[wpforms id="11972" title="false" description="false"]
<div class="wpforms-container wpforms-container-full" id="wpforms-11972"><form id="wpforms-form-11972" class="wpforms-validate wpforms-form" data-formid="11972" method="post" enctype="multipart/form-data" action="/patient-story/stan-theresa/"><noscript class="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</noscript><div class="wpforms-field-container"><div id="wpforms-11972-field_1-container" class="wpforms-field wpforms-field-name" data-field-id="1"><label class="wpforms-field-label" for="wpforms-11972-field_1">Name <span class="wpforms-required-label">*</span></label><div class="wpforms-field-row wpforms-field-medium"><div class="wpforms-field-row-block wpforms-first wpforms-one-half"><input type="text" id="wpforms-11972-field_1" class="wpforms-field-name-first wpforms-field-required" name="wpforms[fields][1][first]" required><label for="wpforms-11972-field_1" class="wpforms-field-sublabel after ">First</label></div><div class="wpforms-field-row-block wpforms-one-half"><input type="text" id="wpforms-11972-field_1-last" class="wpforms-field-name-last wpforms-field-required" name="wpforms[fields][1][last]" required><label for="wpforms-11972-field_1-last" class="wpforms-field-sublabel after ">Last</label></div></div></div><div id="wpforms-11972-field_2-container" class="wpforms-field wpforms-field-email" data-field-id="2"><label class="wpforms-field-label" for="wpforms-11972-field_2">Email <span class="wpforms-required-label">*</span></label><input type="email" id="wpforms-11972-field_2" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][2]" required></div><div id="wpforms-11972-field_3-container" class="wpforms-field wpforms-field-rating wpforms-conditional-trigger" data-field-id="3"><label class="wpforms-field-label" for="wpforms-11972-field_3">Your Experience <span class="wpforms-required-label">*</span></label><div class="wpforms-field-rating-items"><label class="wpforms-field-rating-item choice-1" for="wpforms-11972-field_3_1"><span class="wpforms-screen-reader-element">Rate 1 out of 5</span><input type="radio" id="wpforms-11972-field_3_1" class="wpforms-field-required wpforms-screen-reader-element" name="wpforms[fields][3]" value="1" required><svg width="28" height="28" style="height:28px;width:28px;" fill="currentColor" color="#e27730" viewBox="0 0 1792 1792" xmlns="http://www.w3.org/2000/svg"><path d="M1728 647q0 22-26 48l-363 354 86 500q1 7 1 20 0 21-10.5 35.5t-30.5 14.5q-19 0-40-12l-449-236-449 236q-22 12-40 12-21 0-31.5-14.5t-10.5-35.5q0-6 2-20l86-500-364-354q-25-27-25-48 0-37 56-46l502-73 225-455q19-41 49-41t49 41l225 455 502 73q56 9 56 46z"/></svg></label><label class="wpforms-field-rating-item choice-2" for="wpforms-11972-field_3_2"><span class="wpforms-screen-reader-element">Rate 2 out of 5</span><input type="radio" id="wpforms-11972-field_3_2" class="wpforms-field-required wpforms-screen-reader-element" name="wpforms[fields][3]" value="2" required><svg width="28" height="28" style="height:28px;width:28px;" fill="currentColor" color="#e27730" viewBox="0 0 1792 1792" xmlns="http://www.w3.org/2000/svg"><path d="M1728 647q0 22-26 48l-363 354 86 500q1 7 1 20 0 21-10.5 35.5t-30.5 14.5q-19 0-40-12l-449-236-449 236q-22 12-40 12-21 0-31.5-14.5t-10.5-35.5q0-6 2-20l86-500-364-354q-25-27-25-48 0-37 56-46l502-73 225-455q19-41 49-41t49 41l225 455 502 73q56 9 56 46z"/></svg></label><label class="wpforms-field-rating-item choice-3" for="wpforms-11972-field_3_3"><span class="wpforms-screen-reader-element">Rate 3 out of 5</span><input type="radio" id="wpforms-11972-field_3_3" class="wpforms-field-required wpforms-screen-reader-element" name="wpforms[fields][3]" value="3" required><svg width="28" height="28" style="height:28px;width:28px;" fill="currentColor" color="#e27730" viewBox="0 0 1792 1792" xmlns="http://www.w3.org/2000/svg"><path