{"id":6,"date":"2025-07-26T04:09:50","date_gmt":"2025-07-26T04:09:50","guid":{"rendered":"https:\/\/randrpatientintake.com\/?page_id=6"},"modified":"2025-08-16T04:25:39","modified_gmt":"2025-08-16T04:25:39","slug":"home","status":"publish","type":"page","link":"https:\/\/randrpatientintake.com\/","title":{"rendered":"Home"},"content":{"rendered":"\t\t
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\n\t\t\t\t\t\r\n\r\n\r\n \r\n \r\n Patient Intake Form - Rise and Recover Therapy Clinic<\/title>\r\n <!-- Tailwind CSS CDN -->\r\n <script src=\"https:\/\/cdn.tailwindcss.com\"><\/script>\r\n <style>\r\n \/* Custom styles for Inter font and general body styling *\/\r\n body {\r\n font-family: 'Inter', sans-serif;\r\n background-color: #f0f2f5; \/* Light gray background for a modern feel *\/\r\n display: flex;\r\n justify-content: center;\r\n align-items: flex-start; \/* Align items to the top for better scrolling on long forms *\/\r\n min-height: 100vh;\r\n padding: 2rem 1rem; \/* More padding for a spacious look *\/\r\n }\r\n .container {\r\n max-width: 900px; \/* Slightly wider for modern forms *\/\r\n width: 100%;\r\n margin: 0 auto;\r\n background: #ffffff;\r\n padding: 2.5rem; \/* Increased padding *\/\r\n box-shadow: 0 10px 25px rgba(0, 0, 0, 0.1); \/* Softer, more pronounced shadow *\/\r\n border-radius: 1rem; \/* More rounded corners *\/\r\n }\r\n h1 {\r\n font-size: 2.5rem; \/* Larger main title *\/\r\n font-weight: 700; \/* Bold *\/\r\n text-align: center;\r\n color: #1a202c; \/* Darker text for better contrast *\/\r\n margin-bottom: 1.5rem;\r\n border-bottom: none; \/* Remove border for a cleaner look *\/\r\n padding-bottom: 0;\r\n }\r\n h2 {\r\n font-size: 1.875rem; \/* Slightly smaller, but still prominent *\/\r\n font-weight: 600; \/* Semi-bold *\/\r\n color: #2d3748; \/* Darker gray for section titles *\/\r\n margin-top: 2.5rem; \/* More space above sections *\/\r\n margin-bottom: 1rem;\r\n border-bottom: 1px solid #e2e8f0; \/* Subtle bottom border *\/\r\n padding-bottom: 0.5rem;\r\n }\r\n h3 {\r\n font-size: 1.25rem; \/* Clear sub-section titles *\/\r\n font-weight: 600;\r\n color: #4a5568; \/* Medium gray *\/\r\n margin-top: 1.5rem;\r\n margin-bottom: 0.75rem;\r\n }\r\n .form-group {\r\n margin-bottom: 1.25rem; \/* Consistent spacing *\/\r\n }\r\n .form-group label {\r\n display: block;\r\n margin-bottom: 0.5rem;\r\n font-weight: 500; \/* Medium weight for labels *\/\r\n color: #2d3748;\r\n font-size: 0.95rem;\r\n }\r\n .form-group input[type=\"text\"],\r\n .form-group input[type=\"email\"],\r\n .form-group input[type=\"tel\"],\r\n .form-group input[type=\"date\"],\r\n .form-group input[type=\"number\"],\r\n .form-group textarea,\r\n .form-group select {\r\n width: 100%;\r\n padding: 0.75rem 1rem; \/* Generous padding *\/\r\n border: 1px solid #cbd5e0; \/* Light gray border *\/\r\n border-radius: 0.5rem; \/* Rounded input fields *\/\r\n box-sizing: border-box;\r\n font-size: 1rem;\r\n font-family: 'Inter', sans-serif;\r\n background-color: #f7fafc; \/* Very light background for inputs *\/\r\n transition: all 0.2s ease-in-out;\r\n }\r\n .form-group input:focus,\r\n .form-group textarea:focus,\r\n .form-group select:focus {\r\n outline: none;\r\n border-color: #4299e1; \/* Blue border on focus *\/\r\n box-shadow: 0 0 0 3px rgba(66, 153, 225, 0.5); \/* Soft blue shadow on focus *\/\r\n background-color: #ffffff;\r\n }\r\n \/* Style for file input to match overall design *\/\r\n .form-group input[type=\"file\"] {\r\n padding: 0.75rem 1rem;\r\n border: 1px solid #cbd5e0;\r\n border-radius: 0.5rem;\r\n background-color: #f7fafc;\r\n color: #4a5568;\r\n cursor: pointer;\r\n width: 100%;\r\n }\r\n .form-group input[type=\"file\"]::file-selector-button {\r\n background-color: #4299e1;\r\n color: white;\r\n padding: 0.5rem 1rem;\r\n border: none;\r\n border-radius: 0.375rem;\r\n cursor: pointer;\r\n margin-right: 1rem;\r\n transition: background-color 0.2s ease;\r\n }\r\n .form-group input[type=\"file\"]::file-selector-button:hover {\r\n background-color: #3182ce;\r\n }\r\n\r\n .form-group.checkbox-group label {\r\n display: inline-flex; \/* Use flex for better alignment *\/\r\n align-items: center;\r\n \/* Removed margin-right here to let gap utilities handle spacing *\/\r\n font-weight: normal;\r\n cursor: pointer;\r\n color: #4a5568;\r\n font-size: 0.9rem;\r\n }\r\n .form-group.checkbox-group input[type=\"checkbox\"],\r\n .form-group.checkbox-group input[type=\"radio\"] {\r\n margin-right: 0.5rem;\r\n width: 1.25rem; \/* Larger checkbox\/radio *\/\r\n height: 1.25rem;\r\n border: 1px solid #a0aec0; \/* Darker border for checkboxes *\/\r\n border-radius: 0.25rem; \/* Slightly rounded for checkboxes *\/\r\n appearance: none; \/* Hide default checkbox *\/\r\n -webkit-appearance: none;\r\n -moz-appearance: none;\r\n cursor: pointer;\r\n position: relative;\r\n flex-shrink: 0; \/* Prevent shrinking *\/\r\n }\r\n .form-group.checkbox-group input[type=\"radio\"] {\r\n border-radius: 50%; \/* Make radio buttons perfectly round *\/\r\n }\r\n .form-group.checkbox-group input[type=\"checkbox\"]:checked,\r\n .form-group.checkbox-group input[type=\"radio\"]:checked {\r\n background-color: #4299e1; \/* Blue background when checked *\/\r\n border-color: #4299e1;\r\n }\r\n \/* Custom checkmark for checkboxes *\/\r\n .form-group.checkbox-group input[type=\"checkbox\"]:checked::before {\r\n content: '\\2713'; \/* Unicode checkmark *\/\r\n display: block;\r\n position: absolute;\r\n top: 50%;\r\n left: 50%;\r\n transform: translate(-50%, -50%);\r\n color: white;\r\n font-size: 0.8rem;\r\n }\r\n \/* Custom dot for radio buttons *\/\r\n .form-group.checkbox-group input[type=\"radio\"]:checked::before {\r\n content: '';\r\n display: block;\r\n width: 0.6rem;\r\n height: 0.6rem;\r\n border-radius: 50%;\r\n background-color: white;\r\n position: absolute;\r\n top: 50%;\r\n left: 50%;\r\n transform: translate(-50%, -50%);\r\n }\r\n\r\n \/* Tailwind-like grid classes for responsiveness *\/\r\n .grid-cols-2 {\r\n display: grid;\r\n grid-template-columns: repeat(1, 1fr); \/* Default to single column on small screens *\/\r\n gap: 1.5rem;\r\n }\r\n @media (min-width: 768px) { \/* md breakpoint *\/\r\n .grid-cols-2 {\r\n grid-template-columns: repeat(2, 1fr);\r\n }\r\n }\r\n .grid-cols-3 {\r\n display: grid;\r\n grid-template-columns: repeat(1, 1fr);\r\n gap: 1.5rem;\r\n }\r\n @media (min-width: 768px) {\r\n .grid-cols-3 {\r\n grid-template-columns: repeat(3, 1fr);\r\n }\r\n }\r\n .grid-cols-4 {\r\n display: