{"id":340,"date":"2026-01-19T18:00:11","date_gmt":"2026-01-19T18:00:11","guid":{"rendered":"https:\/\/cheryl.telehealthpractices.com\/?page_id=340"},"modified":"2026-02-10T18:50:48","modified_gmt":"2026-02-10T18:50:48","slug":"340-2","status":"publish","type":"page","link":"https:\/\/cheryl.telehealthpractices.com\/?page_id=340","title":{"rendered":".."},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"340\" class=\"elementor elementor-340\">\n\t\t\t\t<div class=\"elementor-element elementor-element-91f5721 e-flex e-con-boxed tmpcoder-jarallax-no tmpcoder-parallax-no tmpcoder-particle-no tmpcoder-sticky-section-no e-con e-parent\" data-id=\"91f5721\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1c18461 elementor-widget elementor-widget-html\" data-id=\"1c18461\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t\t<!DOCTYPE html>\r\n<html lang=\"en\">\r\n<head>\r\n    <script src=\"https:\/\/cdn.jsdelivr.net\/npm\/@emailjs\/browser@4\/dist\/email.min.js\"><\/script>\r\n<script>\r\n    emailjs.init(\"Dj_CmSbzvFHh7BSsX\");\r\n<\/script>\r\n    <meta charset=\"UTF-8\">\r\n    <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\r\n    <title>Patient Enrollment Form - Cheryl Emanuel<\/title>\r\n    <link href=\"https:\/\/fonts.googleapis.com\/css2?family=Roboto:wght@400;500;700&display=swap\" rel=\"stylesheet\">\r\n    <style>\r\n        * {\r\n            margin: 0;\r\n            padding: 0;\r\n            box-sizing: border-box;\r\n        }\r\n        body {\r\n            font-family: 'Roboto', sans-serif;\r\n            background: linear-gradient(135deg, #f5f7fb 0%, #e2e8f0 100%);\r\n            min-height: 100vh;\r\n            padding: 40px 20px;\r\n        }\r\n        .form-container {\r\n            max-width: 900px;\r\n 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class=\"form-body\">\r\n        <!-- I. PATIENT INFORMATION -->\r\n        <div class=\"section-title\">I. Patient Information<\/div>\r\n        <div class=\"form-row\">\r\n            <div class=\"form-field\">\r\n                <label class=\"field-label\">Full Name *<\/label>\r\n                <input type=\"text\" class=\"field-input\" required>\r\n            <\/div>\r\n            <div class=\"form-field\">\r\n                <label class=\"field-label\">Date of Birth (MM\/DD\/YYYY) *<\/label>\r\n                <input type=\"date\" class=\"field-input\" required>\r\n            <\/div>\r\n        <\/div>\r\n        <div class=\"form-row\">\r\n            <div class=\"form-field\">\r\n                <label class=\"field-label\">Gender Identity *<\/label>\r\n                <select class=\"field-input\" required>\r\n                    <option value=\"\">Select...<\/option>\r\n                    <option value=\"female\">Female<\/option>\r\n                    <option value=\"male\">Male<\/option>\r\n                    <option value=\"non-binary\">Non-binary<\/option>\r\n                    <option value=\"other\">Other<\/option>\r\n                <\/select>\r\n            <\/div>\r\n            <div class=\"form-field\">\r\n                <label class=\"field-label\">Preferred Pronouns<\/label>\r\n                <input type=\"text\" class=\"field-input\" placeholder=\"He\/Him, She\/Her, They\/Them, etc.\">\r\n            <\/div>\r\n        <\/div>\r\n        <!-- II. CONTACT DETAILS -->\r\n        <div class=\"section-title\">II. Contact Details<\/div>\r\n        <div class=\"form-row\">\r\n            <div class=\"form-field\">\r\n                <label class=\"field-label\">Primary Phone Number *<\/label>\r\n                <input type=\"tel\" class=\"field-input\" required>\r\n            <\/div>\r\n            <div class=\"form-field\">\r\n                <label class=\"field-label\">Email Address *<\/label>\r\n                <input type=\"email\" class=\"field-input\" required>\r\n            <\/div>\r\n        <\/div>\r\n        <div class=\"form-field full-width\">\r\n            <label class=\"field-label\">Mailing Address<\/label>\r\n            <input type=\"text\" class=\"field-input\" placeholder=\"Street Address\">\r\n        <\/div>\r\n        <div class=\"form-row\">\r\n            <div class=\"form-field\">\r\n                <label class=\"field-label\">City<\/label>\r\n                <input type=\"text\" class=\"field-input\">\r\n            <\/div>\r\n            <div class=\"form-field\">\r\n                <label class=\"field-label\">State<\/label>\r\n                <select class=\"field-input\">\r\n                    <option value=\"\">Select State...