d="M1728 647q0 22-26 48l-363 354 86 500q1 7 1 20 0 21-10.5 35.5t-30.5 14.5q-19 0-40-12l-449-236-449 236q-22 12-40 12-21 0-31.5-14.5t-10.5-35.5q0-6 2-20l86-500-364-354q-25-27-25-48 0-37 56-46l502-73 225-455q19-41 49-41t49 41l225 455 502 73q56 9 56 46z"/></svg></label><label class="wpforms-field-rating-item choice-4" for="wpforms-11972-field_3_4"><span class="wpforms-screen-reader-element">Rate 4 out of 5</span><input type="radio" id="wpforms-11972-field_3_4" class="wpforms-field-required wpforms-screen-reader-element" name="wpforms[fields][3]" value="4" required><svg width="28" height="28" style="height:28px;width:28px;" fill="currentColor" color="#e27730" viewBox="0 0 1792 1792" xmlns="http://www.w3.org/2000/svg"><path d="M1728 647q0 22-26 48l-363 354 86 500q1 7 1 20 0 21-10.5 35.5t-30.5 14.5q-19 0-40-12l-449-236-449 236q-22 12-40 12-21 0-31.5-14.5t-10.5-35.5q0-6 2-20l86-500-364-354q-25-27-25-48 0-37 56-46l502-73 225-455q19-41 49-41t49 41l225 455 502 73q56 9 56 46z"/></svg></label><label class="wpforms-field-rating-item choice-5" for="wpforms-11972-field_3_5"><span class="wpforms-screen-reader-element">Rate 5 out of 5</span><input type="radio" id="wpforms-11972-field_3_5" class="wpforms-field-required wpforms-screen-reader-element" name="wpforms[fields][3]" value="5" required><svg width="28" height="28" style="height:28px;width:28px;" fill="currentColor" color="#e27730" viewBox="0 0 1792 1792" xmlns="http://www.w3.org/2000/svg"><path d="M1728 647q0 22-26 48l-363 354 86 500q1 7 1 20 0 21-10.5 35.5t-30.5 14.5q-19 0-40-12l-449-236-449 236q-22 12-40 12-21 0-31.5-14.5t-10.5-35.5q0-6 2-20l86-500-364-354q-25-27-25-48 0-37 56-46l502-73 225-455q19-41 49-41t49 41l225 455 502 73q56 9 56 46z"/></svg></label></div><div class="wpforms-field-description">Overall, how would you rate your experience with us?</div></div><div id="wpforms-11972-field_4-container" class="wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show" data-field-id="4" style="display:none;"><label class="wpforms-field-label" for="wpforms-11972-field_4">How can we improve? <span class="wpforms-required-label">*</span></label><textarea id="wpforms-11972-field_4" class="wpforms-field-small wpforms-field-required" name="wpforms[fields][4]" required></textarea><div class="wpforms-field-description">We're sorry you did not have a good experience. Please let us know how we can do better.</div></div><div id="wpforms-11972-field_5-container" class="wpforms-field wpforms-field-likert_scale" data-field-id="5"><label class="wpforms-field-label" for="wpforms-11972-field_5">How satisfied are you with <span class="wpforms-required-label">*</span></label>
<table cellspacing="0" cellpadding="0" class="wpforms-field-large modern">
<thead>
<tr>
<th style="width:20%;"></th><th style="width:16%;">Very Unsatisfied</th><th style="width:16%;">Unsatisfied</th><th style="width:16%;">Neutral</th><th style="width:16%;">Satisfied</th><th style="width:16%;">Very Satisfied</th> </tr>
</thead>
<tbody>
<tr><th>Purchase</th><td><input type="radio" id="wpforms-11972-field_5_1_1" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][1]" value="1" required><label for="wpforms-11972-field_5_1_1"><span class="wpforms-screen-reader-element">Purchase Very Unsatisfied</span></label></td><td><input type="radio" id="wpforms-11972-field_5_1_2" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][1]" value="2" required><label for="wpforms-11972-field_5_1_2"><span class="wpforms-screen-reader-element">Purchase Unsatisfied</span></label></td><td><input type="radio" id="wpforms-11972-field_5_1_3" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][1]" value="3" required><label for="wpforms-11972-field_5_1_3"><span class="wpforms-screen-reader-element">Purchase Neutral</span></label></td><td><input