{"id":888,"date":"2023-04-19T23:16:24","date_gmt":"2023-04-19T23:16:24","guid":{"rendered":"https:\/\/swims.opennube.com\/?page_id=888"},"modified":"2023-04-19T23:29:47","modified_gmt":"2023-04-19T23:29:47","slug":"patient-information-2","status":"publish","type":"page","link":"https:\/\/southwestinternalmedicine.com\/?page_id=888","title":{"rendered":"Patient Information"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"888\" class=\"elementor elementor-888\" data-elementor-settings=\"[]\">\n\t\t\t\t\t\t<div class=\"elementor-inner\">\n\t\t\t\t\t\t\t<div class=\"elementor-section-wrap\">\n\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-b06128b elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"b06128b\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-2f78b70\" data-id=\"2f78b70\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-2dac7b6 elementor-widget elementor-widget-heading\" data-id=\"2dac7b6\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">Southwest Internal Medicine is now offering Telemedicine Services.\nPlease contact our office for more details. <\/h5>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-54baaa1 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"54baaa1\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;motion_fx_motion_fx_scrolling&quot;:&quot;yes&quot;,&quot;sticky&quot;:&quot;top&quot;,&quot;motion_fx_devices&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;],&quot;sticky_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;],&quot;sticky_offset&quot;:0,&quot;sticky_effects_offset&quot;:0}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-9dc2937\" data-id=\"9dc2937\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-393765e elementor-nav-menu__align-right elementor-nav-menu--indicator-classic elementor-nav-menu--dropdown-tablet elementor-nav-menu__text-align-aside elementor-nav-menu--toggle elementor-nav-menu--burger elementor-widget elementor-widget-nav-menu\" data-id=\"393765e\" data-element_type=\"widget\" data-settings=\"{&quot;layout&quot;:&quot;horizontal&quot;,&quot;toggle&quot;:&quot;burger&quot;}\" data-widget_type=\"nav-menu.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t<nav role=\"navigation\" class=\"elementor-nav-menu--main elementor-nav-menu__container elementor-nav-menu--layout-horizontal e--pointer-background e--animation-fade\"><ul id=\"menu-1-393765e\" class=\"elementor-nav-menu\"><li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-home menu-item-40\"><a href=\"https:\/\/southwestinternalmedicine.com\/\" class=\"elementor-item menu-link\">Home<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-39\"><a href=\"https:\/\/southwestinternalmedicine.com\/?page_id=19\" class=\"elementor-item menu-link\">About<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-38\"><a href=\"https:\/\/southwestinternalmedicine.com\/?page_id=21\" class=\"elementor-item menu-link\">Services<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-37\"><a href=\"https:\/\/southwestinternalmedicine.com\/?page_id=27\" class=\"elementor-item menu-link\">Health education<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-36\"><a href=\"https:\/\/southwestinternalmedicine.com\/?page_id=29\" class=\"elementor-item menu-link\">Patient resources<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-41\"><a href=\"https:\/\/southwestinternalmedicine.com\/?page_id=32\" class=\"elementor-item menu-link\">Request an appointment<\/a><\/li>\n<li class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-1141\"><a href=\"https:\/\/mycw196.ecwcloud.com\/portal24804\/jsp\/100mp\/login_otp.jsp\" class=\"elementor-item menu-link\">Customer portal<\/a><\/li>\n<\/ul><\/nav>\n\t\t\t\t\t<div class=\"elementor-menu-toggle\" role=\"button\" tabindex=\"0\" aria-label=\"Menu Toggle\" aria-expanded=\"false\">\n\t\t\t<i class=\"eicon-menu-bar\" aria-hidden=\"true\"><\/i>\n\t\t\t<span class=\"elementor-screen-only\">Menu<\/span>\n\t\t<\/div>\n\t\t\t<nav class=\"elementor-nav-menu--dropdown elementor-nav-menu__container\" role=\"navigation\" aria-hidden=\"true\"><ul id=\"menu-2-393765e\" class=\"elementor-nav-menu\"><li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-home menu-item-40\"><a href=\"https:\/\/southwestinternalmedicine.com\/\" class=\"elementor-item menu-link\">Home<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-39\"><a href=\"https:\/\/southwestinternalmedicine.com\/?page_id=19\" class=\"elementor-item menu-link\">About<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-38\"><a href=\"https:\/\/southwestinternalmedicine.com\/?page_id=21\" class=\"elementor-item menu-link\">Services<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-37\"><a href=\"https:\/\/southwestinternalmedicine.com\/?page_id=27\" class=\"elementor-item menu-link\">Health education<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-36\"><a href=\"https:\/\/southwestinternalmedicine.com\/?page_id=29\" class=\"elementor-item menu-link\">Patient resources<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-41\"><a href=\"https:\/\/southwestinternalmedicine.com\/?page_id=32\" class=\"elementor-item menu-link\">Request an appointment<\/a><\/li>\n<li class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-1141\"><a href=\"https:\/\/mycw196.ecwcloud.com\/portal24804\/jsp\/100mp\/login_otp.jsp\" class=\"elementor-item menu-link\">Customer portal<\/a><\/li>\n<\/ul><\/nav>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-032f250 