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Submitted URL: http://app.care.ssmhealth.com/e/er?s=803238752&lid=652&elqTrackId=5776BCF8A498AFA1EF4597943A930DEC&elq=368075508ed344fdb8db707...
Effective URL: https://www.ssmhealth.com/locations/oklahoma/oklahoma-specialist-request?utm_id=ok-joint-replacement-22-1&sourcelink=ssm_o...
Submission: On August 18 via api from US — Scanned from DE
Effective URL: https://www.ssmhealth.com/locations/oklahoma/oklahoma-specialist-request?utm_id=ok-joint-replacement-22-1&sourcelink=ssm_o...
Submission: On August 18 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
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margin-bottom: 0
}
.elq-form .elq-label-top {
padding-bottom: 3px
}
.elq-form .elq-item-label {
max-width: 100%;
font-weight: 400;
box-sizing: border-box
}
.elq-form .list-order {
margin-left: 0;
white-space: nowrap;
overflow: hidden;
text-overflow: ellipsis
}
.elq-form .one-column {
width: 100%;
clear: both
}
.elq-form .two-column {
float: left;
width: 38%
}
.elq-form .three-column {
float: left;
width: 30%
}
.elq-form .elq-item-textarea {
resize: vertical;
min-height: 48px;
max-height: 360px;
box-sizing: border-box
}
.elq-form .elq-item-input,
.elq-form .elq-item-select,
.elq-form .elq-item-textarea {
font-family: inherit;
font-size: inherit;
line-height: inherit;
color: inherit;
font: inherit;
margin: 0
}
.elq-form .elq-item-select {
text-transform: none
}
.elq-form .row.single-checkbox-row {
margin-left: 0
}
.elq-form .elq-field-style {
padding-bottom: 10px
}
.elq-form .elq-field-style input[type=submit] {
-webkit-appearance: square-button
}
@-webkit-keyframes spin {
0% {
-webkit-transform: rotate(0deg)
}
to {
-webkit-transform: rotate(1turn)
}
}
@keyframes spin {
0% {
transform: rotate(0deg)
}
to {
transform: rotate(1turn)
}
}
.elq-form .loader {
vertical-align: middle;
display: inline-block;
margin-left: 10px;
border: 3px solid #f3f3f3;
border-radius: 50%;
border-top: 3px solid #3498db;
width: 20px;
height: 20px;
-webkit-animation: spin 2s linear infinite;
animation: spin 2s linear infinite
}
.elq-form input[type=checkbox],
.elq-form input[type=radio] {
margin: 0
}
.elq-form .list-order input[type=radio] {
margin-left: 1px
}
.elq-form *,
.elq-form :after,
.elq-form :before {
box-sizing: border-box
}
.elq-form html {
font-size: 10px;
-webkit-tap-highlight-color: transparent
}
.elq-form body {
font-family: Helvetica Neue, Helvetica, Arial, sans-serif;
font-size: 14px;
line-height: 1.42857;
color: #333;
background-color: #fff
}
.elq-form button,
.elq-form input,
.elq-form select,
.elq-form textarea {
font-family: inherit;
font-size: inherit;
line-height: inherit
}
.elq-form a {
color: #337ab7;
text-decoration: none
}
.elq-form a:focus,
.elq-form a:hover {
color: #23527c;
text-decoration: underline
}
.elq-form a:focus {
outline: 5px auto -webkit-focus-ring-color;
outline-offset: -2px
}
.elq-form figure {
margin: 0
}
.elq-form img {
vertical-align: middle
}
.elq-form .img-responsive {
display: block;
max-width: 100%;
height: auto
}
.elq-form .img-rounded {
border-radius: 6px
}
.elq-form .img-thumbnail {
padding: 4px;
line-height: 1.42857;
background-color: #fff;
border: 1px solid #ddd;
border-radius: 4px;
transition: all .2s ease-in-out;
display: inline-block;
max-width: 100%;
height: auto
}
.elq-form .img-circle {
border-radius: 50%
}
.elq-form hr {
margin-top: 20px;
margin-bottom: 20px;
border: 0;
border-top: 1px solid #eee
}
.elq-form .sr-only {
position: absolute;
width: 1px;
height: 1px;
padding: 0;
margin: -1px;
overflow: hidden;
clip: rect(0, 0, 0, 0);
border: 0
}
.elq-form .sr-only-focusable:active,
.elq-form .sr-only-focusable:focus {
position: static;
width: auto;
height: auto;
margin: 0;
overflow: visible;
clip: auto
