{"id":692,"date":"2021-12-27T14:49:40","date_gmt":"2021-12-27T14:49:40","guid":{"rendered":"https:\/\/developer.the-anti-marketer.com\/arp\/?page_id=692"},"modified":"2024-10-02T11:59:05","modified_gmt":"2024-10-02T16:59:05","slug":"prescription-form","status":"publish","type":"page","link":"https:\/\/arpwave.com\/shop\/prescription-form\/","title":{"rendered":"Prescription Form"},"content":{"rendered":"<h2 style=\"text-align: center;\">Prescription Request Form<\/h2>\n<style id=\"wpforms-css-vars-691\">\n\t\t\t\t#wpforms-691 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-691\"><form id=\"wpforms-form-691\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"691\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/shop\/wp-json\/wp\/v2\/pages\/692\" data-token=\"15bacb1fa08e8dcff2db65b61b0b245e\" data-token-time=\"1777594197\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-691-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_9\">Date (mm\/dd\/yyyy)<\/label><input type=\"text\" id=\"wpforms-691-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-691-field_9-error\" ><\/div><div id=\"wpforms-691-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Full Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-691-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-691-field_0-error\" required><label for=\"wpforms-691-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-691-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-691-field_0-last-error\" required><label for=\"wpforms-691-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-691-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_10\">Date of Birth (mm\/dd\/yyyy) <\/label><input type=\"text\" id=\"wpforms-691-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-691-field_10-error\" ><\/div><div id=\"wpforms-691-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_1\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-691-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" aria-errormessage=\"wpforms-691-field_1-error\" required><\/div><div id=\"wpforms-691-field_6-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_6\">Home Street Address (Include State and Zip Code)<\/label><textarea id=\"wpforms-691-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-691-field_6-error\" ><\/textarea><\/div><div id=\"wpforms-691-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_5\">Cell Phone (+ area code): <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-691-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-691-field_5-error\" required><\/div><div id=\"wpforms-691-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_4\">Home Phone (+ area code):<\/label><input type=\"text\" id=\"wpforms-691-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-691-field_4-error\" ><\/div><div id=\"wpforms-691-field_11-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_11\">Sex<\/label><select id=\"wpforms-691-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\"><option value=\"Male\"  class=\"choice-1 depth-1\"  >Male<\/option><option value=\"Female\"  class=\"choice-2 depth-1\"  >Female<\/option><\/select><\/div><div id=\"wpforms-691-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_13\">CONTRAINDICATIONS FOR ARP: <\/label><input type=\"text\" id=\"wpforms-691-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-691-field_13-error\" aria-describedby=\"wpforms-691-field_13-description\" ><div id=\"wpforms-691-field_13-description\" class=\"wpforms-field-description\">NOTE: FDA requires that you answer \"Yes\" or \"No\" to EACH of the following six questions. If you have a contraindication, please notate it, scroll down to the bottom of this form, and click submit. If you do not have a contraindication, please notate and continue filling out the form; hit submit once the form is completed. Unfortunately, if you have a contraindication listed below, FDA will not allow ARPwave to ship or utilize any  ARPwave devices with you.<\/div><\/div><div id=\"wpforms-691-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_14\">1.  Pregnant <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-691-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Choose<\/option><option value=\"YES \"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-691-field_16-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_16\">2. Blood Clots <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-691-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Choose<\/option><option value=\"YES \"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-691-field_17-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_17\">3. History of Blood Clots <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-691-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Choose<\/option><option value=\"YES \"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-691-field_18-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_18\">4. Pacemaker <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-691-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Choose<\/option><option value=\"YES \"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-691-field_19-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_19\">5. ICD <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-691-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Choose<\/option><option value=\"YES \"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-691-field_20-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_20\">6. Any implanted electrical device other than Pacemaker or ICD <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-691-field_20\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][20]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Choose<\/option><option value=\"YES \"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-691-field_40-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_40\">List the areas of where you are experiencing pain in the order you want to work on.