26_2\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_2' >Patient\u2019s 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_2' id='input_26_2' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_26_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_26_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_26_2' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_26_4\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_4' >Patient\u2019s Telephone #<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_4' id='input_26_4' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_26_3\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_3' >Patient Alternative Telephone #<\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_26_3' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_26_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_5' >Patient Insurance 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_5' id='input_26_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_26_6\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_6' >Patient Insurance Policy\/Group Number<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_6' id='input_26_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_26_7\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >What condition is being referred?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_26_7'><div class='gchoice gchoice_26_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='Crohn\u2019s disease'  id='choice_26_7_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_26_7_1' id='label_26_7_1'>Crohn\u2019s disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_26_7_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.2' type='checkbox'  value='Ulcerative colitis'  id='choice_26_7_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_26_7_2' id='label_26_7_2'>Ulcerative colitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_26_7_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.3' type='checkbox'  value='Indeterminate colitis'  id='choice_26_7_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_26_7_3' id='label_26_7_3'>Indeterminate colitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_26_7_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.4' type='checkbox'  value='Microscopic colitis'  id='choice_26_7_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_26_7_4' id='label_26_7_4'>Microscopic colitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_26_8\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Services needed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_26_8'><div class='gchoice gchoice_26_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Seeking second opinion regarding medical therapy'  id='choice_26_8_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_26_8_1' id='label_26_8_1'>Seeking second opinion regarding medical therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_26_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.2' type='checkbox'  value='Evaluation and treatment'  id='choice_26_8_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_26_8_2' id='label_26_8_2'>Evaluation and treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_26_8_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.3' type='checkbox'  value='More precise diagnosis of IBD'  id='choice_26_8_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_26_8_3' id='label_26_8_3'>More precise diagnosis of IBD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_26_8_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.4' type='checkbox'  value='Chromoendoscopy for dysplasia'  id='choice_26_8_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_26_8_4' id='label_26_8_4'>Chromoendoscopy for dysplasia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_26_8_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.5' type='checkbox'  value='Other'  id='choice_26_8_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_26_8_5' id='label_26_8_5'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_26_9\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_9' >Other<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_9' id='input_26_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_26_10\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Urgency<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_26_10'>\n\t\t\t<div class='gchoice gchoice_26_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Within 2 weeks'  id='choice_26_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_10_0' id='label_26_10_0'>Within 2 weeks<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_26_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Within 2 months'  id='choice_26_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_26_10_1' id='label_26_10_1'>Within 2 months<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_26_11\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Referring Physician<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_26_11'>\n                            \n                            <span id='input_26_11_3_container' class='name_first' >\n                                                    <input type='text' name='input_11.3' id='input_26_11_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_26_11_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_26_11_6_container' class='name_last' >\n                                                    <input type='text' name='input_11.6' id='input_26_11_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_26_11_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_26_12\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_12' >Referring Office 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_12' id='input_26_12' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_26_16\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_16' 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