grid;\r\n grid-template-columns: repeat(1, 1fr);\r\n gap: 1.5rem;\r\n }\r\n @media (min-width: 768px) {\r\n .grid-cols-4 {\r\n grid-template-columns: repeat(4, 1fr);\r\n }\r\n }\r\n\r\n .text-center {\r\n text-align: center;\r\n }\r\n .logo-container {\r\n text-align: center;\r\n margin-bottom: 2rem;\r\n }\r\n .logo-container img {\r\n max-width: 250px; \/* Slightly larger logo for modern design *\/\r\n height: auto;\r\n display: block;\r\n margin: 0 auto;\r\n border-radius: 0.5rem; \/* Rounded logo corners *\/\r\n box-shadow: 0 4px 10px rgba(0, 0, 0, 0.08); \/* Subtle shadow for logo *\/\r\n }\r\n .signature-line {\r\n border-bottom: 1px solid #a0aec0; \/* Lighter line *\/\r\n margin-top: 1.5rem;\r\n padding-bottom: 0.5rem;\r\n }\r\n .signature-label {\r\n font-size: 0.8rem;\r\n color: #718096;\r\n margin-top: 0.25rem;\r\n }\r\n .consent-text {\r\n font-size: 0.9rem;\r\n line-height: 1.6;\r\n margin-bottom: 1rem;\r\n padding: 1rem;\r\n background-color: #edf2f7; \/* Lighter background for consent text *\/\r\n border: 1px solid #e2e8f0;\r\n border-radius: 0.5rem;\r\n color: #4a5568;\r\n }\r\n .pain-silhouette {\r\n width: 100%;\r\n max-width: 400px; \/* Larger silhouette *\/\r\n margin: 1.5rem auto;\r\n border: 1px solid #cbd5e0;\r\n padding: 1rem;\r\n background-color: #ffffff;\r\n display: block;\r\n border-radius: 0.75rem;\r\n box-shadow: 0 2px 8px rgba(0, 0, 0, 0.05);\r\n }\r\n .pain-silhouette svg {\r\n width: 100%;\r\n height: auto;\r\n display: block;\r\n }\r\n .disclaimer {\r\n font-size: 0.75rem;\r\n color: #718096;\r\n margin-top: 2rem;\r\n text-align: center;\r\n }\r\n \/* Styles for the custom modal *\/\r\n .modal {\r\n display: none; \/* Hidden by default *\/\r\n position: fixed; \/* Stay in place *\/\r\n z-index: 1000; \/* Sit on top *\/\r\n left: 0;\r\n top: 0;\r\n width: 100%; \/* Full width *\/\r\n height: 100%; \/* Full height *\/\r\n overflow: auto; \/* Enable scroll if needed *\/\r\n background-color: rgba(0,0,0,0.6); \/* Darker overlay *\/\r\n display: flex; \/* Use flex for centering *\/\r\n justify-content: center;\r\n align-items: center;\r\n }\r\n .modal-content {\r\n background-color: #ffffff;\r\n padding: 2.5rem;\r\n border-radius: 1rem; \/* Rounded corners *\/\r\n box-shadow: 0 10px 30px rgba(0,0,0,0.25); \/* Stronger shadow *\/\r\n width: 90%;\r\n max-width: 550px;\r\n text-align: center;\r\n transform: translateY(-20px); \/* Slight animation effect *\/\r\n animation: fadeIn 0.3s ease-out forwards;\r\n }\r\n @keyframes fadeIn {\r\n from { opacity: 0; transform: translateY(-30px); }\r\n to { opacity: 1; transform: translateY(0); }\r\n }\r\n .modal-content h3 {\r\n color: #1a202c;\r\n font-size: 1.875rem;\r\n margin-bottom: 1rem;\r\n font-weight: 700;\r\n }\r\n .modal-content p {\r\n margin-bottom: 1.5rem;\r\n color: #4a5568;\r\n font-size: 1rem;\r\n }\r\n .modal-content button {\r\n background-color: #4299e1; \/* Blue button *\/\r\n color: white;\r\n padding: 0.75rem 1.5rem;\r\n border: none;\r\n border-radius: 0.5rem;\r\n cursor: pointer;\r\n font-size: 1rem;\r\n font-weight: 600;\r\n transition: background-color 0.2s ease, transform 0.1s ease;\r\n }\r\n .modal-content button:hover {\r\n background-color: #3182ce;\r\n transform: translateY(-2px);\r\n }\r\n \/* Submit button styling *\/\r\n .submit-button {\r\n display: block;\r\n width: auto;\r\n margin: 2.5rem auto 0 auto;\r\n padding: 1rem 2.5rem;\r\n background-color: #38a169; \/* Green for submit *\/\r\n color: white;\r\n border: none;\r\n border-radius: 0.75rem; \/* More rounded *\/\r\n font-size: 1.15rem;\r\n font-weight: 700;\r\n cursor: pointer;\r\n transition: background-color 0.3s ease, transform 0.1s ease, box-shadow 0.3s ease;\r\n box-shadow: 0 5px 15px rgba(56, 161, 105, 0.3); \/* Green shadow *\/\r\n }\r\n .submit-button:hover {\r\n background-color: #2f855a;\r\n transform: translateY(-3px);\r\n box-shadow: 0 8px 20px rgba(56, 161, 105, 0.4);\r\n }\r\n .submit-button:active {\r\n transform: translateY(0);\r\n box-shadow: 0 2px 5px rgba(56, 161, 105, 0.2);\r\n }\r\n <\/style>\r\n<\/head>\r\n<body>\r\n <div class=\"container\">\r\n <div class=\"logo-container\">\r\n <img decoding=\"async\" src=\"https:\/\/randrpatientintake.com\/wp-content\/uploads\/2025\/07\/PHOTO-2024-12-18-11-04-04-e1753677205110.jpg\" alt=\"Rise and Recover Therapy Clinic Logo\">\r\n <\/div>\r\n <h1>Patient Intake Form<\/h1>\r\n <div class=\"text-center text-gray-600 mb-8 text-sm\">\r\n <p class=\"font-semibold text-gray-800 text-base mb-1\">Rise and Recover Therapy Clinic<\/p>\r\n <p>6537 Preston Rd Suite B-1, Plano, TX 75024<\/p>\r\n <p>Phone: (972) 565-3585 | Email: randrtherapyclinics@gmail.com | Fax: (972) 433 \ufffd 6620<\/p>\r\n <p class=\"mt-4 text-gray-700\">To provide you with the best possible care, please take a few moments to complete your intake information. This helps us understand your needs better before your visit. Your privacy is our priority.\" to this one: \"To ensure you receive the highest quality care, please take a few moments to complete your intake information. This allows us to better understand your needs ahead of your visit. Your privacy is always our top priority.<\/p>\r\n <\/div>\r\n\r\n <form id=\"patientForm\" action=\"https:\/\/script.google.com\/macros\/s\/AKfycbz1QV_z9a_w9yIRoUUkxZHF4VLRD46CCjMAFMmQTU5LvDAaCAxqVjiQKX94kTrWLDCN\/exec\" method=\"POST\">\r\n>\r\n <h2>Patient Information<\/h2>\r\n <div class=\"grid-cols-2\">\r\n <div class=\"form-group\">\r\n <label for=\"firstName\">First Name <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"text\" id=\"firstName\" name=\"firstName\" required>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"lastName\">Last Name <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"text\" id=\"lastName\" name=\"lastName\" required>\r\n <\/div>\r\n <\/div>\r\n <div class=\"grid-cols-2\">\r\n <div class=\"form-group\">\r\n <label for=\"middleInitial\">Middle Initial<\/label>\r\n <input type=\"text\" id=\"middleInitial\" name=\"middleInitial\" maxlength=\"1\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"dob\">Date of Birth <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"date\" id=\"dob\" name=\"dob\" required>\r\n <\/div>\r\n <\/div>\r\n <div class=\"grid-cols-2\">\r\n <div class=\"form-group\">\r\n <label for=\"ssn\">Social Security Number<\/label>\r\n <input type=\"text\" id=\"ssn\" name=\"ssn\" placeholder=\"XXX-XX-XXXX\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"gender\">Gender <span