{"id":2857,"date":"2022-07-27T18:02:33","date_gmt":"2022-07-27T18:02:33","guid":{"rendered":"https:\/\/eyectexas.com\/?page_id=2857"},"modified":"2023-08-10T18:43:02","modified_gmt":"2023-08-10T18:43:02","slug":"schedule-an-appointment-online","status":"publish","type":"page","link":"https:\/\/eyectexas.com\/schedule-an-appointment-online\/","title":{"rendered":"Schedule an Appointment"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var 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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-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/wp-json\/wp\/v2\/pages\/2857#gf_2' data-formid='2' novalidate>\n        <div id='gf_progressbar_wrapper_2' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>3<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_2_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_2_12\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_12\" ><h3 class=\"gsection_title\">Contact Details<\/h3><\/div><fieldset id=\"field_2_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >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_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_2_2\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_2\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_2_2_container'>\n                                <span id='input_2_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_2_2' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                    <input class='' type='email' name='input_2' id='input_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <span id='input_2_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_2_2_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                    <input class='' type='email' name='input_2_2' id='input_2_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_2_3\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\" ><label class='gfield_label gform-field-label' for='input_2_3'>Phone<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_3' id='input_2_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><div id=\"field_2_20\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\" ><label class='gfield_label gform-field-label' for='input_2_20'>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_20' id='input_2_20' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_20_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_20_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_20' class='gform_hidden' value='https:\/\/eyectexas.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_9' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-9' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_2' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_2_13\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\" ><h3 class=\"gsection_title\">When would you like your appointment?<\/h3><\/div><div id=\"field_2_21\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_21\" ><label class='gfield_label gform-field-label' for='input_2_21'>Prefered Date<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_21' id='input_2_21' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_21_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_21_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_21' class='gform_hidden' value='https:\/\/eyectexas.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_22\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_22\" ><label class='gfield_label gform-field-label' for='input_2_22'>Prefered Time<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_22' id='input_2_22' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Please select' >Please select<\/option><option value='No Preference' selected='selected'>No Preference<\/option><option value='Early Morning' >Early Morning<\/option><option value='Late Morning' >Late Morning<\/option><option value='Early Afternoon' >Early Afternoon<\/option><option value='Late Afternoon' >Late Afternoon<\/option><\/select><\/div><\/div><div id=\"field_2_23\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_23\" ><label class='gfield_label gform-field-label' for='input_2_23'>Notes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_2_23' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_10' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_10' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' data-js='page-field-id-10' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_3' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_2_24\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_24\" ><label class='gfield_label gform-field-label' for='input_2_24'>What type of eye issues are having? Please be as specific as possible.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_2_24' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\" ><legend class='gfield_label gform-field-label' >Do you currently have an eye care provider (ophthalmologist or optometrist)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_25'>\n\t\t\t<div class='gchoice gchoice_2_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_2_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_25_0' id='label_2_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_2_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_25_1' id='label_2_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_26\" ><legend class='gfield_label gform-field-label' >Have you had eye surgery before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_26'>\n\t\t\t<div class='gchoice gchoice_2_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_2_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_26_0' id='label_2_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_2_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_26_1' id='label_2_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_27\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_27\" ><label class='gfield_label gform-field-label' for='input_2_27'>If yes: Please list the following for up to three (3) of you most recent eye surgeries.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_2_27' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_28\" class=\"gfield gfield--type-captcha gfield--width-full field_sublabel_above gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_28\" ><label class='gfield_label gform-field-label' for='input_2_28'>reCAPTCHA<\/label><div 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