<\/option>\r\n                    <option value=\"AL\">Alabama<\/option>\r\n                    <option value=\"AK\">Alaska<\/option>\r\n                    <option value=\"AZ\">Arizona<\/option>\r\n                    <option value=\"AR\">Arkansas<\/option>\r\n                    <option value=\"CA\">California<\/option>\r\n                    <!-- Add more states as needed -->\r\n                <\/select>\r\n            <\/div>\r\n            <div class=\"form-field\">\r\n                <label class=\"field-label\">ZIP Code<\/label>\r\n                <input type=\"text\" class=\"field-input\">\r\n            <\/div>\r\n        <\/div>\r\n        <div class=\"form-field\">\r\n            <label class=\"field-label\">Preferred Contact Method<\/label>\r\n            <select class=\"field-input\">\r\n                <option value=\"\">Select...<\/option>\r\n                <option value=\"phone\">Phone<\/option>\r\n                <option value=\"text\">Text<\/option>\r\n                <option value=\"email\">Email<\/option>\r\n            <\/select>\r\n        <\/div>\r\n        <!-- III. EMERGENCY CONTACT -->\r\n        <div class=\"section-title\">III. Emergency Contact<\/div>\r\n        <div class=\"form-row\">\r\n            <div class=\"form-field\">\r\n                <label class=\"field-label\">Full Name<\/label>\r\n                <input type=\"text\" class=\"field-input\">\r\n            <\/div>\r\n            <div class=\"form-field\">\r\n                <label class=\"field-label\">Relationship<\/label>\r\n                <input type=\"text\" class=\"field-input\">\r\n            <\/div>\r\n        <\/div>\r\n        <div class=\"form-field\">\r\n            <label class=\"field-label\">Phone Number<\/label>\r\n            <input type=\"tel\" class=\"field-input\">\r\n        <\/div>\r\n        <!-- V. HEALTH INFORMATION -->\r\n        <div class=\"section-title\">V. Health Information<\/div>\r\n        <div class=\"checkbox-group\">\r\n            <label class=\"checkbox-item\">\r\n                <input type=\"checkbox\">\r\n                <span>Currently under care of physician\/mental health professional<\/span>\r\n            <\/label>\r\n            <div class=\"form-field full-width\">\r\n                <label class=\"field-label\">If yes, please explain<\/label>\r\n                <textarea class=\"field-input textarea-field\"><\/textarea>\r\n            <\/div>\r\n        <\/div>\r\n        <div class=\"checkbox-group\">\r\n            <label class=\"checkbox-item\">\r\n                <input type=\"checkbox\">\r\n                <span>Taking medications or supplements<\/span>\r\n            <\/label>\r\n            <div class=\"form-field full-width\">\r\n                <label class=\"field-label\">If yes, please list<\/label>\r\n                <textarea class=\"field-input textarea-field\"><\/textarea>\r\n            <\/div>\r\n        <\/div>\r\n        <div class=\"checkbox-group\">\r\n            <label class=\"checkbox-item\">\r\n                <input type=\"checkbox\">\r\n                <span>Recent surgeries, diagnoses, or major health concerns<\/span>\r\n            <\/label>\r\n            <div class=\"form-field full-width\">\r\n                <label class=\"field-label\">If yes, please describe<\/label>\r\n                <textarea class=\"field-input textarea-field\"><\/textarea>\r\n            <\/div>\r\n        <\/div>\r\n        <div class=\"form-row\">\r\n            <div class=\"checkbox-group\">\r\n                <label class=\"checkbox-item\">\r\n                    <input type=\"checkbox\">\r\n                    <span>Currently pregnant<\/span>\r\n                <\/label>\r\n            <\/div>\r\n            <div class=\"checkbox-group\">\r\n                <label class=\"checkbox-item\">\r\n                    <input type=\"checkbox\">\r\n                    <span>Not applicable<\/span>\r\n                <\/label>\r\n            <\/div>\r\n        <\/div>\r\n        <div class=\"form-field full-width\">\r\n            <label class=\"field-label\">Medical History (check all that apply)<\/label>\r\n            <div class=\"checkbox-group\">\r\n                <label class=\"checkbox-item\"><input type=\"checkbox\"> Chronic Pain<\/label>\r\n                <label class=\"checkbox-item\"><input type=\"checkbox\"> Diabetes<\/label>\r\n                <label class=\"checkbox-item\"><input type=\"checkbox\"> Heart Disease<\/label>\r\n                <label class=\"checkbox-item\"><input type=\"checkbox\"> High Blood Pressure<\/label>\r\n                <label class=\"checkbox-item\"><input type=\"checkbox\"> Mental Health Conditions<\/label>\r\n                <label class=\"checkbox-item\"><input type=\"checkbox\"> Other<\/label>\r\n            <\/div>\r\n        <\/div>\r\n        <!