class=\"text-red-500\">*<\/span><\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"radio\" name=\"gender\" value=\"male\" required> Male<\/label>\r\n <label><input type=\"radio\" name=\"gender\" value=\"female\"> Female<\/label>\r\n <label><input type=\"radio\" name=\"gender\" value=\"non-binary\"> Non-binary<\/label>\r\n <label><input type=\"radio\" name=\"gender\" value=\"prefer-not-to-say\"> Prefer not to say<\/label>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"medicalDiagnosis\">Medical Diagnosis (ICD-10 Code & Description)<\/label>\r\n <textarea id=\"medicalDiagnosis\" name=\"medicalDiagnosis\" rows=\"3\" placeholder=\"e.g., M54.5 - Low back pain\"><\/textarea>\r\n <\/div>\r\n\r\n <h3>Address and Contact Details<\/h3>\r\n <div class=\"form-group\">\r\n <label for=\"address\">Street Address <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"text\" id=\"address\" name=\"address\" required placeholder=\"123 Main St\">\r\n <\/div>\r\n <div class=\"grid-cols-3\">\r\n <div class=\"form-group\">\r\n <label for=\"city\">City <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"text\" id=\"city\" name=\"city\" required placeholder=\"Anytown\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"state\">State <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"text\" id=\"state\" name=\"state\" required placeholder=\"TX\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"zip\">Zip Code <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"text\" id=\"zip\" name=\"zip\" required placeholder=\"12345\">\r\n <\/div>\r\n <\/div>\r\n <div class=\"grid-cols-2\">\r\n <div class=\"form-group\">\r\n <label for=\"phoneHome\">Home Phone<\/label>\r\n <input type=\"tel\" id=\"phoneHome\" name=\"phoneHome\" placeholder=\"(123) 456-7890\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"phoneMobile\">Mobile Phone <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"tel\" id=\"phoneMobile\" name=\"phoneMobile\" required placeholder=\"(123) 456-7890\">\r\n <\/div>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"email\">Email Address <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"email\" id=\"email\" name=\"email\" required placeholder=\"patient@example.com\">\r\n <\/div>\r\n\r\n <h3>Occupation and Demographics<\/h3>\r\n <div class=\"grid-cols-2\">\r\n <div class=\"form-group\">\r\n <label for=\"occupation\">Occupation<\/label>\r\n <input type=\"text\" id=\"occupation\" name=\"occupation\" placeholder=\"e.g., Software Engineer\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"employer\">Employer<\/label>\r\n <input type=\"text\" id=\"employer\" name=\"employer\" placeholder=\"e.g., Tech Solutions Inc.\">\r\n <\/div>\r\n <\/div>\r\n <div class=\"grid-cols-2\">\r\n <div class=\"form-group\">\r\n <label for=\"maritalStatus\">Marital Status<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"radio\" name=\"maritalStatus\" value=\"single\"> Single<\/label>\r\n <label><input type=\"radio\" name=\"maritalStatus\" value=\"married\"> Married<\/label>\r\n <label><input type=\"radio\" name=\"maritalStatus\" value=\"divorced\"> Divorced<\/label>\r\n <label><input type=\"radio\" name=\"maritalStatus\" value=\"widowed\"> Widowed<\/label>\r\n <label><input type=\"radio\" name=\"maritalStatus\" value=\"separated\"> Separated<\/label>\r\n <\/div>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"ethnicity\">Ethnicity<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"radio\" name=\"ethnicity\" value=\"hispanic_latino\"> Hispanic or Latino<\/label>\r\n <label><input type=\"radio\" name=\"ethnicity\" value=\"not_hispanic_latino\"> Not Hispanic or Latino<\/label>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"race\">Race (Select all that apply)<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"checkbox\" name=\"race\" value=\"american_indian_alaska_native\"> American Indian or Alaska Native<\/label>\r\n <label><input type=\"checkbox\" name=\"race\" value=\"asian\"> Asian<\/label>\r\n <label><input type=\"checkbox\" name=\"race\" value=\"black_african_american\"> Black or African American<\/label>\r\n <label><input type=\"checkbox\" name=\"race\" value=\"native_hawaiian_pacific_islander\"> Native Hawaiian or Other Pacific Islander<\/label>\r\n <label><input type=\"checkbox\" name=\"race\" value=\"white\"> White<\/label>\r\n <label><input type=\"checkbox\" name=\"race\" value=\"other\"> Other<\/label>\r\n <\/div>\r\n <\/div>\r\n\r\n <h2>Emergency Contact<\/h2>\r\n <div class=\"grid-cols-2\">\r\n <div class=\"form-group\">\r\n <label for=\"emergencyName\">Full Name <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"text\" id=\"emergencyName\" name=\"emergencyName\" required placeholder=\"Jane Doe\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"emergencyRelationship\">Relationship to Patient <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"text\" id=\"emergencyRelationship\" name=\"emergencyRelationship\" required placeholder=\"Spouse, Parent, Friend\">\r\n <\/div>\r\n <\/div>\r\n <div class=\"grid-cols-2\">\r\n <div class=\"form-group\">\r\n <label for=\"emergencyPhone\">Phone Number <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"tel\" id=\"emergencyPhone\" name=\"emergencyPhone\" required placeholder=\"(123) 987-6543\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"emergencyEmail\">Email Address<\/label>\r\n <input type=\"email\" id=\"emergencyEmail\" name=\"emergencyEmail\" placeholder=\"jane.doe@example.com\">\r\n <\/div>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label>Does this emergency contact hold Medical Power of Attorney (POA) for you?<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"radio\" name=\"medicalPOA\" value=\"yes\"> Yes<\/label>\r\n <label><input type=\"radio\" name=\"medicalPOA\" value=\"no\" checked> No<\/label>\r\n <\/div>\r\n <p class=\"signature-label mt-1\">If yes, please be prepared to provide documentation.