{"id":137888,"date":"2023-04-26T13:38:09","date_gmt":"2023-04-26T18:38:09","guid":{"rendered":"https:\/\/www.totalwellnesshealth.com\/?page_id=137888"},"modified":"2023-04-26T13:39:40","modified_gmt":"2023-04-26T18:39:40","slug":"documentation-request","status":"publish","type":"page","link":"https:\/\/www.totalwellnesshealth.com\/documentation-request\/","title":{"rendered":"Documentation Request"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"137888\" class=\"elementor elementor-137888\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-34eb97a elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"34eb97a\" 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<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-acd7fed\" data-id=\"acd7fed\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-44383a3 uael-gf-ajax-true uael-gf-style-box uael-gf-input-size-sm uael-gf-enable-classes-no uael-gf-button-left uael-gf-btn-size-sm elementor-widget elementor-widget-uael-gf-styler\" data-id=\"44383a3\" data-element_type=\"widget\" data-widget_type=\"uael-gf-styler.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"uael-gf-style uael-gf-check-style elementor-clickable\">\n\t\t<h3 class=\"uael-gf-form-title\">Vaccination or Screening Documentation Request Form<\/h3>\n\t\t<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_688'  action='\/wp-json\/wp\/v2\/pages\/137888' data-formid='688' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_688' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_688_15\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please complete the form below to request a copy of your service documentation.<\/div><div id=\"field_688_16\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_688_16'>Have you already received the service you are requesting documentation for?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_688_16' class='large gfield_select' tabindex='1'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No, I will receive the service in the future' >No, I will receive the service in the future<\/option><\/select><\/div><\/div><div id=\"field_688_17\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>We recommend using your phone to take a picture of your completed consent form at the time of service.<\/strong> We only allow documentation requests for services that have already been provided. Please return to this form after services have been provided if you prefer not to take a picture of your consent form.<\/p><\/div><fieldset id=\"field_688_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Participant Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_688_1'>\n                            \n                            <span id='input_688_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_688_1_3' value='' tabindex='3'  aria-required='true'     \/>\n                                                    <label for='input_688_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_688_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_688_1_6' value='' tabindex='5'  aria-required='true'     \/>\n                                                    <label for='input_688_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_688_18\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_688_18'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_18' id='input_688_18' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='7'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_688_18_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_688_18_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_688_18' class='gform_hidden' value='https:\/\/www.totalwellnesshealth.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_688_8\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_688_8'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_688_8' type='email' value='' class='large' tabindex='8'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_688_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_688_3'>Company Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_688_3' type='text' value='' class='large'   tabindex='9'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_688_4\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Location where service was provided:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address gform-grid-row' id='input_688_4' >\n                        <span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_688_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_688_4_3' value='' tabindex='11'   aria-required='true'    \/>\n                                    <label for='input_688_4_3' id='input_688_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_688_4_4_container' >\n                                        <input type='text' name='input_4.4' id='input_688_4_4' value='' tabindex='13'     aria-required='true'    \/>\n                                        <label for='input_688_4_4' id='input_688_4_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_688_4_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_688_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_688_5'>Date of Event<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_688_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='15'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_688_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_688_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_688_5' class='gform_hidden' value='https:\/\/www.totalwellnesshealth.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_688_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_688_6'>Please select the type of documentation you are requesting.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_688_6' class='large gfield_select' tabindex='16'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Proof of Flu Vaccination' >Proof of Flu Vaccination<\/option><option value='Proof of Covid Vaccination' >Proof of Covid Vaccination<\/option><option value='Proof of Flu &amp; Covid Vaccinations' >Proof of Flu &amp; Covid Vaccinations<\/option><option value='Screening Results obtained via Onsite Event' >Screening Results obtained via Onsite Event<\/option><option value='Screening Results obtained via Lab Voucher' >Screening Results obtained via Lab Voucher<\/option><option value='Screening Results obtained via Home Kit' >Screening Results obtained via Home Kit<\/option><\/select><\/div><\/div><div id=\"field_688_7\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_688_7'>How would you like to receive your documentation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_688_7' class='large gfield_select' tabindex='17'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Email' >Email<\/option><option value='Fax' >Fax<\/option><option value='Mail' >Mail<\/option><\/select><\/div><\/div><div id=\"field_688_12\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_688_12'>Fax Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_12' id='input_688_12' type='tel' value='' class='large' tabindex='18'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_688_11\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_688_11' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_688_11_1_container' >\n                                        <input type='text' name='input_11.1' id='input_688_11_1' value='' tabindex='19'   aria-required='true'    \/>\n                                        <label for='input_688_11_1' id='input_688_11_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_688_11_2_container' >\n                                        <input type='text' name='input_11.2' id='input_688_11_2' value='' tabindex='20'    aria-required='false'   \/>\n                                        <label for='input_688_11_2' id='input_688_11_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_688_11_3_container' >\n                                    <input type='text' name='input_11.3' id='input_688_11_3' value='' tabindex='21'   aria-required='true'    \/>\n                                    <label for='input_688_11_3' id='input_688_11_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_688_11_4_container' >\n                                        <select name='input_11.4' id='input_688_11_4' tabindex='22'    aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_688_11_4' id='input_688_11_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_688_11_5_container' >\n                                    <input type='text' name='input_11.5' id='input_688_11_5' value='' tabindex='24'   aria-required='true'    \/>\n                                    <label for='input_688_11_5' id='input_688_11_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_11.6' id='input_688_11_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_688_13\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>By completing and signing this form, I give TotalWellness permission to release to me a copy of my flu shot consent form as proof of vaccination or my screening results according to the method identified above.&nbsp; I understand that if I select fax or email, the information will be sent via an unencrypted email or unencrypted fax line.&nbsp; I understand that it may take up to 48 hours to receive the requested documentation. 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