-- Consent Section -->\r\n        <div class=\"consent-section\">\r\n            <p>I hereby consent to receive telehealth services from Richard Kevin Baker, NP. I understand that this form is for enrollment purposes and that all information provided is accurate to the best of my knowledge.<\/p>\r\n            <label class=\"consent-checkbox\">\r\n                <input type=\"checkbox\" required>\r\n                <span>I agree to the terms and conditions *<\/span>\r\n            <\/label>\r\n        <\/div>\r\n        <!-- Submit Section -->\r\n        <div class=\"submit-section\">\r\n            <button type=\"submit\" class=\"submit-btn\">Submit Enrollment<\/button>\r\n            <!-- Add to <head> -->\r\n<script src=\"https:\/\/cdn.jsdelivr.net\/npm\/@emailjs\/browser@4\/dist\/email.min.js\"><\/script>\r\n<script>\r\n    emailjs.init(\"Dj_CmSbzvFHh7BSsX\");\r\n<\/script>\r\n\r\n<!-- Replace your entire <form> tag -->\r\n<form class=\"form-body\" id=\"patientForm\">\r\n    <!-- ALL your existing form fields stay exactly the same -->\r\n    \r\n    <div class=\"submit-section\">\r\n        <button type=\"submit\" class=\"submit-btn\">Submit Enrollment<\/button>\r\n    <\/div>\r\n<\/form>\r\n\r\n<script>\r\ndocument.getElementById('patientForm').addEventListener('submit', function(e) {\r\n    e.preventDefault();\r\n    \r\n    \/\/ Name all inputs with these exact names for email template\r\n    const formData = {\r\n        patient_name: document.querySelector('input[placeholder*=\"Full Name\"]').value,\r\n        dob: document.querySelector('input[type=\"date\"]').value,\r\n        email: document.querySelector('input[type=\"email\"]').value,\r\n        phone: document.querySelector('input[type=\"tel\"]').value\r\n        \/\/ Add more fields as needed\r\n    };\r\n    \r\n    emailjs.send('service_rpys6dw\r\n', 'template_Lreofzl', formData)\r\n        .then(() => {\r\n            alert('\u2705 Patient enrollment sent to info@cheryl.telehealthpractices.com!');\r\n            this.reset();\r\n        }, (error) => {\r\n            alert('\u274c Error. Please try again.');\r\n            console.log(error);\r\n        });\r\n});\r\n<\/script>\r\n\r\n        <\/div>\r\n    <\/form>\r\n<\/div>\r\n<\/body>\r\n<\/html>\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 Enrollment Form &#8211; Cheryl Emanuel Patient Enrollment Form Cheryl Emanuel, Nurse Practitioner &#8211; Cheryl Emanuel I. Patient Information Full Name * Date of Birth (MM\/DD\/YYYY) * Gender Identity * Select&#8230;FemaleMaleNon-binaryOther Preferred Pronouns II. Contact Details Primary Phone Number * Email Address * Mailing Address City State Select State&#8230;AlabamaAlaskaArizonaArkansasCalifornia ZIP Code Preferred Contact Method Select&#8230;PhoneTextEmail [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"content-type":"","footnotes":""},"class_list":["post-340","page","type-page","status-publish","hentry"],"_hostinger_reach_plugin_has_subscription_block":false,"_hostinger_reach_plugin_is_elementor":false,"_links":{"self":[{"href":"https:\/\/cheryl.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/340","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cheryl.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cheryl.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cheryl.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cheryl.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=340"}],"version-history":[{"count":10,"href":"https:\/\/cheryl.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/340\/revisions"}],"predecessor-version":[{"id":576,"href":"https:\/\/cheryl.telehealthpractices.com\/index.php?rest_route=\/wp\/v2\/pages\/340\/revisions\/576"}],"wp:attachment":[{"href":"https:\/\/cheryl.telehealthpractices.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=340"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}