}
.elq-form [role=button] {
cursor: pointer
}
.elq-form .container {
padding-right: 15px;
padding-left: 15px;
margin-right: auto;
margin-left: auto
}
.elq-form .container:after,
.elq-form .container:before {
display: table;
content: " "
}
.elq-form .container:after {
clear: both
}
@media (min-width:768px) {
.elq-form .container {
width: 750px
}
}
@media (min-width:992px) {
.elq-form .container {
width: 970px
}
}
@media (min-width:1200px) {
.elq-form .container {
width: 1170px
}
}
.elq-form .container-fluid {
padding-right: 15px;
padding-left: 15px;
margin-right: auto;
margin-left: auto
}
.elq-form .container-fluid:after,
.elq-form .container-fluid:before {
display: table;
content: " "
}
.elq-form .container-fluid:after {
clear: both
}
.elq-form .row {
margin-right: -15px;
margin-left: -15px
}
.elq-form .row:after,
.elq-form .row:before {
display: table;
content: " "
}
.elq-form .row:after {
clear: both
}
.elq-form .row-no-gutters {
margin-right: 0;
margin-left: 0
}
.elq-form .row-no-gutters [class*=col-] {
padding-right: 0;
padding-left: 0
}
.elq-form .col-lg-1,
.elq-form .col-lg-2,
.elq-form .col-lg-3,
.elq-form .col-lg-4,
.elq-form .col-lg-5,
.elq-form .col-lg-6,
.elq-form .col-lg-7,
.elq-form .col-lg-8,
.elq-form .col-lg-9,
.elq-form .col-lg-10,
.elq-form .col-lg-11,
.elq-form .col-lg-12,
.elq-form .col-md-1,
.elq-form .col-md-2,
.elq-form .col-md-3,
.elq-form .col-md-4,
.elq-form .col-md-5,
.elq-form .col-md-6,
.elq-form .col-md-7,
.elq-form .col-md-8,
.elq-form .col-md-9,
.elq-form .col-md-10,
.elq-form .col-md-11,
.elq-form .col-md-12,
.elq-form .col-sm-1,
.elq-form .col-sm-2,
.elq-form .col-sm-3,
.elq-form .col-sm-4,
.elq-form .col-sm-5,
.elq-form .col-sm-6,
.elq-form .col-sm-7,
.elq-form .col-sm-8,
.elq-form .col-sm-9,
.elq-form .col-sm-10,
.elq-form .col-sm-11,
.elq-form .col-sm-12,
.elq-form .col-xs-1,
.elq-form .col-xs-2,
.elq-form .col-xs-3,
.elq-form .col-xs-4,
.elq-form .col-xs-5,
.elq-form .col-xs-6,
.elq-form .col-xs-7,
.elq-form .col-xs-8,
.elq-form .col-xs-9,
.elq-form .col-xs-10,
.elq-form .col-xs-11,
.elq-form .col-xs-12 {
position: relative;
min-height: 1px;
padding-right: 15px;
padding-left: 15px
}
.elq-form .col-xs-1,
.elq-form .col-xs-2,
.elq-form .col-xs-3,
.elq-form .col-xs-4,
.elq-form .col-xs-5,
.elq-form .col-xs-6,
.elq-form .col-xs-7,
.elq-form .col-xs-8,
.elq-form .col-xs-9,
.elq-form .col-xs-10,
.elq-form .col-xs-11,
.elq-form .col-xs-12 {
float: left
}
.elq-form .col-xs-1 {
width: 8.33333%
}
.elq-form .col-xs-2 {
width: 16.66667%
}
.elq-form .col-xs-3 {
width: 25%
}
.elq-form .col-xs-4 {
width: 33.33333%
}
.elq-form .col-xs-5 {
width: 41.66667%
}
.elq-form .col-xs-6 {
width: 50%
}
.elq-form .col-xs-7 {
width: 58.33333%
}
.elq-form .col-xs-8 {
width: 66.66667%
}
.elq-form .col-xs-9 {
width: 75%
}
.elq-form .col-xs-10 {
width: 83.33333%
}
.elq-form .col-xs-11 {
width: 91.66667%
}
.elq-form .col-xs-12 {
width: 100%
}
.elq-form .col-xs-pull-0 {
right: auto
}
.elq-form .col-xs-pull-1 {
right: 8.33333%
}
.elq-form .col-xs-pull-2 {
right: 16.66667%
}
.elq-form .col-xs-pull-3 {
right: 25%
}
.elq-form .col-xs-pull-4 {
right: 33.33333%
}
.elq-form .col-xs-pull-5 {
right: 41.66667%
}
.elq-form .col-xs-pull-6 {
right: 50%
}
.elq-form .col-xs-pull-7 {
right: 58.33333%
}
.elq-form .col-xs-pull-8 {
right: 66.66667%
}
.elq-form .col-xs-pull-9 {
right: 75%
}
.elq-form .col-xs-pull-10 {
right: 83.33333%
}
.elq-form .col-xs-pull-11 {
right: 91.66667%
}
.elq-form .col-xs-pull-12 {
right: 100%
}
.elq-form .col-xs-push-0 {
left: auto
}
.elq-form .col-xs-push-1 {
left: 8.33333%
}
.elq-form .col-xs-push-2 {
left: 16.66667%
}
.elq-form .col-xs-push-3 {
left: 25%
}
.elq-form .col-xs-push-4 {
left: 33.33333%
}
.elq-form .col-xs-push-5 {
left: 41.66667%
}
.elq-form .col-xs-push-6 {