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"032f250\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-383d030\" data-id=\"383d030\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-8faa816 elementor-widget elementor-widget-image\" data-id=\"8faa816\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-image\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"http:\/\/southwestinternalmedicine.com\/\">\n\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"219\" height=\"282\" src=\"https:\/\/southwestinternalmedicine.com\/wp-content\/uploads\/2023\/04\/logo4.png\" class=\"attachment-large size-large\" alt=\"\" \/>\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e879d24 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"e879d24\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-634b3c6\" data-id=\"634b3c6\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-baddea6 elementor-widget elementor-widget-spacer\" data-id=\"baddea6\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-8f8180a elementor-widget elementor-widget-heading\" data-id=\"8f8180a\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Patient Information<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9a51eb5 elementor-widget elementor-widget-heading\" data-id=\"9a51eb5\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">To help reduce your waiting time, you can complete the below forms prior to your office visit. <\/h4>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0123b22 elementor-widget elementor-widget-spacer\" data-id=\"0123b22\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-27f74ed elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"27f74ed\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-cc3afcd\" data-id=\"cc3afcd\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-45e92aa patientinfo elementor-widget elementor-widget-shortcode\" data-id=\"45e92aa\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f761-o1\" lang=\"es-ES\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F888#wpcf7-f761-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulario de contacto\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"761\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.7.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"es_ES\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f761-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"redirect_nonce\" value=\"27cc6af53d\" \/>\n<input type=\"hidden\" name=\"wpcf7cfpdf_hidden_name\" value=\"document-pdf-\" \/>\n<input type=\"hidden\" name=\"wpcf7cfpdf_hidden_reference\" value=\"6a2923446d40f\" \/>\n<input type=\"hidden\" name=\"wpcf7cfpdf_hidden_date\" value=\"10dejuniode2026\" \/>\n<\/div>\n<div class=\"cf-container\">\n\t<header>\n\t\t<center>\n\t\t\t<p><img decoding=\"async\" src=\"http:\/\/swims.opennube.com\/wp-content\/uploads\/2023\/04\/portada-spanish-form-3.png\" \/>\n\t\t\t<\/p>\n\t\t<\/center>\n\t<\/header>\n\t<div class=\"cf-col-12\">\n\t\t<center>\n\t\t\t<p><strong>PATIENT INFORMATION<\/strong>\n\t\t\t<\/p>\n\t\t<\/center>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><label>Patient Name:<span class=\"wpcf7-form-control-wrap\" data-name=\"Last\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Last\" value=\"\" type=\"text\" name=\"Last\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"First\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"First\" value=\"\" type=\"text\" name=\"First\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Initial\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Initial\" value=\"\" type=\"text\" name=\"Initial\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t\t<p><label>How did you hear about us?&nbsp;<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-808\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"menu-808\"><option value=\"-Please choose an option-\">-Please choose an option-<\/option><option value=\"Holy Family Church\">Holy Family Church<\/option><option value=\"South Bulletin\">South Bulletin<\/option><option value=\"Friend\/ Family\">Friend\/ Family<\/option><option value=\"Physician\">Physician<\/option><option value=\"Current Patient\">Current Patient<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t<\/div>\n\t<div class=\"cf-col-12\">\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"HomeAddress\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Home Address\" value=\"\" type=\"text\" name=\"HomeAddress\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"city\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"State\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"State\" value=\"\" type=\"text\" name=\"State\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"zip\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" placeholder=\"Zip\" value=\"\" type=\"number\" name=\"zip\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p>Date of Birth:&nbsp;<span class=\"wpcf7-form-control-wrap\" data-name=\"dateofbirth\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dateofbirth\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Mailingadress\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" placeholder=\"Mailing Address (if different)\" value=\"\" type=\"email\" name=\"Mailingadress\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"MaleFemalecb\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Male<\/span><input type=\"checkbox\" name=\"MaleFemalecb[]\" value=\"Male\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">Female<\/span><input type=\"checkbox\" name=\"MaleFemalecb[]\" value=\"Female\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"SocialSecurityNumber\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Social