{"id":251,"date":"2021-07-01T06:31:29","date_gmt":"2021-07-01T06:31:29","guid":{"rendered":"https:\/\/mzcustomfit.com\/?page_id=251"},"modified":"2021-09-27T07:47:53","modified_gmt":"2021-09-27T07:47:53","slug":"in-service-request","status":"publish","type":"page","link":"https:\/\/mzcustomfit.com\/virtual-services\/in-service-request\/","title":{"rendered":"In-Service Request"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"251\" class=\"elementor elementor-251\">\n\t\t\t\t\t\t<div class=\"elementor-inner\">\n\t\t\t\t<div class=\"elementor-section-wrap\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-5823823 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"5823823\" 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-2246dac\" data-id=\"2246dac\" 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-59f1065 elementor-widget elementor-widget-heading\" data-id=\"59f1065\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">In-Service Request<\/h1>\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-ddee27a elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"ddee27a\" 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-5fcd005\" data-id=\"5fcd005\" 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<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-c519172 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"c519172\" 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-25 elementor-inner-column elementor-element elementor-element-ce737d2\" data-id=\"ce737d2\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\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-25 elementor-inner-column elementor-element elementor-element-c6f0568\" data-id=\"c6f0568\" 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-d63ed81 elementor-align-justify elementor-widget elementor-widget-button\" data-id=\"d63ed81\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t<a href=\"https:\/\/mzcustomfit.com\/virtual-services\/in-service-request\/\" class=\"elementor-button-link elementor-button elementor-size-sm\" role=\"button\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-text\">In-Service Request Form<\/span>\n\t\t<\/span>\n\t\t\t\t\t<\/a>\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<div class=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-c65328c\" data-id=\"c65328c\" 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-de82562 elementor-align-justify elementor-widget elementor-widget-button\" data-id=\"de82562\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t<a href=\"https:\/\/mzcustomfit.com\/virtual-services\/request-a-virtual-fitting\/\" class=\"elementor-button-link elementor-button elementor-size-sm\" role=\"button\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-text\">VIRTUAL\/TELEHEALTH REQUEST Form<\/span>\n\t\t<\/span>\n\t\t\t\t\t<\/a>\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<div class=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-501cf46\" data-id=\"501cf46\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\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<div class=\"elementor-element elementor-element-b465d20 pp-wpforms-labels-yes pp-wpforms-form-button-custom elementor-widget elementor-widget-pp-wpforms\" data-id=\"b465d20\" data-element_type=\"widget\" data-widget_type=\"pp-wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"pp-contact-form pp-wpforms\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-242\"><form id=\"wpforms-form-242\" class=\"wpforms-validate wpforms-form\" data-formid=\"242\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wp-json\/wp\/v2\/pages\/251\" data-token=\"bc8daef37b6ce2e1b9af76f3880b0dc5\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-242-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_1\">FIRST NAME AND LAST NAME <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-242-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" required><\/div><div id=\"wpforms-242-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_2\">TITLE (PT, OT, ETC.) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-242-field_2\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][2]\" required><\/div><div id=\"wpforms-242-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_3\">HEALTHCARE NETWORK <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-242-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-242-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_4\">CLINIC NAME <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-242-field_4\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][4]\" required><\/div><div id=\"wpforms-242-field_5-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_5\">ADDRESS <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-242-field_5\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][5][address1]\" required><label for=\"wpforms-242-field_5\" class=\"wpforms-field-sublabel after \">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-242-field_5-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][5][city]\" required><label for=\"wpforms-242-field_5-city\" class=\"wpforms-field-sublabel after \">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-242-field_5-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][5][state]\" required><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-242-field_5-state\" class=\"wpforms-field-sublabel