{"forms":[{"id":622,"title":"Healthcare Intake Form","status":"publish","_form":"[eacf7-row]\n    [eacf7-col col:2]\n    <label> First Name <span class=\"required\">*</span>\n        [text* your-first-name autocomplete:first-name] </label>\n    [/eacf7-col]\n    [eacf7-col col:2]\n    <label> Last Name <span class=\"required\">*</span>\n        [text* your-last-name autocomplete:last-name] </label>\n    [/eacf7-col]\n[/eacf7-row]\n\n<label> Patient Age <span class=\"required\">*</span>\n    [number* patient-age] </label>\n\n<label> Prefered Name / Nickname <span class=\"required\">*</span>\n    [text* patient-name] </label>\n\n<label> Patient Gender <span class=\"required\">*</span>\n    [select* patient-gender first_as_label \"-select-\" \"Male\" \"Female\" \"Shemale\"] </label>\n\n<label> Phone Number <span class=\"required\">*</span>\n    [phone* phone validation:1] </label>\n\n<label> Spouce Name\n    [text spouce-name] </label>\n\n<label> With whome do you live?\n    [text live] </label>\n\n<label> Marital Status <span class=\"required\">*</span>\n    [select* marital-status first_as_label \"-select-\" \"Married\" \"Unmarried\" \"other\"]</label>\n\n<label> Marital status(other)\n    [text marital-status-other]</label>\n\n<label> Occupation\n    [text occupation]</label>\n\n<label> Retired? <span class=\"required\">*</span>\n    [select* retired first_as_label \"-select-\" \"Yes\" \"No\"]</label>\n\n[conditional conditional-retired]\n<label> Date of retirement\n    [date_time date_time-743 \"m/d/Y\"]</label>\n[/conditional]\n\n<label> Disability ? <span class=\"required\">*</span>\n    [select* disability first_as_label \"-select-\" \"Yes\" \"No\"]</label>\n\n<label> Who is your primary care doctor: \n    [text primary-care-doctor]</label>\n\n<label> Where is your primary care doctor located ?\n    [text primary-care-doctor-located]</label>\n\n<label> Phone Number of primary care doctor:\n    [phone* care-doctor-phone validation:1]</label>\n\n<label> Allergic to any medications\n    [select allergic first_as_label \"-select-\" \"Yes\" \"No\"]</label>\n\n<label> Allergic to any medications\n    [text allergic-medications]</label>\n\n<label> Do you smoke? \n    [select smoke first_as_label \"-select-\" \"Yes\" \"No\"]</label>\n\n[conditional conditional-smoke]\n    <label> How many years did you smoke?\n        [number smoke-year]</label>\n[/conditional]\n\n<label> If you quit, when did you stop?\n    [text smoke-stop]</label>\n\n<label> Do you drink alcohol? \n    [text drink-alcohol]</label>\n\n<label> Personal opinion\n    [textarea personal-opinion x3]</label>\n\n[submit \"Submit\"]","_mail":{"active":true,"subject":"[_site_title] \"[your-subject]\"","sender":"[_site_title] <wordpress@softlab.local>","recipient":"[_site_admin_email]","body":"From: [your-name] [your-email]\nSubject: [your-subject]\n\nMessage Body:\n[your-message]\n\n-- \nThis is a notification that a contact form was submitted on your website ([_site_title] [_site_url]).","additional_headers":"Reply-To: [your-email]","attachments":"","use_html":false,"exclude_blank":false},"_mail_2":{"active":false,"subject":"[_site_title] \"[your-subject]\"","sender":"[_site_title] <wordpress@softlab.local>","recipient":"[your-email]","body":"Message Body:\n[your-message]\n\n-- \nThis email is a receipt for your contact form submission on our website ([_site_title] [_site_url]) in which your email address was used. If that was not you, please ignore this message.","additional_headers":"Reply-To: [_site_admin_email]","attachments":"","use_html":false,"exclude_blank":false},"_messages":{"mail_sent_ok":"Thank you for your message. It has been sent.","mail_sent_ng":"There was an error trying to send your message. Please try again later.","validation_error":"One or more fields have an error. Please check and try again.","spam":"There was an error trying to send your message. Please try again later.","accept_terms":"You must accept the terms and conditions before sending your message.","invalid_required":"Please fill out this field.","invalid_too_long":"This field has a too long input.","invalid_too_short":"This field has a too short input.","upload_failed":"There was an unknown error uploading the file.","upload_file_type_invalid":"You are not allowed to upload files of this type.","upload_file_too_large":"The uploaded file is too large.","upload_failed_php_error":"There was an error uploading the file.","invalid_date":"Please enter a date in YYYY-MM-DD format.","date_too_early":"This field has a too early date.","date_too_late":"This field has a too late date.","invalid_number":"Please enter a number.","number_too_small":"This field has a too small number.","number_too_large":"This field has a too large number.","quiz_answer_not_correct":"The answer to the quiz is incorrect.","invalid_email":"Please enter an email address.","invalid_url":"Please enter a URL.","invalid_tel":"Please enter a telephone number.","invalid_captcha":"Could not verify the reCaptcha response."},"_locale":"en_US","_hash":"7faf0c05878be43388e2d4199a014933b2631edd"}]}