left: 50%
}
.elq-form .col-xs-push-7 {
left: 58.33333%
}
.elq-form .col-xs-push-8 {
left: 66.66667%
}
.elq-form .col-xs-push-9 {
left: 75%
}
.elq-form .col-xs-push-10 {
left: 83.33333%
}
.elq-form .col-xs-push-11 {
left: 91.66667%
}
.elq-form .col-xs-push-12 {
left: 100%
}
.elq-form .col-xs-offset-0 {
margin-left: 0
}
.elq-form .col-xs-offset-1 {
margin-left: 8.33333%
}
.elq-form .col-xs-offset-2 {
margin-left: 16.66667%
}
.elq-form .col-xs-offset-3 {
margin-left: 25%
}
.elq-form .col-xs-offset-4 {
margin-left: 33.33333%
}
.elq-form .col-xs-offset-5 {
margin-left: 41.66667%
}
.elq-form .col-xs-offset-6 {
margin-left: 50%
}
.elq-form .col-xs-offset-7 {
margin-left: 58.33333%
}
.elq-form .col-xs-offset-8 {
margin-left: 66.66667%
}
.elq-form .col-xs-offset-9 {
margin-left: 75%
}
.elq-form .col-xs-offset-10 {
margin-left: 83.33333%
}
.elq-form .col-xs-offset-11 {
margin-left: 91.66667%
}
.elq-form .col-xs-offset-12 {
margin-left: 100%
}
@media (min-width:768px) {
.elq-form .col-sm-1,
.elq-form .col-sm-2,
.elq-form .col-sm-3,
.elq-form .col-sm-4,
.elq-form .col-sm-5,
.elq-form .col-sm-6,
.elq-form .col-sm-7,
.elq-form .col-sm-8,
.elq-form .col-sm-9,
.elq-form .col-sm-10,
.elq-form .col-sm-11,
.elq-form .col-sm-12 {
float: left
}
.elq-form .col-sm-1 {
width: 8.33333%
}
.elq-form .col-sm-2 {
width: 16.66667%
}
.elq-form .col-sm-3 {
width: 25%
}
.elq-form .col-sm-4 {
width: 33.33333%
}
.elq-form .col-sm-5 {
width: 41.66667%
}
.elq-form .col-sm-6 {
width: 50%
}
.elq-form .col-sm-7 {
width: 58.33333%
}
.elq-form .col-sm-8 {
width: 66.66667%
}
.elq-form .col-sm-9 {
width: 75%
}
.elq-form .col-sm-10 {
width: 83.33333%
}
.elq-form .col-sm-11 {
width: 91.66667%
}
.elq-form .col-sm-12 {
width: 100%
}
.elq-form .col-sm-pull-0 {
right: auto
}
.elq-form .col-sm-pull-1 {
right: 8.33333%
}
.elq-form .col-sm-pull-2 {
right: 16.66667%
}
.elq-form .col-sm-pull-3 {
right: 25%
}
.elq-form .col-sm-pull-4 {
right: 33.33333%
}
.elq-form .col-sm-pull-5 {
right: 41.66667%
}
.elq-form .col-sm-pull-6 {
right: 50%
}
.elq-form .col-sm-pull-7 {
right: 58.33333%
}
.elq-form .col-sm-pull-8 {
right: 66.66667%
}
.elq-form .col-sm-pull-9 {
right: 75%
}
.elq-form .col-sm-pull-10 {
right: 83.33333%
}
.elq-form .col-sm-pull-11 {
right: 91.66667%
}
.elq-form .col-sm-pull-12 {
right: 100%
}
.elq-form .col-sm-push-0 {
left: auto
}
.elq-form .col-sm-push-1 {
left: 8.33333%
}
.elq-form .col-sm-push-2 {
left: 16.66667%
}
.elq-form .col-sm-push-3 {
left: 25%
}
.elq-form .col-sm-push-4 {
left: 33.33333%
}
.elq-form .col-sm-push-5 {
left: 41.66667%
}
.elq-form .col-sm-push-6 {
left: 50%
}
.elq-form .col-sm-push-7 {
left: 58.33333%
}
.elq-form .col-sm-push-8 {
left: 66.66667%
}
.elq-form .col-sm-push-9 {
left: 75%
}
.elq-form .col-sm-push-10 {
left: 83.33333%
}
.elq-form .col-sm-push-11 {
left: 91.66667%
}
.elq-form .col-sm-push-12 {
left: 100%
}
.elq-form .col-sm-offset-0 {
margin-left: 0
}
.elq-form .col-sm-offset-1 {
margin-left: 8.33333%
}
.elq-form .col-sm-offset-2 {
margin-left: 16.66667%
}
.elq-form .col-sm-offset-3 {
margin-left: 25%
}
.elq-form .col-sm-offset-4 {
margin-left: 33.33333%
}
.elq-form .col-sm-offset-5 {
margin-left: 41.66667%
}
.elq-form .col-sm-offset-6 {
margin-left: 50%
}
.elq-form .col-sm-offset-7 {
margin-left: 58.33333%
}
.elq-form .col-sm-offset-8 {
margin-left: 66.66667%
}
.elq-form .col-sm-offset-9 {
margin-left: 75%
}
.elq-form .col-sm-offset-10 {
margin-left: 83.33333%
}
.elq-form .col-sm-offset-11 {
margin-left: 91.66667%
}
.elq-form .col-sm-offset-12 {
margin-left: 100%
}
}
@media (min-width:992px) {
.elq-form .col-md-1,
.elq-form .col-md-2,
.elq-form .col-md-3,
.elq-form .col-md-4,
.elq-form .col-md-5,
.elq-form .col-md-6,
.elq-form .col-md-7,
.elq-form .col-md-8,
.elq-form .col-md-9,
.elq-form .col-md-10,