<\/p>\r\n <\/div>\r\n\r\n <h2>Medical Provider Details<\/h2>\r\n <div class=\"form-group\">\r\n <label for=\"PCPName\">Primary Care Provider (PCP) Name<\/label>\r\n <input type=\"text\" id=\"PCPName\" name=\"PCPName\" placeholder=\"Dr. Sarah Lee\">\r\n <\/div>\r\n <div class=\"grid-cols-2\">\r\n <div class=\"form-group\">\r\n <label for=\"PCPPhone\">PCP Phone Number<\/label>\r\n <input type=\"tel\" id=\"PCPPhone\" name=\"PCPPhone\" placeholder=\"(123) 555-1234\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"PCPAddress\">PCP Clinic Address<\/label>\r\n <input type=\"text\" id=\"PCPAddress\" name=\"PCPAddress\" placeholder=\"456 Oak Ave, Anytown, TX\">\r\n <\/div>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"referringProvider\">Referring Provider (if any)<\/label>\r\n <input type=\"text\" id=\"referringProvider\" name=\"referringProvider\" placeholder=\"Dr. Michael Chen\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"referringProviderSpecialty\">Referring Provider Specialty<\/label>\r\n <input type=\"text\" id=\"referringProviderSpecialty\" name=\"referringProviderSpecialty\" placeholder=\"Orthopedics\">\r\n <\/div>\r\n\r\n <h2>Insurance Details<\/h2>\r\n <div class=\"form-group\">\r\n <label for=\"primaryInsuranceName\">Primary Insurance Company Name<\/label>\r\n <input type=\"text\" id=\"primaryInsuranceName\" name=\"primaryInsuranceName\" placeholder=\"Blue Cross Blue Shield\">\r\n <\/div>\r\n <div class=\"grid-cols-2\">\r\n <div class=\"form-group\">\r\n <label for=\"primaryPolicyNumber\">Policy Number<\/label>\r\n <input type=\"text\" id=\"primaryPolicyNumber\" name=\"primaryPolicyNumber\" placeholder=\"ABC123456789\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"primaryGroupNumber\">Group Number<\/label>\r\n <input type=\"text\" id=\"primaryGroupNumber\" name=\"primaryGroupNumber\" placeholder=\"GRP98765\">\r\n <\/div>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"primarySubscriberName\">Policy Holder\/Subscriber Name (if different from patient)<\/label>\r\n <input type=\"text\" id=\"primarySubscriberName\" name=\"primarySubscriberName\" placeholder=\"Optional\">\r\n <\/div>\r\n <div class=\"grid-cols-2\">\r\n <div class=\"form-group\">\r\n <label for=\"primarySubscriberDOB\">Subscriber Date of Birth<\/label>\r\n <input type=\"date\" id=\"primarySubscriberDOB\" name=\"primarySubscriberDOB\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"primarySubscriberRelationship\">Subscriber Relationship to Patient<\/label>\r\n <input type=\"text\" id=\"primarySubscriberRelationship\" name=\"primarySubscriberRelationship\" placeholder=\"Self, Spouse, Child\">\r\n <\/div>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"primaryInsuranceFront\">Upload Front of Primary Insurance Card<\/label>\r\n <input type=\"file\" id=\"primaryInsuranceFront\" name=\"primaryInsuranceFront\" accept=\"image\/*\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"primaryInsuranceBack\">Upload Back of Primary Insurance Card<\/label>\r\n <input type=\"file\" id=\"primaryInsuranceBack\" name=\"primaryInsuranceBack\" accept=\"image\/*\">\r\n <\/div>\r\n <p class=\"text-gray-600 text-sm mt-1 mb-4\">\r\n Please ensure images are clear. For your security, avoid uploading sensitive information if possible.\r\n <\/p>\r\n\r\n <div class=\"form-group\">\r\n <label>Do you have secondary insurance?<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"radio\" name=\"secondaryInsurance\" value=\"yes\"> Yes<\/label>\r\n <label><input type=\"radio\" name=\"secondaryInsurance\" value=\"no\" checked> No<\/label>\r\n <\/div>\r\n <\/div>\r\n <!-- Secondary insurance details are always visible for print\/static form -->\r\n <div id=\"secondaryInsuranceDetails\">\r\n <div class=\"form-group\">\r\n <label for=\"secondaryInsuranceName\">Secondary Insurance Company Name<\/label>\r\n <input type=\"text\" id=\"secondaryInsuranceName\" name=\"secondaryInsuranceName\" placeholder=\"Optional\">\r\n <\/div>\r\n <div class=\"grid-cols-2\">\r\n <div class=\"form-group\">\r\n <label for=\"secondaryPolicyNumber\">Policy Number<\/label>\r\n <input type=\"text\" id=\"secondaryPolicyNumber\" name=\"secondaryPolicyNumber\" placeholder=\"Optional\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"secondaryGroupNumber\">Group Number<\/label>\r\n <input type=\"text\" id=\"secondaryGroupNumber\" name=\"secondaryGroupNumber\" placeholder=\"Optional\">\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n <div class=\"form-group mt-6\">\r\n <label>Is your condition related to a work injury?<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"radio\" name=\"workInjury\" value=\"yes\"> Yes<\/label>\r\n <label><input type=\"radio\" name=\"workInjury\" value=\"no\" checked> No<\/label>\r\n <\/div>\r\n <\/div>\r\n <!-- Work injury details are always visible for print\/static form -->\r\n <div id=\"workInjuryDetails\">\r\n <div class=\"form-group\">\r\n <label for=\"workInjuryDate\">Date of Injury<\/label>\r\n <input type=\"date\" id=\"workInjuryDate\" name=\"workInjuryDate\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"workersCompCarrier\">Worker's Comp Carrier<\/label>\r\n <input type=\"text\" id=\"workersCompCarrier\" name=\"workersCompCarrier\" placeholder=\"Optional\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"claimNumber\">Claim Number<\/label>\r\n <input type=\"text\" id=\"claimNumber\" name=\"claimNumber\" placeholder=\"Optional\">\r\n <\/div>\r\n <\/div>\r\n\r\n <h2>Patient Medical History<\/h2>\r\n <div class=\"form-group\">\r\n <label for=\"chiefComplaint\">What is your primary reason for seeking therapy today? <span class=\"text-red-500\">*<\/span><\/label>\r\n <textarea id=\"chiefComplaint\" name=\"chiefComplaint\" rows=\"3\" required placeholder=\"e.g., Persistent lower back pain, difficulty walking\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"onsetSymptoms\">When did your symptoms begin? (Date or approximate time)<\/label>\r\n <input type=\"text\" id=\"onsetSymptoms\" name=\"onsetSymptoms\" placeholder=\"e.g., 3 months ago, after a fall\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label>Please mark on the silhouette below where you are experiencing pain, numbness, or other symptoms.<\/label>\r\n <div class=\"pain-silhouette\">\r\n <svg viewBox=\"0 0 300 400\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\r\n <!-- Head -->\r\n <circle cx=\"150\" cy=\"40\" r=\"30\" fill=\"#f0f0f0\" stroke=\"#333\" stroke-width=\"1\"\/>\r\n <!-- Neck -->\r\n <rect x=\"140\" y=\"70\" width=\"20\" height=\"20\" fill=\"#f0f0f0\" stroke=\"#333\" stroke-width=\"1\"\/>\r\n <!-- Torso -->\r\n <path d=\"M120 90 H180 V250 H120 Z\" fill=\"#f0f0f0\" stroke=\"#333\" stroke-width=\"1\"\/>\r\n <!-- Arms -->\r\n <path d=\"M120 100 Q100 150 90 200 L80 250 Q70 280 80 290 Q90 300 100 290 L110 250 Q120 200 120 100 Z\" fill=\"#f0f0f0\" stroke=\"#333\" stroke-width=\"1\"\/>\r\n <path d=\"M180 100 Q200 150 210 200 L220 250 Q230 280 220 290 Q210 300 200 290 L190 250 Q180 200 180 100 Z\" fill=\"#f0f0f0\" stroke=\"#333\" stroke-width=\"1\"\/>\r\n <!-- Legs -->\r\n <path d=\"M120 250 H180 V350 H120 Z\" fill=\"#f0f0f0\" stroke=\"#333\" stroke-width=\"1\"\/>\r\n <!