{"id":833,"date":"2024-03-19T09:15:13","date_gmt":"2024-03-19T09:15:13","guid":{"rendered":"https:\/\/drkhayyat.com\/?page_id=833"},"modified":"2024-03-19T09:16:20","modified_gmt":"2024-03-19T09:16:20","slug":"form-for-diagnosing-the-patients-condition","status":"publish","type":"page","link":"https:\/\/drkhayyat.com\/form-for-diagnosing-the-patients-condition\/","title":{"rendered":"Form for diagnosing the patient&#8217;s condition"},"content":{"rendered":"<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f832-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/833#wpcf7-f832-o1\" method=\"post\" class=\"wpcf7-form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"832\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"4.9.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f832-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<\/div>\n<div class=\"form-group\">\n<div class=\"custom-input-box\">\n<i class=\"Simple-Line-Icons-user\"><\/i><span class=\"wpcf7-form-control-wrap your-name\"><input type=\"text\" name=\"your-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"patient Name*\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"form-group\">\n<div class=\"custom-input-box\">\n<i class=\"Simple-Line-Icons-envelope\"><\/i><span class=\"wpcf7-form-control-wrap your-email\"><input type=\"email\" name=\"your-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email*\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"form-group\">\n<div class=\"custom-input-box\">\n<i class=\"fa fa-mobile\"><\/i><span class=\"wpcf7-form-control-wrap text-phone\"><input type=\"text\" name=\"text-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone No*\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"form-group\">\n<div class=\"custom-input-box\">\n<i class=\"fa fa-pencil\"><\/i><span class=\"wpcf7-form-control-wrap your-sub\"><input type=\"text\" name=\"your-sub\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Subject*\" \/><\/span>\n<\/div>\n<\/div>\n<div class=\"form-group\">\n<div class=\"custom-input-box\">\n<i class=\"Simple-Line-Icons-bubble\"><\/i><span class=\"wpcf7-form-control-wrap your-message\"><textarea name=\"your-message\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Message*\"><\/textarea><\/span>\n<\/div>\n<\/div>\n<div class=\"form-group\">\n<div class=\"custom-input-box\">\n<p><label>Upload the report or x-ray<br \/>\n<span class=\"wpcf7-form-control-wrap file-833\"><input type=\"file\" name=\"file-833\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"wpcf7-form-control-wrap\"><div data-sitekey=\"6LeMjj8qAAAAAIIYR85vlfysBmkza8Ydmch2AhNI\" class=\"wpcf7-form-control g-recaptcha wpcf7-recaptcha\"><\/div>\n<noscript>\n\t<div style=\"width: 302px; height: 422px;\">\n\t\t<div style=\"width: 302px; height: 422px; position: relative;\">\n\t\t\t<div style=\"width: 302px; height: 422px; position: absolute;\">\n\t\t\t\t<iframe src=\"https:\/\/www.google.com\/recaptcha\/api\/fallback?k=6LeMjj8qAAAAAIIYR85vlfysBmkza8Ydmch2AhNI\" frameborder=\"0\" scrolling=\"no\" style=\"width: 302px; height:422px; border-style: none;\">\n\t\t\t\t<\/iframe>\n\t\t\t<\/div>\n\t\t\t<div style=\"width: 300px; height: 60px; border-style: none; bottom: 12px; left: 25px; margin: 0px; padding: 0px; right: 25px; background: #f9f9f9; border: 1px solid #c1c1c1; border-radius: 3px;\">\n\t\t\t\t<textarea id=\"g-recaptcha-response\" name=\"g-recaptcha-response\" class=\"g-recaptcha-response\" style=\"width: 250px; height: 40px; border: 1px solid #c1c1c1; margin: 10px 25px; padding: 0px; resize: none;\">\n\t\t\t\t<\/textarea>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/noscript>\n<\/div>\n<div class=\"submit-btn\"><input type=\"submit\" value=\"Submit Now\" class=\"wpcf7-form-control wpcf7-submit\" \/><\/div>\n<div class=\"wpcf7-response-output wpcf7-display-none\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"Upload the report or x-ray","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-833","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Form for diagnosing the patient&#039;s condition - Dr. Ghassan Khayyat M.B.B.S. 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