.elq-form .col-md-11,
.elq-form .col-md-12 {
float: left
}
.elq-form .col-md-1 {
width: 8.33333%
}
.elq-form .col-md-2 {
width: 16.66667%
}
.elq-form .col-md-3 {
width: 25%
}
.elq-form .col-md-4 {
width: 33.33333%
}
.elq-form .col-md-5 {
width: 41.66667%
}
.elq-form .col-md-6 {
width: 50%
}
.elq-form .col-md-7 {
width: 58.33333%
}
.elq-form .col-md-8 {
width: 66.66667%
}
.elq-form .col-md-9 {
width: 75%
}
.elq-form .col-md-10 {
width: 83.33333%
}
.elq-form .col-md-11 {
width: 91.66667%
}
.elq-form .col-md-12 {
width: 100%
}
.elq-form .col-md-pull-0 {
right: auto
}
.elq-form .col-md-pull-1 {
right: 8.33333%
}
.elq-form .col-md-pull-2 {
right: 16.66667%
}
.elq-form .col-md-pull-3 {
right: 25%
}
.elq-form .col-md-pull-4 {
right: 33.33333%
}
.elq-form .col-md-pull-5 {
right: 41.66667%
}
.elq-form .col-md-pull-6 {
right: 50%
}
.elq-form .col-md-pull-7 {
right: 58.33333%
}
.elq-form .col-md-pull-8 {
right: 66.66667%
}
.elq-form .col-md-pull-9 {
right: 75%
}
.elq-form .col-md-pull-10 {
right: 83.33333%
}
.elq-form .col-md-pull-11 {
right: 91.66667%
}
.elq-form .col-md-pull-12 {
right: 100%
}
.elq-form .col-md-push-0 {
left: auto
}
.elq-form .col-md-push-1 {
left: 8.33333%
}
.elq-form .col-md-push-2 {
left: 16.66667%
}
.elq-form .col-md-push-3 {
left: 25%
}
.elq-form .col-md-push-4 {
left: 33.33333%
}
.elq-form .col-md-push-5 {
left: 41.66667%
}
.elq-form .col-md-push-6 {
left: 50%
}
.elq-form .col-md-push-7 {
left: 58.33333%
}
.elq-form .col-md-push-8 {
left: 66.66667%
}
.elq-form .col-md-push-9 {
left: 75%
}
.elq-form .col-md-push-10 {
left: 83.33333%
}
.elq-form .col-md-push-11 {
left: 91.66667%
}
.elq-form .col-md-push-12 {
left: 100%
}
.elq-form .col-md-offset-0 {
margin-left: 0
}
.elq-form .col-md-offset-1 {
margin-left: 8.33333%
}
.elq-form .col-md-offset-2 {
margin-left: 16.66667%
}
.elq-form .col-md-offset-3 {
margin-left: 25%
}
.elq-form .col-md-offset-4 {
margin-left: 33.33333%
}
.elq-form .col-md-offset-5 {
margin-left: 41.66667%
}
.elq-form .col-md-offset-6 {
margin-left: 50%
}
.elq-form .col-md-offset-7 {
margin-left: 58.33333%
}
.elq-form .col-md-offset-8 {
margin-left: 66.66667%
}
.elq-form .col-md-offset-9 {
margin-left: 75%
}
.elq-form .col-md-offset-10 {
margin-left: 83.33333%
}
.elq-form .col-md-offset-11 {
margin-left: 91.66667%
}
.elq-form .col-md-offset-12 {
margin-left: 100%
}
}
@media (min-width:1200px) {
.elq-form .col-lg-1,
.elq-form .col-lg-2,
.elq-form .col-lg-3,
.elq-form .col-lg-4,
.elq-form .col-lg-5,
.elq-form .col-lg-6,
.elq-form .col-lg-7,
.elq-form .col-lg-8,
.elq-form .col-lg-9,
.elq-form .col-lg-10,
.elq-form .col-lg-11,
.elq-form .col-lg-12 {
float: left
}
.elq-form .col-lg-1 {
width: 8.33333%
}
.elq-form .col-lg-2 {
width: 16.66667%
}
.elq-form .col-lg-3 {
width: 25%
}
.elq-form .col-lg-4 {
width: 33.33333%
}
.elq-form .col-lg-5 {
width: 41.66667%
}
.elq-form .col-lg-6 {
width: 50%
}
.elq-form .col-lg-7 {
width: 58.33333%
}
.elq-form .col-lg-8 {
width: 66.66667%
}
.elq-form .col-lg-9 {
width: 75%
}
.elq-form .col-lg-10 {
width: 83.33333%
}
.elq-form .col-lg-11 {
width: 91.66667%
}
.elq-form .col-lg-12 {
width: 100%
}
.elq-form .col-lg-pull-0 {
right: auto
}
.elq-form .col-lg-pull-1 {
right: 8.33333%
}
.elq-form .col-lg-pull-2 {
right: 16.66667%
}
.elq-form .col-lg-pull-3 {
right: 25%
}
.elq-form .col-lg-pull-4 {
right: 33.33333%
}
.elq-form .col-lg-pull-5 {
right: 41.66667%
}
.elq-form .col-lg-pull-6 {
right: 50%
}
.elq-form .col-lg-pull-7 {
right: 58.33333%
}
.elq-form .col-lg-pull-8 {
right: 66.66667%
}
.elq-form .col-lg-pull-9 {
right: 75%
}
.elq-form .col-lg-pull-10 {
right: 83.33333%
}
.elq-form .col-lg-pull-11 {
right: 91.66667%
}
.elq-form .col-lg-pull-12 {
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left: 41.66667%