-- Feet -->\r\n <rect x=\"120\" y=\"350\" width=\"30\" height=\"20\" fill=\"#f0f0f0\" stroke=\"#333\" stroke-width=\"1\"\/>\r\n <rect x=\"150\" y=\"350\" width=\"30\" height=\"20\" fill=\"#f0f0f0\" stroke=\"#333\" stroke-width=\"1\"\/>\r\n\r\n <!-- Front Outline -->\r\n <path d=\"M150 10 L120 70 V90 H100 Q90 120 85 170 Q80 220 80 250 V350 L120 370 H180 L220 350 V250 Q220 220 215 170 Q210 120 200 90 H180 V70 Z\" fill=\"none\" stroke=\"#333\" stroke-width=\"2\"\/>\r\n\r\n <!-- Back Outline (simplified, could be separate) -->\r\n <path d=\"M150 10 L120 70 V90 H100 Q90 120 85 170 Q80 220 80 250 V350 L120 370 H180 L220 350 V250 Q220 220 215 170 Q210 120 200 90 H180 V70 Z\" fill=\"none\" stroke=\"#666\" stroke-width=\"1\" stroke-dasharray=\"2,2\"\/>\r\n \r\n <!-- Instructions -->\r\n <text x=\"15\" y=\"380\" font-size=\"12\" fill=\"#555\">Mark with 'X' for pain, 'O' for numbness\/tingling.<\/text>\r\n <\/svg>\r\n <\/div>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"painLevel\">On a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable, what is your current pain level?<\/label>\r\n <input type=\"number\" id=\"painLevel\" name=\"painLevel\" min=\"0\" max=\"10\" placeholder=\"e.g., 7\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label>Do you use any assistive devices?<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"checkbox\" name=\"assistiveDevice\" value=\"cane\"> Cane<\/label>\r\n <label><input type=\"checkbox\" name=\"assistiveDevice\" value=\"walker\"> Walker<\/label>\r\n <label><input type=\"checkbox\" name=\"assistiveDevice\" value=\"crutches\"> Crutches<\/label>\r\n <label><input type=\"checkbox\" name=\"assistiveDevice\" value=\"wheelchair\"> Wheelchair<\/label>\r\n <label><input type=\"checkbox\" name=\"other_device\" id=\"otherDeviceCheckbox\"> Other (specify)<\/label>\r\n <input type=\"text\" name=\"otherDeviceSpecify\" id=\"otherDeviceSpecify\" class=\"ml-2 flex-grow\" style=\"display: none;\" placeholder=\"e.g., Prosthetic leg\">\r\n <\/div>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label>Do you use any braces\/supports?<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"checkbox\" name=\"braces\" value=\"back\"> Back Brace<\/label>\r\n <label><input type=\"checkbox\" name=\"braces\" value=\"knee\"> Knee Brace<\/label>\r\n <label><input type=\"checkbox\" name=\"braces\" value=\"ankle\"> Ankle Brace<\/label>\r\n <label><input type=\"checkbox\" name=\"braces\" value=\"wrist\"> Wrist Brace<\/label>\r\n <label><input type=\"checkbox\" name=\"other_brace\" id=\"otherBraceCheckbox\"> Other (specify)<\/label>\r\n <input type=\"text\" name=\"otherBraceSpecify\" id=\"otherBraceSpecify\" class=\"ml-2 flex-grow\" style=\"display: none;\" placeholder=\"e.g., Shoulder sling\">\r\n <\/div>\r\n <\/div>\r\n\r\n <h3>Current Level of Function<\/h3>\r\n <div class=\"form-group\">\r\n <label for=\"selfCareImpact\">How does your condition affect your self-care activities (e.g., dressing, bathing, eating)?<\/label>\r\n <textarea id=\"selfCareImpact\" name=\"selfCareImpact\" rows=\"2\" placeholder=\"e.g., Difficulty reaching overhead to dress\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"householdDutiesImpact\">How does your condition affect your ability to perform household duties (e.g., cleaning, cooking, laundry)?<\/label>\r\n <textarea id=\"householdDutiesImpact\" name=\"householdDutiesImpact\" rows=\"2\" placeholder=\"e.g., Cannot lift heavy items for laundry\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"hobbiesRecreationImpact\">How does your condition affect your hobbies\/recreational activities?<\/label>\r\n <textarea id=\"hobbiesRecreationImpact\" name=\"hobbiesRecreationImpact\" rows=\"2\" placeholder=\"e.g., Unable to play golf due to knee pain\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"exerciseHistory\">Describe your typical exercise history\/routine prior to your symptoms:<\/label>\r\n <textarea id=\"exerciseHistory\" name=\"exerciseHistory\" rows=\"2\" placeholder=\"e.g., Ran 3 miles daily, lifted weights 3x\/week\"><\/textarea>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label>History of Falls:<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"radio\" name=\"fallHistory\" value=\"yes\" id=\"fallHistoryYes\"> Yes<\/label>\r\n <label><input type=\"radio\" name=\"fallHistory\" value=\"no\" checked id=\"fallHistoryNo\"> No<\/label>\r\n <\/div>\r\n <input type=\"text\" name=\"fallDetails\" id=\"fallDetails\" class=\"mt-2 w-full\" style=\"display: none;\" placeholder=\"e.g., Fell once last month, no injury\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label>History of Broken Bones:<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"radio\" name=\"brokenBonesHistory\" value=\"yes\" id=\"brokenBonesYes\"> Yes<\/label>\r\n <label><input type=\"radio\" name=\"brokenBonesHistory\" value=\"no\" checked id=\"brokenBonesNo\"> No<\/label>\r\n <\/div>\r\n <input type=\"text\" name=\"brokenBonesDetails\" id=\"brokenBonesDetails\" class=\"mt-2 w-full\" style=\"display: none;\" placeholder=\"e.g., Broken arm in 2010\">\r\n <\/div>\r\n\r\n <h2>Family Medical History<\/h2>\r\n <p class=\"text-gray-700 text-sm mb-4\">Please list any significant conditions, e.g., heart disease, diabetes, cancer:<\/p>\r\n <div class=\"form-group\">\r\n <textarea id=\"familyMedicalHistory\" name=\"familyMedicalHistory\" rows=\"3\" placeholder=\"e.g., Mother has diabetes, Father had heart disease\"><\/textarea>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label>History of Swelling:<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"radio\" name=\"swellingHistory\" value=\"yes\" id=\"swellingHistoryYes\"> Yes<\/label>\r\n <label><input type=\"radio\" name=\"swellingHistory\" value=\"no\" checked id=\"swellingHistoryNo\"> No<\/label>\r\n <\/div>\r\n <input type=\"text\" name=\"swellingDetails\" id=\"swellingDetails\" class=\"mt-2 w-full\" style=\"display: none;\" placeholder=\"e.g., Swelling in ankles after prolonged standing\">\r\n <\/div>\r\n\r\n <h3>For Lymphedema Therapy Only<\/h3>\r\n <div class=\"form-group\">\r\n <label>History of Cancer?<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"radio\" name=\"cancerHistory\" value=\"yes\" id=\"cancerHistoryYes\"> Yes<\/label>\r\n <label><input type=\"radio\" name=\"cancerHistory\" value=\"no\" checked id=\"cancerHistoryNo\"> No<\/label>\r\n <\/div>\r\n <\/div>\r\n <div id=\"cancerDetails\" style=\"display: none;\">\r\n <div class=\"form-group\">\r\n <label for=\"cancerType\">What type(s) of cancer?