type="radio" id="wpforms-11972-field_5_1_4" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][1]" value="4" required><label for="wpforms-11972-field_5_1_4"><span class="wpforms-screen-reader-element">Purchase Satisfied</span></label></td><td><input type="radio" id="wpforms-11972-field_5_1_5" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][1]" value="5" required><label for="wpforms-11972-field_5_1_5"><span class="wpforms-screen-reader-element">Purchase Very Satisfied</span></label></td></tr><tr><th>Service</th><td><input type="radio" id="wpforms-11972-field_5_2_1" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][2]" value="1" required><label for="wpforms-11972-field_5_2_1"><span class="wpforms-screen-reader-element">Service Very Unsatisfied</span></label></td><td><input type="radio" id="wpforms-11972-field_5_2_2" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][2]" value="2" required><label for="wpforms-11972-field_5_2_2"><span class="wpforms-screen-reader-element">Service Unsatisfied</span></label></td><td><input type="radio" id="wpforms-11972-field_5_2_3" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][2]" value="3" required><label for="wpforms-11972-field_5_2_3"><span class="wpforms-screen-reader-element">Service Neutral</span></label></td><td><input type="radio" id="wpforms-11972-field_5_2_4" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][2]" value="4" required><label for="wpforms-11972-field_5_2_4"><span class="wpforms-screen-reader-element">Service Satisfied</span></label></td><td><input type="radio" id="wpforms-11972-field_5_2_5" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][2]" value="5" required><label for="wpforms-11972-field_5_2_5"><span class="wpforms-screen-reader-element">Service Very Satisfied</span></label></td></tr><tr><th>Company Overall</th><td><input type="radio" id="wpforms-11972-field_5_3_1" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][3]" value="1" required><label for="wpforms-11972-field_5_3_1"><span class="wpforms-screen-reader-element">Company Overall Very Unsatisfied</span></label></td><td><input type="radio" id="wpforms-11972-field_5_3_2" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][3]" value="2" required><label for="wpforms-11972-field_5_3_2"><span class="wpforms-screen-reader-element">Company Overall Unsatisfied</span></label></td><td><input type="radio" id="wpforms-11972-field_5_3_3" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][3]" value="3" required><label for="wpforms-11972-field_5_3_3"><span class="wpforms-screen-reader-element">Company Overall Neutral</span></label></td><td><input type="radio" id="wpforms-11972-field_5_3_4" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][3]" value="4" required><label for="wpforms-11972-field_5_3_4"><span class="wpforms-screen-reader-element">Company Overall Satisfied</span></label></td><td><input type="radio" id="wpforms-11972-field_5_3_5" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][5][3]" value="5" required><label for="wpforms-11972-field_5_3_5"><span class="wpforms-screen-reader-element">Company Overall Very Satisfied</span></label></td></tr> </tbody>
</table>
</div><div id="wpforms-11972-field_6-container" class="wpforms-field wpforms-field-likert_scale" data-field-id="6"><label class="wpforms-field-label" for="wpforms-11972-field_6">How likely are you to <span class="wpforms-required-label">*</span></label>
<table cellspacing="0" cellpadding="0" class="wpforms-field-large modern">
<thead>
<tr>
<th style="width:20%;"></th><th style="width:16%;">Very Unlikely</th><th style="width:16%;">Unlikely</th><th style="width:16%;">Neutral</th><th style="width:16%;">Likely</th><th style="width:16%;">Very Likely</th> </tr>
</thead>
<tbody>
