{"id":2964,"date":"2026-07-10T13:43:10","date_gmt":"2026-07-10T17:43:10","guid":{"rendered":"https:\/\/truenorthimaging.com\/?page_id=2964"},"modified":"2026-07-10T15:13:54","modified_gmt":"2026-07-10T19:13:54","slug":"upload-req","status":"publish","type":"page","link":"https:\/\/truenorthimaging.com\/?page_id=2964","title":{"rendered":"Upload Req"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2964\" class=\"elementor elementor-2964\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d88a86d e-flex e-con-boxed e-con e-parent\" data-id=\"d88a86d\" 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-58ba7a4 elementor-widget elementor-widget-shortcode\" data-id=\"58ba7a4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">  \n            <form id='request-Appointment_type_form' method=\"POST\" enctype='multipart\/form-data' action=\"\">\n                <div class='requestappointment-header'>\n                    <h3>Upload your Requisition<\/h3>\n                    Please fill out the following information and attach your requisition below:\n\t\t\t\t\t<br><br>\n                <\/div>\n                <div class=\"upload-container\">\n                    <div class=\"upload-information\">\n                        <span class='modality'>\n                            <label class='request-contactformlabel'>First Name:  <\/label>\n\t\t\t\t\t\t\t<input type=\"text\" name='fname' required maxlength=\"30\" style=\"width: 350px\">\n                        <\/span><br><br>\n                        <span class='modality'>\n                            <label class='request-contactformlabel'>Last Name:  <\/label>\n                            <input type=\"text\" name='lname' required maxlength=\"30\" style=\"width: 350px\">\n                        <\/span><br><br>\n                        <span class='modality'>\n                            <label class='request-contactformlabel'>Health Card #<\/label>\n                            <input type=\"text\" name='healthcard1' pattern=\"^[0-9]{4,}\" style=\"width:75px\" maxlength=\"4\" class='inputhc' required> - \n                            <input type=\"text\" name='healthcard2' pattern=\"^[0-9]{3,}\" style=\"width:65px\" maxlength=\"3\" class='inputhc' required> - \n                            <input type=\"text\" name='healthcard3' pattern=\"^[0-9]{3,}\" style=\"width:65px\" maxlength=\"3\" class='inputhc' required> - \n                            <input type=\"text\" name='healthcard4' pattern=\"^[A-Za-z]{2,}\" style=\"width:55px\" maxlength=\"2\" class='inputhc'>\n                        <\/span><br><br>\n                        Please attach your requisition form: <input type=\"file\" name=\"file\" id='req' required><br><br>\n                    <\/div>\n\t\t\t\t\t<div >\n\t                    <input type=\"submit\" value='Upload' id='UploadButton' name='Upload' style=\"text-align: center;\"><br><br>\n\t\t\t\t\t<\/div>\n                <\/div>\n            <\/form>\n            <\/div>\n\t\t\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":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":"","_members_access_role":[],"_members_access_error":""},"class_list":["post-2964","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/truenorthimaging.com\/index.php?rest_route=\/wp\/v2\/pages\/2964","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/truenorthimaging.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/truenorthimaging.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/truenorthimaging.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/truenorthimaging.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2964"}],"version-history":[{"count":6,"href":"https:\/\/truenorthimaging.com\/index.php?rest_route=\/wp\/v2\/pages\/2964\/revisions"}],"predecessor-version":[{"id":2972,"href":"https:\/\/truenorthimaging.com\/index.php?rest_route=\/wp\/v2\/pages\/2964\/revisions\/2972"}],"wp:attachment":[{"href":"https:\/\/truenorthimaging.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2964"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}