{"id":656,"date":"2024-08-05T09:47:13","date_gmt":"2024-08-05T14:47:13","guid":{"rendered":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/?page_id=656"},"modified":"2024-08-05T09:47:27","modified_gmt":"2024-08-05T14:47:27","slug":"cardiovascular-mri-procedure-request","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/cardiovascular-mri-procedure-request\/","title":{"rendered":"Cardiovascular MRI Procedure 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_169' style='display:none'><div id='gf_169' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_169' id='gform_169'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/656#gf_169' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_169' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_169_8\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >Thank you for your interest in UAB Medicine.<\/br>\n<\/br>\nFor your convenience, we offer two easy methods to refer your patient. <a href=\"https:\/\/www.uabmedicine.org\/wp-content\/uploads\/sites\/3\/2023\/03\/CV-MRI-Procedure-Form-1.pdf\" target=\"_blank\">Click here<\/a> to download a printable form, which may be completed and faxed back to us, or simply complete and submit the electronic form below and we will contact your office.<\/div><fieldset id=\"field_169_1\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Patient Name<\/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_169_1'>\n                            \n                            <span id='input_169_1_3_container' class='name_first' >\n                                                    <input type='text' name='input_1.3' id='input_169_1_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_169_1_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_169_1_6_container' class='name_last' >\n                                                    <input type='text' name='input_1.6' id='input_169_1_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_169_1_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_169_2\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_2' >MRN<\/label><div class='ginput_container ginput_container_number'><input name='input_2' id='input_169_2' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_169_3\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_3' >DOB<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_169_3' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_169_3_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_169_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_169_3' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_169_4\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_4' >Sex<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_169_4' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_169_5\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_5' >Age<\/label><div class='ginput_container ginput_container_number'><input name='input_5' id='input_169_5' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_169_6\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_6' >Height<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_169_6' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_169_7\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_7' >Weight<\/label><div class='ginput_container ginput_container_number'><input name='input_7' id='input_169_7' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_169_10\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>If patient has cardiac pacemaker, defibrillator, ICD, aneurysm clips, or metallic foreign body please notify CVMRI technologist at 205.934.9906. Failure to identify the above can be potentially life threatening to the patient.<\/br>\nIf patient weighs more than 250 lbs, please call a CVMRI technologist prior to scheduling study.<\/p><\/div><div id=\"field_169_11\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Diagnosis<\/h3><\/div><div id=\"field_169_12\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_12' >Reason Study is Requested: (Please be very specific. Must include enough clinical information to justify use of Cardiac Magnetic Resonance Imaging. Include any pertinent previous diagnostic testing results.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_169_12' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_169_13\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Cardiac MRI Procedures Requested:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_169_13'><div class='gchoice gchoice_169_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Ventricular Function'  id='choice_169_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_13_1' id='label_169_13_1'>Ventricular Function<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_169_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Valve Assessment'  id='choice_169_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_13_2' id='label_169_13_2'>Valve Assessment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_169_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Rule-Out Mass'  id='choice_169_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_13_3' id='label_169_13_3'>Rule-Out Mass<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_169_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Congenital'  id='choice_169_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_13_4' id='label_169_13_4'>Congenital<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_169_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Pericardial Disease'  id='choice_169_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_13_5' id='label_169_13_5'>Pericardial Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_169_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='Renal Arteries'  id='choice_169_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_13_6' id='label_169_13_6'>Renal Arteries<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_169_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='Thoracic Aorta'  id='choice_169_13_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_13_7' id='label_169_13_7'>Thoracic Aorta<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_169_13_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.8' type='checkbox'  value='Abdominal Aorta'  id='choice_169_13_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_13_8' id='label_169_13_8'>Abdominal Aorta<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_169_13_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.9' type='checkbox'  value='Iliofemorals'  id='choice_169_13_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_13_9' id='label_169_13_9'>Iliofemorals<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_169_13_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.11' type='checkbox'  value='Other'  id='choice_169_13_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_13_11' id='label_169_13_11'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_169_14\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_14' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_169_14' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_169_15\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Lab<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_169_15'><div class='gchoice gchoice_169_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='STAT Creatinine\/I-STAT'  id='choice_169_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_15_1' id='label_169_15_1'>STAT Creatinine\/I-STAT<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_169_16\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Insurance Information<\/h3><\/div><div id=\"field_169_17\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_17' >Primary Carrier:<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_169_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_169_18\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Policy Holder:<\/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_169_18'>\n                            \n                            <span id='input_169_18_3_container' class='name_first' >\n                                                    <input type='text' name='input_18.3' id='input_169_18_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_169_18_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_169_18_6_container' class='name_last' >\n                                                    <input type='text' name='input_18.6' id='input_169_18_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_169_18_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_169_19\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_19' >Policy Number:<\/label><div class='ginput_container ginput_container_number'><input name='input_19' id='input_169_19' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_169_20\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_20' >Group Number:<\/label><div class='ginput_container ginput_container_number'><input name='input_20' id='input_169_20' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_169_21\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Pre-certification Required:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_169_21'><div class='gchoice gchoice_169_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Yes'  id='choice_169_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_21_1' id='label_169_21_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_169_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='No'  id='choice_169_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_169_21_2' id='label_169_21_2'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_169_22\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_22' >Secondary Carrier:<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_169_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_169_23\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Policy Holder:<\/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_169_23'>\n                            \n                            <span id='input_169_23_3_container' class='name_first' >\n                                                    <input type='text' name='input_23.3' id='input_169_23_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_169_23_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_169_23_6_container' class='name_last' >\n                                                    <input type='text' name='input_23.6' id='input_169_23_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_169_23_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_169_24\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_24' >Policy Number:<\/label><div class='ginput_container ginput_container_number'><input name='input_24' id='input_169_24' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_169_25\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_25' >Group Number:<\/label><div class='ginput_container ginput_container_number'><input name='input_25' id='input_169_25' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_169_26\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_26' >Authorization Number:<\/label><div class='ginput_container ginput_container_number'><input name='input_26' id='input_169_26' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_169_27\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>Note: Many insurance companies require pre-certification for Cardiac MRI procedures. Please call the number on the back of the patient\u2019s insurance card and obtain an authorization number before scheduling MRI.