<\/label>\r\n <input type=\"text\" id=\"cancerType\" name=\"cancerType\" placeholder=\"e.g., Breast Cancer\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"cancerStatus\">Present status of cancer (e.g., in remission, active, post-treatment)?<\/label>\r\n <input type=\"text\" id=\"cancerStatus\" name=\"cancerStatus\" placeholder=\"e.g., In remission since 2022\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label>Have you had lymphedema before or received treatment for it?<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"radio\" name=\"previousLymphedemaTreatment\" value=\"yes\" id=\"prevLymphedemaYes\"> Yes<\/label>\r\n <label><input type=\"radio\" name=\"previousLymphedemaTreatment\" value=\"no\" checked id=\"prevLymphedemaNo\"> No<\/label>\r\n <\/div>\r\n <\/div>\r\n <div class=\"form-group\" id=\"lymphedemaTreatmentDetails\" style=\"display: none;\">\r\n <label>If yes, what treatments have you received for lymphedema?<\/label>\r\n <div class=\"checkbox-group flex flex-wrap gap-x-6 gap-y-2\">\r\n <label><input type=\"checkbox\" name=\"lymphedemaTreatment\" value=\"compression_bandage\"> Compression Bandaging<\/label>\r\n <label><input type=\"checkbox\" name=\"lymphedemaTreatment\" value=\"kinesio_taping\"> Kinesio Taping<\/label>\r\n <label><input type=\"checkbox\" name=\"lymphedemaTreatment\" value=\"self_drainage\"> Self-Drainage Techniques<\/label>\r\n <label><input type=\"checkbox\" name=\"lymphedemaTreatment\" value=\"compression_garment\"> Compression Garment Use<\/label>\r\n <label><input type=\"checkbox\" name=\"pneumatic_compression\"> Pneumatic Compression Pump<\/label>\r\n <label><input type=\"checkbox\" name=\"other_lymphedema\" id=\"otherLymphedemaCheckbox\"> Other (specify)<\/label>\r\n <input type=\"text\" name=\"otherLymphedemaSpecify\" id=\"otherLymphedemaSpecify\" class=\"ml-2 flex-grow\" style=\"display: none;\" placeholder=\"e.g., Manual Lymphatic Drainage\">\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n <h2>Patient Goals<\/h2>\r\n <p class=\"text-gray-700 text-sm mb-4\">What are your primary goals for therapy? Please check all that apply and feel free to add specifics.<\/p>\r\n <div class=\"form-group checkbox-group grid-cols-2 gap-x-6 gap-y-2\">\r\n <label><input type=\"checkbox\" name=\"patientGoals\" value=\"return_to_work\"> Return to Work<\/label>\r\n <label><input type=\"checkbox\" name=\"patientGoals\" value=\"able_to_drive\"> Able to Drive<\/label>\r\n <label><input type=\"checkbox\" name=\"patientGoals\" value=\"return_to_sport\"> Return to Sport\/Activity<\/label>\r\n <label><input type=\"checkbox\" name=\"patientGoals\" value=\"ability_to_walk\"> Improve Ability to Walk<\/label>\r\n <label><input type=\"checkbox\" name=\"patientGoals\" value=\"reduce_pain\"> Reduce Pain<\/label>\r\n <label><input type=\"checkbox\" name=\"patientGoals\" value=\"improve_strength\"> Improve Strength<\/label>\r\n <label><input type=\"checkbox\" name=\"patientGoals\" value=\"improve_balance\"> Improve Balance<\/label>\r\n <label><input type=\"checkbox\" name=\"patientGoals\" value=\"increase_flexibility\"> Increase Flexibility\/Range of Motion<\/label>\r\n <label><input type=\"checkbox\" name=\"patientGoals\" value=\"manage_swelling\"> Manage Swelling\/Lymphedema<\/label>\r\n <label><input type=\"checkbox\" name=\"other_goal\" id=\"otherGoalCheckbox\"> Other (specify)<\/label>\r\n <\/div>\r\n <div class=\"form-group\" id=\"otherGoalsSpecifyGroup\" style=\"display: none;\">\r\n <label for=\"otherGoalsSpecify\">Please specify any other goals:<\/label>\r\n <textarea id=\"otherGoalsSpecify\" name=\"otherGoalsSpecify\" rows=\"2\" placeholder=\"e.g., Be able to lift my grandchild\"><\/textarea>\r\n <\/div>\r\n\r\n <h2>Consents and Authorizations<\/h2>\r\n\r\n <h3>Consent to E-Signature<\/h3>\r\n <div class=\"consent-text\">\r\n By typing your name below, you agree that your electronic signature is the legal equivalent of your manual signature on this form. You understand that you are signing this document electronically and it is legally binding.\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label><input type=\"checkbox\" name=\"consentEsignature\" required> I agree to use an electronic signature for this form. <span class=\"text-red-500\">*<\/span><\/label>\r\n <\/div>\r\n\r\n <h3>Electronic Communications Consent<\/h3>\r\n <div class=\"consent-text\">\r\n I authorize Rise and Recover Therapy Clinic to communicate with me via electronic methods, including email and text messages, for purposes related to my healthcare, such as appointment reminders, scheduling, billing, and general information. I understand that while reasonable efforts are made to protect my privacy, electronic communications may not be entirely secure. I can opt-out of these communications at any time by notifying the clinic.\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label><input type=\"checkbox\" name=\"consentElectronicComm\" required> I consent to receive electronic communications. <span class=\"text-red-500\">*<\/span><\/label>\r\n <\/div>\r\n\r\n <h3>Insurance Verification and Benefits Consent<\/h3>\r\n <div class=\"consent-text\">\r\n I authorize Rise and Recover Therapy Clinic to verify my insurance benefits, eligibility, and coverage with my insurance company(ies) for all services provided. I understand that verification of benefits is not a guarantee of payment and that I am ultimately responsible for any charges not covered by my insurance.\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label><input type=\"checkbox\" name=\"consentInsuranceVerification\" required> I consent to insurance verification and understand my financial responsibility. <span class=\"text-red-500\">*<\/span><\/label>\r\n <\/div>\r\n\r\n <h3>Acknowledgement and Authorization to Receive Health Records and Insurance Benefits<\/h3>\r\n <div class=\"consent-text\">\r\n I understand that I am responsible for all charges incurred. I authorize the release of any medical information necessary to process my claims to my insurance company, other healthcare providers involved in my care, or any third party payers. I also authorize and direct my insurance company to pay benefits directly to Rise and Recover Therapy Clinic for services rendered. This authorization remains in effect until revoked by me in writing. A photocopy of this authorization shall be considered as valid as valid as the original.