<tr><th>Buy from us again</th><td><input type="radio" id="wpforms-11972-field_6_1_1" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][1]" value="1" required><label for="wpforms-11972-field_6_1_1"><span class="wpforms-screen-reader-element">Buy from us again Very Unlikely</span></label></td><td><input type="radio" id="wpforms-11972-field_6_1_2" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][1]" value="2" required><label for="wpforms-11972-field_6_1_2"><span class="wpforms-screen-reader-element">Buy from us again Unlikely</span></label></td><td><input type="radio" id="wpforms-11972-field_6_1_3" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][1]" value="3" required><label for="wpforms-11972-field_6_1_3"><span class="wpforms-screen-reader-element">Buy from us again Neutral</span></label></td><td><input type="radio" id="wpforms-11972-field_6_1_4" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][1]" value="4" required><label for="wpforms-11972-field_6_1_4"><span class="wpforms-screen-reader-element">Buy from us again Likely</span></label></td><td><input type="radio" id="wpforms-11972-field_6_1_5" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][1]" value="5" required><label for="wpforms-11972-field_6_1_5"><span class="wpforms-screen-reader-element">Buy from us again Very Likely</span></label></td></tr><tr><th>Recommend our product to others</th><td><input type="radio" id="wpforms-11972-field_6_2_1" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][2]" value="1" required><label for="wpforms-11972-field_6_2_1"><span class="wpforms-screen-reader-element">Recommend our product to others Very Unlikely</span></label></td><td><input type="radio" id="wpforms-11972-field_6_2_2" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][2]" value="2" required><label for="wpforms-11972-field_6_2_2"><span class="wpforms-screen-reader-element">Recommend our product to others Unlikely</span></label></td><td><input type="radio" id="wpforms-11972-field_6_2_3" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][2]" value="3" required><label for="wpforms-11972-field_6_2_3"><span class="wpforms-screen-reader-element">Recommend our product to others Neutral</span></label></td><td><input type="radio" id="wpforms-11972-field_6_2_4" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][2]" value="4" required><label for="wpforms-11972-field_6_2_4"><span class="wpforms-screen-reader-element">Recommend our product to others Likely</span></label></td><td><input type="radio" id="wpforms-11972-field_6_2_5" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][2]" value="5" required><label for="wpforms-11972-field_6_2_5"><span class="wpforms-screen-reader-element">Recommend our product to others Very Likely</span></label></td></tr><tr><th>Recommend our company to others</th><td><input type="radio" id="wpforms-11972-field_6_3_1" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][3]" value="1" required><label for="wpforms-11972-field_6_3_1"><span class="wpforms-screen-reader-element">Recommend our company to others Very Unlikely</span></label></td><td><input type="radio" id="wpforms-11972-field_6_3_2" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][3]" value="2" required><label for="wpforms-11972-field_6_3_2"><span class="wpforms-screen-reader-element">Recommend our company to others Unlikely</span></label></td><td><input type="radio" id="wpforms-11972-field_6_3_3" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][3]" value="3" required><label for="wpforms-11972-field_6_3_3"><span class="wpforms-screen-reader-element">Recommend our company to others Neutral</span></label></td><td><input type="radio" id="wpforms-11972-field_6_3_4" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][3]" value="4" required><label for="wpforms-11972-field_6_3_4"><span class="wpforms-screen-reader-element">Recommend our company to others Likely</span></label></td><td><input type="radio" id="wpforms-11972-field_6_3_5" class="wpforms-screen-reader-element wpforms-likert-scale-option wpforms-field-required" name="wpforms[fields][6][3]" value="5" required><label for="wpforms-11972-field_6_3_5"><span class="wpforms-screen-reader-element">Recommend our company to others Very Likely</span></label></td></tr> </tbody>