Security Number\" value=\"\" type=\"text\" name=\"SocialSecurityNumber\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"maritalstatus\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Marital Status\" value=\"\" type=\"text\" name=\"maritalstatus\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"homephone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Home Phone\" value=\"\" type=\"tel\" name=\"homephone\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"celphone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Cel Phone\" value=\"\" type=\"tel\" name=\"celphone\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"employer\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Employer\" value=\"\" type=\"text\" name=\"employer\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"occupation\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Occupation\" value=\"\" type=\"text\" name=\"occupation\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"employerphone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Telephone\" value=\"\" type=\"tel\" name=\"employerphone\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t<\/div>\n\t<div class=\"cf-col-4\">\n\t\t<p><label>Friend or Relative not living With You:<span class=\"wpcf7-form-control-wrap\" data-name=\"namefriend\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Name\" value=\"\" type=\"text\" name=\"namefriend\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"relationship\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Relationship\" value=\"\" type=\"text\" name=\"relationship\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-5\">\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"friendaddress\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Address\" value=\"\" type=\"text\" name=\"friendaddress\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"friendtelephone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Telephone\" value=\"\" type=\"text\" name=\"friendtelephone\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><label>Medical Insurance Information:<span class=\"wpcf7-form-control-wrap\" data-name=\"primaryinsurance\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Primary Insurance\" value=\"\" type=\"text\" name=\"primaryinsurance\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"policyholder\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Policy Holder\" value=\"\" type=\"text\" name=\"policyholder\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><label>DOB:&nbsp;<span class=\"wpcf7-form-control-wrap\" data-name=\"DOB\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"DOB\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ssn2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"SSN#\" value=\"\" type=\"text\" name=\"ssn2\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"secundaryinsurance\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Secundary Insurance\" value=\"\" type=\"text\" name=\"secundaryinsurance\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"policyholder2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Policy Holder\" value=\"\" type=\"text\" name=\"policyholder2\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"spouce\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Name of Spouse or (if a minor) parent\" value=\"\" type=\"text\" name=\"spouce\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"spouce2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Spouse\u2019s\/Parent\u2019s Employer\" value=\"\" type=\"text\" name=\"spouce2\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-3\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"spoucetelephone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Telephone\" value=\"\" type=\"text\" name=\"spoucetelephone\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t<\/div>\n\t<div class=\"cf-col-12\">\n\t<hr \/>\n\t<\/div>\n\t<div class=\"cf-col-12\">\n\t\t<center>\n\t\t\t<p><strong>Authorization and Assignment<\/strong>\n\t\t\t<\/p>\n\t\t<\/center>\n\t<\/div>\n\t<div class=\"cf-col-12\">\n\t\t<p>I hereby authorize my insurance carrier, attorney, or any third-party payer to pay directly to Southwest Internal Medicine Specialists all charges submitted for services incurred by me. I understand I will be responsible for any and all charges not paid by my insurance company. I authorize Southwest Internal Medicine Specialists to release information concerning my medical condition to my insurance company, employer, hospital, physician or attorney for the purpose of processing a claim. I assign payment directly to the physicians at Southwest Internal Medicine Specialists which may be due from the Medicare program or any other insurance company, including supplemental insurance, which may cover in whole or part medical services which I have received. The authorization and assignment shall be valid until I notify Southwest Internal Medicine Specialists in writing of the cancellation. A photocopy of this authorization shall be valid as the original copy.