<\/p><\/div><fieldset id=\"field_169_28\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Ordered by:<\/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_169_28'>\n                            \n                            <span id='input_169_28_3_container' class='name_first' >\n                                                    <input type='text' name='input_28.3' id='input_169_28_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_169_28_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_169_28_6_container' class='name_last' >\n                                                    <input type='text' name='input_28.6' id='input_169_28_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_169_28_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_169_29\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_29' >Date Scheduled:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_29' id='input_169_29' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_169_29_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_169_29_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_169_29' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_169_30\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Time Scheduled:<\/legend><div class=\"ginput_complex\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time' id='input_169_30'>\n                            <input type='number' maxlength='2' name='input_30[]' id='input_169_30_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='hour_label screen-reader-text' for='input_169_30_1' >Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time'>\n                            <input type='number' maxlength='2' name='input_30[]' id='input_169_30_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='minute_label screen-reader-text' for='input_169_30_2' >Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below' >\n                                \n                                <select name='input_30[]' id='input_169_30_3'   aria-label='AM\/PM'>\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                           <\/div>\n                    <\/div><\/fieldset><fieldset id=\"field_169_32\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Attending MD:<\/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_169_32'>\n                            \n                            <span id='input_169_32_3_container' class='name_first' >\n                                                    <input type='text' name='input_32.3' id='input_169_32_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_169_32_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_169_32_6_container' class='name_last' >\n                                                    <input type='text' name='input_32.6' id='input_169_32_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_169_32_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_169_31\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_169_31' >Extension:<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_169_31' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_169_33\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >CVMRI Technologist:<\/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_169_33'>\n                            \n                            <span id='input_169_33_3_container' class='name_first' >\n                                                    <input type='text' name='input_33.3' id='input_169_33_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_169_33_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_169_33_6_container' class='name_last' >\n                                                    <input type='text' name='input_33.6' id='input_169_33_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_169_33_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_169_34\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Referring MD:<\/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_169_34'>\n                            \n                            <span id='input_169_34_3_container' class='name_first' >\n                                                    <input type='text' name='input_34.3' id='input_169_34_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_169_34_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_169_34_6_container' class='name_last' >\n                                                    <input type='text' name='input_34.6' id='input_169_34_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_169_34_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_169_35\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><address>Boshell Diabetes Building \u2022 1808 7th Avenue South, Suite 101 \u2022 Birmingham, AL 35294 \u2022 205.934.9906 Phone \u2022 205.975.1952 Fax<\/address><\/div><div id=\"field_169_9\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><style>\nbody {font-family: 'Helvetica', Arial, serif;}\nbody .label .gform_wrapper .gform_body, h1, h2, h2 a, h2 a:visited, h3, h4, h5, h6, p, span, select, textarea {\n    font-family: 'Helvetica', Arial, serif !important;\n}\ninput, label, select, textarea {\nfont-family: 'Helvetica', Arial, serif !important;\n}\n.gform_title { color: #006666 !important; }\nbody .gform_wrapper .gform_footer input[type=submit] {background: #006666;\nborder: 1px solid #006666;\n}\nbody.mocha-gravity-plain {background: transparent !important;\n}\n#content {\n-webkit-box-shadow: 0px 0px 0px 0px !important;\nbox-shadow: 0px 0px 0px 0px !important;\nbackground: #fff !important;\n}\n<\/style><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_169' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_169\"]){return false;}  if( !jQuery(\"#gform_169\")[0].checkValidity || jQuery(\"#gform_169\")[0].checkValidity()){window[\"gf_submitting_169\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_169\"]){return false;} if( !jQuery(\"#gform_169\")[0].checkValidity || jQuery(\"#gform_169\")[0].checkValidity()){window[\"gf_submitting_169\"]=true;}  jQuery(\"#gform_169\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=169&amp;title=&amp;description=&amp;tabindex=0' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_169' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='169' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_169' value='WyJbXSIsImQ4OGVkZmY0NjE4YzNjYTY4YTYyNWRhMjJjNDUzY2JkIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_169' id='gform_target_page_number_169' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_169' id='gform_source_page_number_169' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_169' id='gform_ajax_frame_169' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 169, 'https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery('#gform_ajax_frame_169').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_169');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_169').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){jQuery('#gform_wrapper_169').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_169').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_169').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_169').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_169').val();gformInitSpinner( 169, 'https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery(document).trigger('gform_page_loaded', [169, current_page]);window['gf_submitting_169'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_169').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_169').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [169]);window['gf_submitting_169'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_169').text());}, 50);}else{jQuery('#gform_169').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [169, current_page]);} );} );\n<\/script>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":5,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"\/web\/sites\/blogs\/greyform\/wp-content\/plugins\/uab-blank-page-templates\/templates\/uabmed-blank-template.php","meta":{"footnotes":""},"class_list":["post-656","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/656","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/users\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/comments?post=656"}],"version-history":[{"count":1,"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/656\/revisions"}],"predecessor-version":[{"id":657,"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/656\/revisions\/657"}],"wp:attachment":[{"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/media?parent=656"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}