<\/label><textarea id=\"wpforms-691-field_40\" class=\"wpforms-field-medium\" name=\"wpforms[fields][40]\" aria-errormessage=\"wpforms-691-field_40-error\" ><\/textarea><\/div><div id=\"wpforms-691-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_23\">Where is your pain located:<\/label><input type=\"text\" id=\"wpforms-691-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-691-field_23-error\" ><\/div><div id=\"wpforms-691-field_21-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_21\">Rate the intensity of your pain:<\/label><select id=\"wpforms-691-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select Pain Level<\/option><option value=\"1\"  class=\"choice-1 depth-1\"  >1<\/option><option value=\"2\"  class=\"choice-2 depth-1\"  >2<\/option><option value=\"3\"  class=\"choice-3 depth-1\"  >3<\/option><option value=\"4\"  class=\"choice-8 depth-1\"  >4<\/option><option value=\"5\"  class=\"choice-7 depth-1\"  >5<\/option><option value=\"6\"  class=\"choice-6 depth-1\"  >6<\/option><option value=\"7\"  class=\"choice-5 depth-1\"  >7<\/option><option value=\"8\"  class=\"choice-4 depth-1\"  >8<\/option><option value=\"9\"  class=\"choice-10 depth-1\"  >9<\/option><option value=\"10 (worst possible pain)\"  class=\"choice-9 depth-1\"  >10 (worst possible pain)<\/option><\/select><\/div><div id=\"wpforms-691-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_24\">When did your complaint\/symptoms begin:<\/label><input type=\"text\" id=\"wpforms-691-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" aria-errormessage=\"wpforms-691-field_24-error\" ><\/div><div id=\"wpforms-691-field_26-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_26\">What was the cause of the symptoms:<\/label><textarea id=\"wpforms-691-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-691-field_26-error\" ><\/textarea><\/div><div id=\"wpforms-691-field_27-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_27\">What does your pain feel like:<\/label><select id=\"wpforms-691-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select<\/option><option value=\"Aching\"  class=\"choice-1 depth-1\"  >Aching<\/option><option value=\"Burning\"  class=\"choice-2 depth-1\"  >Burning<\/option><option value=\"Numbness\"  class=\"choice-3 depth-1\"  >Numbness<\/option><option value=\"Pins and Needles\"  class=\"choice-4 depth-1\"  >Pins and Needles<\/option><option value=\"Stabbing\"  class=\"choice-5 depth-1\"  >Stabbing<\/option><\/select><\/div><div id=\"wpforms-691-field_28-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_28\">How have the symptoms progressed:<\/label><input type=\"text\" id=\"wpforms-691-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-691-field_28-error\" ><\/div><div id=\"wpforms-691-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_29\">What movement or activity bothers you most:<\/label><input type=\"text\" id=\"wpforms-691-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" aria-errormessage=\"wpforms-691-field_29-error\" ><\/div><div id=\"wpforms-691-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_30\">Have you had surgery:<\/label><input type=\"text\" id=\"wpforms-691-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" aria-errormessage=\"wpforms-691-field_30-error\" ><\/div><div id=\"wpforms-691-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_31\">Have you been told you need surgery:<\/label><input type=\"text\" id=\"wpforms-691-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" aria-errormessage=\"wpforms-691-field_31-error\" ><\/div><div id=\"wpforms-691-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_32\">What have you done to relieve symptoms?<\/label><input type=\"text\" id=\"wpforms-691-field_32\" class=\"wpforms-field-medium\" name=\"wpforms[fields][32]\" aria-errormessage=\"wpforms-691-field_32-error\" ><\/div><div id=\"wpforms-691-field_33-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_33\">List any medication you are taking:<\/label><textarea id=\"wpforms-691-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" aria-errormessage=\"wpforms-691-field_33-error\" ><\/textarea><\/div><div id=\"wpforms-691-field_34-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_34\">Have you had Physical Therapy as a treatment:<\/label><select id=\"wpforms-691-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>SELECT<\/option><option value=\"YES\"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-691-field_35-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_35\">Have you had Chiropractic as a treatment:<\/label><select id=\"wpforms-691-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>SELECT<\/option><option value=\"YES\"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-691-field_36-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_36\">Your Primary Physician name:<\/label><input type=\"text\" id=\"wpforms-691-field_36\" class=\"wpforms-field-medium\" name=\"wpforms[fields][36]\" aria-errormessage=\"wpforms-691-field_36-error\" ><\/div><div id=\"wpforms-691-field_37-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_37\">Your Primary Physician Phone:<\/label><input type=\"text\" id=\"wpforms-691-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\" aria-errormessage=\"wpforms-691-field_37-error\" ><\/div><div id=\"wpforms-691-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-691-field_38\">Truthful Representation:<\/label><input type=\"text\" id=\"wpforms-691-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\" placeholder=\"Enter name to agree \" aria-errormessage=\"wpforms-691-field_38-error\" aria-describedby=\"wpforms-691-field_38-description\" ><div id=\"wpforms-691-field_38-description\" class=\"wpforms-field-description\">Upon entering my full name below, I hereby state that all the information I have provided is true, correct and complete. If more information about my condition becomes known, I will tell the doctor when possible so that it can be added to my record.\r\n<\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"691\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/arpwave.com\/shop\/wp-json\/wp\/v2\/pages\/692\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-691\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/arpwave.com\/shop\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n","protected":false},"excerpt":{"rendered":"<p>Prescription Request Form<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-692","page","type-page","status-publish","hentry","post-wrapper","thrv_wrapper"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - 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