\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t\t<p><strong>Please sign below (required)<span class=\"wpcf7-form-control-wrap wpcf7-sign-wrap sign-453\"><input class=\"wpcf7-form-control wpcf7-sign\" aria-invalid=\"false\" name=\"sign-453\" type=\"hidden\" \/>\n            <canvas style=\"display:block\" data-hidden=\"sign-453\" class=\"signature-pad\" width=400 height=200><\/canvas>\n            <button class=\"btn btn-primary cf7sg-sign\">Clear<\/button>\n        <\/span><\/strong>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-6\">\n\t\t<p>(<strong>Witness) Please sign below (required)<span class=\"wpcf7-form-control-wrap wpcf7-sign-wrap sign-393\"><input class=\"wpcf7-form-control wpcf7-sign\" aria-invalid=\"false\" name=\"sign-393\" type=\"hidden\" \/>\n            <canvas style=\"display:block\" data-hidden=\"sign-393\" class=\"signature-pad\" width=400 height=200><\/canvas>\n            <button class=\"btn btn-primary cf7sg-sign\">Clear<\/button>\n        <\/span><\/strong>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-2\">\n\t\t<p><label>Signature Date: <span class=\"wpcf7-form-control-wrap\" data-name=\"date-signature\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-signature\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-4\">\n\t<\/div>\n\t<div class=\"cf-col-2\">\n\t\t<p><label> (WITNESS) Date:<span class=\"wpcf7-form-control-wrap\" data-name=\"date-witness\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-witness\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf-col-4\">\n\t<\/div>\n\t<div class=\"cf-col-12\">\n\t<hr \/>\n\t<\/div>\n\t<div class=\"cf-col-12\">\n\t\t<center>\n\t\t\t<p><strong>5979 Vineland Road, Suite 310, Orlando, FL 32819 (407) 345-0005<\/strong>\n\t\t\t<\/p>\n\t\t<\/center>\n\t<\/div>\n\t<div class=\"cf-col-12\">\n\t\t<p><input class=\"wpcf7-form-control has-spinner wpcf7-submit\" type=\"submit\" value=\"Submit\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-5838bc6 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"5838bc6\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-eb7a25e\" data-id=\"eb7a25e\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-b02dfa0 elementor-widget elementor-widget-spacer\" data-id=\"b02dfa0\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-3f80833 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"3f80833\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-79c21ad\" data-id=\"79c21ad\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-2fcf4ed elementor-widget elementor-widget-heading\" data-id=\"2fcf4ed\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Contact us<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-ee589f7 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"ee589f7\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-d953e23\" data-id=\"d953e23\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-bd40d51 elementor-widget elementor-widget-image\" data-id=\"bd40d51\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-image\">\n\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"219\" height=\"282\" src=\"https:\/\/southwestinternalmedicine.com\/wp-content\/uploads\/2023\/04\/logo4.png\" class=\"attachment-large size-large\" alt=\"\" \/>\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-8f00bfd\" data-id=\"8f00bfd\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9f619d5 elementor-widget elementor-widget-heading\" data-id=\"9f619d5\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">Ph: 407-345-0005<br>\nFx: 888-219-6957<br>\ninfo@southwestinternalmedicine.com<br>\n\nOffice Location<br>\n5979 Vineland Rd.\nSuite 310\nOrlando, FL 32819<\/h4>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-ca11abb\" data-id=\"ca11abb\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-835bdfa elementor-widget elementor-widget-google_maps\" data-id=\"835bdfa\" data-element_type=\"widget\" data-widget_type=\"google_maps.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"elementor-custom-embed\"><iframe frameborder=\"0\" scrolling=\"no\" marginheight=\"0\" marginwidth=\"0\" src=\"https:\/\/maps.google.com\/maps?q=5979%20Vineland%20Rd.%2C%20Suite%20310%20Orlando%2C%20FL%2032819&amp;t=m&amp;z=10&amp;output=embed&amp;iwloc=near\" title=\"5979 Vineland Rd., Suite 310 Orlando, FL 32819\" aria-label=\"5979 Vineland Rd., Suite 310 Orlando, FL 32819\"><\/iframe><\/div>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Southwest Internal Medicine is now offering Telemedicine Services. Please contact our office for more details. Patient Information To help reduce your waiting time, you can complete the below forms prior to your office visit. Contact us Ph: 407-345-0005 Fx: 888-219-6957 info@southwestinternalmedicine.com Office Location 5979 Vineland Rd. Suite 310 Orlando, FL 32819<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":32,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-global-header-display":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","footnotes":""},"class_list":["post-888","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/southwestinternalmedicine.com\/index.php?rest_route=\/wp\/v2\/pages\/888","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/southwestinternalmedicine.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/southwestinternalmedicine.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/southwestinternalmedicine.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/southwestinternalmedicine.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=888"}],"version-history":[{"count":10,"href":"https:\/\/southwestinternalmedicine.com\/index.php?rest_route=\/wp\/v2\/pages\/888\/revisions"}],"predecessor-version":[{"id":900,"href":"https:\/\/southwestinternalmedicine.com\/index.php?rest_route=\/wp\/v2\/pages\/888\/revisions\/900"}],"wp:attachment":[{"href":"https:\/\/southwestinternalmedicine.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=888"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}