</table>
</div><div id="wpforms-11972-field_7-container" class="wpforms-field wpforms-field-textarea" data-field-id="7"><label class="wpforms-field-label" for="wpforms-11972-field_7">Additional comments or suggestions</label><textarea id="wpforms-11972-field_7" class="wpforms-field-medium" name="wpforms[fields][7]" ></textarea></div></div><div class="wpforms-field wpforms-field-hp"><label for="wpforms-11972-field-hp" class="wpforms-field-label">Comment</label><input type="text" name="wpforms[hp]" id="wpforms-11972-field-hp" class="wpforms-field-medium"></div><div class="wpforms-submit-container" ><input type="hidden" name="wpforms[id]" value="11972"><input type="hidden" name="wpforms[author]" value="2"><input type="hidden" name="wpforms[post_id]" value="11619"><button type="submit" name="wpforms[submit]" class="wpforms-submit " id="wpforms-submit-11972" value="wpforms-submit" aria-live="assertive" data-alt-text="Sending..." data-submit-text="Submit">Submit</button></div></form></div> <!-- .wpforms-container -->
[wpforms id="11968" title="false" description="false"]
<div class="wpforms-container wpforms-container-full" id="wpforms-11968"><form id="wpforms-form-11968" class="wpforms-validate wpforms-form" data-formid="11968" method="post" enctype="multipart/form-data" action="/patient-story/stan-theresa/"><noscript class="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</noscript><div class="wpforms-field-container"><div id="wpforms-11968-field_2-container" class="wpforms-field wpforms-field-radio wpforms-conditional-trigger" data-field-id="2"><label class="wpforms-field-label" for="wpforms-11968-field_2">Will you answer our one question survey?</label><ul id="wpforms-11968-field_2"><li class="choice-1 depth-1"><input type="radio" id="wpforms-11968-field_2_1" name="wpforms[fields][2]" value="Yes" ><label class="wpforms-field-label-inline" for="wpforms-11968-field_2_1">Yes</label></li><li class="choice-2 depth-1"><input type="radio" id="wpforms-11968-field_2_2" name="wpforms[fields][2]" value="No" ><label class="wpforms-field-label-inline" for="wpforms-11968-field_2_2">No</label></li></ul></div><div id="wpforms-11968-field_1-container" class="wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show" data-field-id="1" style="display:none;"><label class="wpforms-field-label" for="wpforms-11968-field_1">After reading the information on the page, are you more likely to talk to your partner?</label><ul id="wpforms-11968-field_1"><li class="choice-1 depth-1"><input type="radio" id="wpforms-11968-field_1_1" name="wpforms[fields][1]" value="Yes" ><label class="wpforms-field-label-inline" for="wpforms-11968-field_1_1">Yes</label></li><li class="choice-2 depth-1"><input type="radio" id="wpforms-11968-field_1_2" name="wpforms[fields][1]" value="No" ><label class="wpforms-field-label-inline" for="wpforms-11968-field_1_2">No</label></li></ul></div></div><div class="wpforms-field wpforms-field-hp"><label for="wpforms-11968-field-hp" class="wpforms-field-label">Message</label><input type="text" name="wpforms[hp]" id="wpforms-11968-field-hp" class="wpforms-field-medium"></div><div class="wpforms-submit-container" ><input type="hidden" name="wpforms[id]" value="11968"><input type="hidden" name="wpforms[author]" value="2"><input type="hidden" name="wpforms[post_id]" value="11619"><button type="submit" name="wpforms[submit]" class="wpforms-submit " id="wpforms-submit-11968" value="wpforms-submit" aria-live="assertive" data-alt-text="Sending..." data-submit-text="Submit">Submit</button></div></form></div> <!-- .wpforms-container -->