\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label><input type=\"checkbox\" name=\"consentHealthRecordsBenefits\" required> I acknowledge and authorize the release of records and assignment of benefits. <span class=\"text-red-500\">*<\/span><\/label>\r\n <\/div>\r\n\r\n <h3>HIPAA\/Privacy Practices Acknowledgement<\/h3>\r\n <div class=\"consent-text\">\r\n I acknowledge that I have received, reviewed, or been offered the opportunity to review Rise and Recover Therapy Clinic's Notice of Privacy Practices, which describes how my protected health information may be used and disclosed.\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label><input type=\"checkbox\" name=\"hipaaAcknowledgement\" required> I acknowledge receipt\/review of the Notice of Privacy Practices. <span class=\"text-red-500\">*<\/span><\/label>\r\n <\/div>\r\n\r\n <h3>Contact Authorization<\/h3>\r\n <div class=\"consent-text\">\r\n I authorize Rise and Recover Therapy Clinic and its staff to contact me at the phone numbers and email addresses provided for appointment reminders, scheduling, billing, and other treatment-related communications.\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label><input type=\"checkbox\" name=\"contactAuthorization\" required> I authorize contact for treatment-related communications. <span class=\"text-red-500\">*<\/span><\/label>\r\n <\/div>\r\n\r\n <h3>Cancellation and No-Show Policy<\/h3>\r\n <div class=\"consent-text\">\r\n I understand that Rise and Recover Therapy Clinic requires at least 24-hour notice for appointment cancellations or rescheduling. Appointments canceled or missed without 24-hour notice will incur a <strong>$75.00 cancellation\/no-show fee<\/strong>. This fee is not covered by insurance and will be my direct responsibility. Repeated cancellations or no-shows may result in discharge from the clinic.\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label><input type=\"checkbox\" name=\"cancellationPolicy\" required> I have read and understand the cancellation and no-show policy and agree to its terms. <span class=\"text-red-500\">*<\/span><\/label>\r\n <\/div>\r\n\r\n <h3>Consent to Use Photo\/Non-Medical Information for Marketing<\/h3>\r\n <div class=\"consent-text\">\r\n I voluntarily consent to Rise and Recover Therapy Clinic using my photo and\/or non-medical information (e.g., testimonials about my experience, general progress, but NOT specific protected health information) for promotional, educational, and marketing purposes on their website, social media, brochures, or other clinic materials. I understand that my participation is voluntary and I can revoke this consent in writing at any time. My decision to consent or not will not affect the quality of my care.\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label><input type=\"checkbox\" name=\"consentMarketing\"> I consent to the use of my photo\/non-medical information for marketing purposes.<\/label>\r\n <\/div>\r\n\r\n <h3>Consent to All Financial Obligations<\/h3>\r\n <div class=\"consent-text\">\r\n I acknowledge and accept full financial responsibility for all services rendered by Rise and Recover Therapy Clinic that are not covered by my insurance or other third-party payers. This includes, but is not limited to, deductibles, co-payments, co-insurance, and any services deemed non-covered or medically unnecessary by my insurance company. I agree to pay all charges incurred in a timely manner.\r\n <br><br>\r\n Furthermore, I authorize Rise and Recover Therapy Clinic to charge my credit card or debit card on file for any outstanding balances, including but not limited to co-payments, deductibles, co-insurance, and cancellation\/no-show fees, as per the clinic's financial policies.\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label><input type=\"checkbox\" name=\"financialObligations\" required> I understand and agree to all financial obligations. <span class=\"text-red-500\">*<\/span><\/label>\r\n <\/div>\r\n\r\n <h2 class=\"mt-8\">Patient Signature<\/h2>\r\n <div class=\"form-group\">\r\n <label for=\"patientSignature\">Patient's Full Name (Type to sign) <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"text\" id=\"patientSignature\" name=\"patientSignature\" required class=\"signature-line\">\r\n <div class=\"signature-label\">Electronic Signature<\/div>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"signatureDate\">Date <span class=\"text-red-500\">*<\/span><\/label>\r\n <input type=\"date\" id=\"signatureDate\" name=\"signatureDate\" required>\r\n <\/div>\r\n\r\n <div class=\"form-group flex items-center mt-6\">\r\n <input type=\"checkbox\" id=\"sendCopy\" name=\"sendCopy\" class=\"mr-2\">\r\n <label for=\"sendCopy\" class=\"!mb-0\">Send a copy of my intake information to my email address<\/label>\r\n <\/div>\r\n\r\n <button type=\"submit\" class=\"submit-button\">Submit Intake Form<\/button>\r\n\r\n <div class=\"disclaimer\">\r\n <p>Please complete all sections thoroughly to help us provide you with the best possible care.<\/p>\r\n <p>© 2024 Rise and Recover Therapy Clinic. All rights reserved.<\/p>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n\r\n <!-- This popup modal shows after form submission. Removed because clients did not like the popup. -->\r\n\r\n <!-- Custom Modal for Messages -->\r\n <!-- <div id=\"messageModal\" class=\"modal\">\r\n <div class=\"modal-content\">\r\n <h3 id=\"modalTitle\"><\/h3>\r\n <p id=\"modalMessage\"><\/p>\r\n <button onclick=\"closeModal()\">OK<\/button>\r\n <\/div>\r\n <\/div> -->\r\n\r\n <script>\r\n \/\/ Function to show the custom modal\r\n function showModal(title, message) {\r\n document.getElementById('modalTitle').innerText = title;\r\n document.getElementById('modalMessage').innerText = message;\r\n document.getElementById('messageModal').style.display = 'flex'; \/\/ Use flex to center\r\n }\r\n\r\n \/\/ Function to close the custom modal\r\n function closeModal() {\r\n document.getElementById('messageModal').style.display = 'none';\r\n }\r\n\r\n \/\/ Helper function to toggle visibility of \"Other (specify)\" text inputs\r\n function setupOtherSpecifyToggle(checkboxId, inputId) {\r\n const checkbox = document.getElementById(checkboxId);\r\n const input = document.getElementById(inputId);\r\n if (checkbox && input) {\r\n checkbox.addEventListener('change', function() {\r\n input.style.display = this.checked ? 'inline-block' : 'none';\r\n if (!this.checked) {\r\n input.value = ''; \/\/ Clear input if checkbox is unchecked\r\n }\r\n });\r\n \/\/ Set initial state on load\r\n input.style.display = checkbox.checked ? 