after \">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-242-field_5-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"99999[-9999]\" data-inputmask-greedy=\"false\" data-rule-empty-blanks=\"1\" name=\"wpforms[fields][5][postal]\" required><label for=\"wpforms-242-field_5-postal\" class=\"wpforms-field-sublabel after \">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-242-field_6-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_6\">WORK EMAIL <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-242-field_6\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][6]\" required><\/div><div id=\"wpforms-242-field_7-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_7\">PERSONAL EMAIL FOR UPCOMING EVENTS <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-242-field_7\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][7]\" required><\/div><div id=\"wpforms-242-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_8\">HOW MANY NEW UPPER EXTREMITY PATIENTS DO YOU SEE ON AVERAGE PER MONTH? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-242-field_8\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][8]\" required><\/div><div id=\"wpforms-242-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_9\">HOW MANY NEW LOWER EXTREMITY PATIENTS DO YOU SEE ON AVERAGE PER MONTH? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-242-field_9\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][9]\" required><\/div><div id=\"wpforms-242-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_10\">WHAT PERCENTAGE OF YOUR PATIENTS HAVE COMMERCIAL INSURANCE AS THEIR PRIMARY PAYOR? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-242-field_10\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][10]\" required><\/div><div id=\"wpforms-242-field_11-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_11\">HAVE YOU OR DO YOU REFER LYMPHEDEMA PATIENTS TO MZ CUSTOMFIT?<\/label><select id=\"wpforms-242-field_11\" class=\"wpforms-field-large\" name=\"wpforms[fields][11]\"><option value=\"Yes\" >Yes<\/option><option value=\"No\" >No<\/option><\/select><\/div><div id=\"wpforms-242-field_12-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"12\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_12\">IF THE ANSWER IS YES, HOW WOULD YOU RATE OUR SERVICES ON A SCALE OF 1-10?<\/label><select id=\"wpforms-242-field_12\" class=\"wpforms-field-large\" name=\"wpforms[fields][12]\"><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><\/select><\/div><div id=\"wpforms-242-field_13-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_13\">ARE THERE ANY COMMENTS YOU WOULD LIKE TO SHARE ABOUT MZ CUSTOMFIT\u2019S TEAM OF PATIENT ADVOCATES THAT WE CAN SHARE WITH OTHER LYMPHEDEMA CLINICIANS ON OUR HOME PAGE?<\/label><textarea id=\"wpforms-242-field_13\" class=\"wpforms-field-large\" name=\"wpforms[fields][13]\" ><\/textarea><\/div><div id=\"wpforms-242-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_14\">IF YOU DON&#039;T MIND SHARING, WHICH PROVIDERS DO YOU CURRENTLY REFER COMMERCIAL INSURANCE TO?<\/label><input type=\"text\" id=\"wpforms-242-field_14\" class=\"wpforms-field-large\" name=\"wpforms[fields][14]\" ><\/div><div id=\"wpforms-242-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_15\">IF YOU DON&#039;T MIND SHARING, WHICH PROVIDERS DO YOU REFER PRIVATE PAY TO?<\/label><input type=\"text\" id=\"wpforms-242-field_15\" class=\"wpforms-field-large\" name=\"wpforms[fields][15]\" ><div class=\"wpforms-field-description\">NOTE: WE ARE IN THE PROCESS OF LAUNCHING A PRIVATE PAY WEBSITE HOWEVER IN THE INTERIM, PLEASE NOTE THAT WE OFFER PRIVATE PAY PRICING.<\/div><\/div><div id=\"wpforms-242-field_16-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-242-field_16\">ADDITIONAL COMMENTS<\/label><textarea id=\"wpforms-242-field_16\" class=\"wpforms-field-large\" name=\"wpforms[fields][16]\" ><\/textarea><\/div><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"242\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"2\"><button type=\"submit\" name=\"wpforms[submit]\" class=\"wpforms-submit \" id=\"wpforms-submit-242\" value=\"wpforms-submit\" aria-live=\"assertive\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\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\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>In-Service Request In-Service Request Form VIRTUAL\/TELEHEALTH REQUEST Form Please enable JavaScript in your browser to complete this form.FIRST NAME AND LAST NAME *TITLE (PT, OT, ETC.) *HEALTHCARE NETWORK *CLINIC NAME *ADDRESS *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWORK EMAIL *PERSONAL EMAIL FOR UPCOMING EVENTS *HOW MANY [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":188,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/pages\/251"}],"collection":[{"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/comments?post=251"}],"version-history":[{"count":0,"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/pages\/251\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/pages\/188"}],"wp:attachment":[{"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/media?parent=251"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}