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}
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left: 58.33333%
}
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left: 66.66667%
}
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left: 75%
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left: 83.33333%
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left: 91.66667%
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margin-left: 50%
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margin-left: 58.33333%
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margin-left: 66.66667%
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margin-left: 91.66667%
}
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margin-left: 100%
}
}
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display: inherit
}
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input.LV_invalid_field:active,
input.LV_invalid_field:hover,
textarea.LV_invalid_field:active,
textarea.LV_invalid_field:hover {
outline: 1px solid #c00
}
.LV_validation_message {
font-weight: 700;
margin: 0 0 0 5px
}
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display: none
}
.LV_invalid {
color: #c00;
font-size: 10px
}
.submit-button-style {
padding: 7px 20px;
border: 1px solid #979797;
border-radius: 3px;
background-color: #fff;
color: #4a4a4a;
cursor: pointer
}
.checkbox-aligned {
margin-left: 5px;
display: inline
}
.form-element-layout {
padding: 5px 10px
}
.form-element-instruction {
font-size: 10px
}
.form-element-form-text {
margin: 0
}
.form-field-visible-xs-block {
display: none
}
.elq-form-design-field .list-order input[type=radio] {
margin-left: 1px
}
@media (max-width:767px) {
.form-field-visible-xs-block {
display: block
}
}
.form-field-hidden-xs {
display: block
}
@media (max-width:767px) {
.form-field-hidden-xs {
display: none
}
}
.custom-overlay {
margin-left: 2px;
background: #fff;
box-shadow: 0 0 4px 0 #777;
border-radius: 2px;
max-width: 256px
}
</style>
<div data-method="post" name="Ok-specialist-request" data-action="https://s803238752.t.eloqua.com/e/f2" data-onsubmit="return handleFormSubmit(this)" id="form87" class="elq-form">
<input value="Ok-specialist-request" type="hidden" name="elqFormName">
<input value="803238752" type="hidden" name="elqSiteId">
<input name="elqCampaignId" type="hidden">
<div class="layout container-fluid">
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement0" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe1993">First Name <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<input type="text" class="elq-item-input required" name="first_name" id="fe1993" value="" style="width:100%;">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement1" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe1994">Last Name <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<input type="text" class="elq-item-input required" name="last_name" id="fe1994" value="" style="width:100%;">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement2" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe1995">Email Address <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<input type="text" class="elq-item-input required" name="email_address" id="fe1995" value="" style="width:100%;">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement3" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe3551">Birth Date <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<input type="text" class="elq-item-input required" name="birthDate1" id="fe3551" value="" style="width:100%;">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement4" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe2109">Address <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<input