'inline-block' : 'none';\r\n }\r\n }\r\n\r\n \/\/ Helper function to toggle visibility of details based on radio button selection\r\n function setupRadioToggle(radioYesId, radioNoId, detailsContainerId) {\r\n const radioYes = document.getElementById(radioYesId);\r\n const radioNo = document.getElementById(radioNoId);\r\n const detailsContainer = document.getElementById(detailsContainerId);\r\n\r\n if (radioYes && radioNo && detailsContainer) {\r\n const toggleVisibility = () => {\r\n detailsContainer.style.display = radioYes.checked ? 'block' : 'none';\r\n \/\/ Clear inputs if container is hidden\r\n if (!radioYes.checked) {\r\n const inputs = detailsContainer.querySelectorAll('input, textarea');\r\n inputs.forEach(input => {\r\n if (input.type !== 'radio' && input.type !== 'checkbox') {\r\n input.value = '';\r\n } else if (input.type === 'checkbox') {\r\n input.checked = false;\r\n } else if (input.type === 'radio') {\r\n \/\/ For radio groups, uncheck all or set default 'no'\r\n if (input.name === 'previousLymphedemaTreatment' && input.value === 'no') {\r\n input.checked = true;\r\n } else {\r\n input.checked = false;\r\n }\r\n }\r\n });\r\n \/\/ Also hide nested 'other specify' inputs if they exist\r\n detailsContainer.querySelectorAll('[id$=\"Specify\"]').forEach(input => input.style.display = 'none');\r\n }\r\n };\r\n\r\n radioYes.addEventListener('change', toggleVisibility);\r\n radioNo.addEventListener('change', toggleVisibility);\r\n \/\/ Set initial state on load\r\n toggleVisibility();\r\n }\r\n }\r\n\r\n \/\/ Handles the form submission\r\n function handleSubmit(event) {\r\n event.preventDefault(); \/\/ Prevent default form submission\r\n\r\n const form = event.target;\r\n const formData = new FormData(form);\r\n const data = {};\r\n for (let [key, value] of formData.entries()) {\r\n \/\/ For checkboxes and radio buttons, collect all selected values\r\n if (form.elements[key] && form.elements[key].type === 'checkbox') {\r\n if (!data[key]) {\r\n data[key] = [];\r\n }\r\n data[key].push(value);\r\n } else if (form.elements[key] && form.elements[key].type === 'radio') {\r\n data[key] = value; \/\/ Only one radio value is selected\r\n } else {\r\n data[key] = value;\r\n }\r\n }\r\n\r\n console.log(\"Form Data Submitted:\", data);\r\n\r\n let message = \"Thank you for submitting your intake information. We will review it shortly.\";\r\n const sendCopy = document.getElementById('sendCopy').checked;\r\n const patientEmail = document.getElementById('email').value;\r\n\r\n if (sendCopy && patientEmail) {\r\n \/\/ Simulate sending email - in a real application, you'd send this data to a backend service\r\n const emailContent = formatFormDataForEmail(data);\r\n console.log(\"Simulating sending email copy to:\", patientEmail);\r\n console.log(\"Email content:\\n\", emailContent);\r\n message += \"\\n\\nA copy of your intake information has been sent to your email address.\";\r\n } else if (sendCopy && !patientEmail) {\r\n message += \"\\n\\nCould not send a copy to your email. Please ensure your email address is provided.\";\r\n }\r\n\r\n showModal(\"Submission Successful!\", message);\r\n\r\n \/\/ Optionally, clear the form after submission\r\n form.reset();\r\n \/\/ Re-hide conditional fields after reset\r\n setupOtherSpecifyToggle('otherDeviceCheckbox', 'otherDeviceSpecify');\r\n setupOtherSpecifyToggle('otherBraceCheckbox', 'otherBraceSpecify');\r\n setupRadioToggle('fallHistoryYes', 'fallHistoryNo', 'fallDetails');\r\n setupRadioToggle('brokenBonesYes', 'brokenBonesNo', 'brokenBonesDetails');\r\n setupSwellingHistoryToggle(); \/\/ Re-initialize swelling history toggle\r\n setupRadioToggle('cancerHistoryYes', 'cancerHistoryNo', 'cancerDetails');\r\n setupRadioToggle('prevLymphedemaYes', 'prevLymphedemaNo', 'lymphedemaTreatmentDetails');\r\n setupOtherSpecifyToggle('otherLymphedemaCheckbox', 'otherLymphedemaSpecify');\r\n setupOtherSpecifyToggle('otherGoalCheckbox', 'otherGoalsSpecifyGroup');\r\n }\r\n\r\n \/\/ Helper function to format form data for a simulated email\r\n function formatFormDataForEmail(data) {\r\n let formattedString = \"Patient Intake Information Summary:\\n\\n\";\r\n for (const key in data) {\r\n if (data.hasOwnProperty(key)) {\r\n const value = data[key];\r\n \/\/ Convert camelCase to readable text\r\n const readableKey = key.replace(\/([A-Z])\/g, ' $1').replace(\/^.\/, str => str.toUpperCase());\r\n if (Array.isArray(value)) {\r\n formattedString += `${readableKey}: ${value.join(', ')}\\n`;\r\n } else if (value) { \/\/ Only add if value is not empty\r\n formattedString += `${readableKey}: ${value}\\n`;\r\n }\r\n }\r\n }\r\n return formattedString;\r\n }\r\n\r\n \/\/ New function to handle swelling history toggle specifically, as it's a radio group with an input\r\n function setupSwellingHistoryToggle() {\r\n const radioYes = document.getElementById('swellingHistoryYes');\r\n const radioNo = document.getElementById('swellingHistoryNo');\r\n const input = document.getElementById('swellingDetails');\r\n\r\n if (radioYes && radioNo && input) {\r\n const toggleVisibility = () => {\r\n input.style.display = radioYes.checked ? 'block' : 'none';\r\n if (!radioYes.checked) {\r\n input.value = ''; \/\/ Clear input if 'No' is selected\r\n }\r\n };\r\n\r\n radioYes.addEventListener('change', toggleVisibility);\r\n radioNo.addEventListener('change', toggleVisibility);\r\n toggleVisibility(); \/\/ Set initial state\r\n }\r\n }\r\n\r\n \/\/ Initialize toggles on page load\r\n document.addEventListener('DOMContentLoaded', function() {\r\n setupOtherSpecifyToggle('otherDeviceCheckbox', 'otherDeviceSpecify');\r\n setupOtherSpecifyToggle('otherBraceCheckbox', 'otherBraceSpecify');\r\n setupRadioToggle('fallHistoryYes', 'fallHistoryNo', 'fallDetails');\r\n setupRadioToggle('brokenBonesYes', 'brokenBonesNo', 'brokenBonesDetails');\r\n setupSwellingHistoryToggle(); \/\/ Call the specific swelling history toggle\r\n setupRadioToggle('cancerHistoryYes', 'cancerHistoryNo', 'cancerDetails');\r\n setupRadioToggle('prevLymphedemaYes', 'prevLymphedemaNo', 'lymphedemaTreatmentDetails');\r\n setupOtherSpecifyToggle('otherLymphedemaCheckbox', 'otherLymphedemaSpecify');\r\n setupOtherSpecifyToggle('otherGoalCheckbox', 'otherGoalsSpecifyGroup');\r\n });\r\n <\/script>\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 Intake Form – Rise and Recover Therapy Clinic Patient Intake Form Rise and Recover Therapy Clinic 6537 Preston Rd 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