type="text" class="elq-item-input required" name="address1" id="fe2109" value="" style="width:100%;">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement5" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe2110">Address 2 </label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<input type="text" class="elq-item-input" name="address2" id="fe2110" value="" style="width:100%;">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement6" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe2111">City <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<input type="text" class="elq-item-input required" name="city" id="fe2111" value="" style="width:100%;">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement7" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe2114">State <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<select class="elq-item-select required" id="fe2114" name="stateProv" style="width:100%;" data-value="~~eloqua..type--emailfield..syntax--State_Prov~~">
<option value="AK">Alaska </option>
<option value="AL">Alabama </option>
<option value="AR">Arkansas </option>
<option value="AZ">Arizona </option>
<option value="CA">California </option>
<option value="CO">Colorado </option>
<option value="CT">Connecticut </option>
<option value="DC">D.C. </option>
<option value="DE">Delaware </option>
<option value="FL">Florida </option>
<option value="GA">Georgia </option>
<option value="HI">Hawaii </option>
<option value="IA">Iowa </option>
<option value="ID">Idaho </option>
<option value="IL">Illinois </option>
<option value="IN">Indiana </option>
<option value="KS">Kansas </option>
<option value="KY">Kentucky </option>
<option value="LA">Louisiana </option>
<option value="MA">Massachusetts </option>
<option value="MD">Maryland </option>
<option value="ME">Maine </option>
<option value="MI">Michigan </option>
<option value="MN">Minnesota </option>
<option value="MO">Missouri </option>
<option value="MS">Mississippi </option>
<option value="MT">Montana </option>
<option value="NC">North Carolina </option>
<option value="ND">North Dakota </option>
<option value="NE">Nebraska </option>
<option value="NH">New Hampshire </option>
<option value="NJ">New Jersey </option>
<option value="NM">New Mexico </option>
<option value="NV">Nevada </option>
<option value="NY">New York </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="VA">Virginia </option>
<option value="VT">Vermont </option>
<option value="WA">Washington </option>
<option value="WI">Wisconsin </option>
<option value="WV">West Virginia </option>
<option value="WY">Wyoming </option>
<option value="">Please Select... </option>
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</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement8" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe2112">ZIP <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<input type="text" class="elq-item-input required" name="zipPostal" id="fe2112" value="" style="width:100%;">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement9" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe2017">Phone <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<input type="text" class="elq-item-input required" name="mobilePhone" id="fe2017" value="" style="width:100%;">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement10" class="elq-field-style form-element-layout row">
<div style="text-align:left;" class="col-sm-12 col-xs-12">
<label class="elq-label " for="fe4835">What type of care do you need? <span class="elq-required">* </span>
</label>
</div>
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div class="field-control-wrapper">
<select class="elq-item-select required" id="fe4835" name="dropdownMenu" style="width:100%;" data-value="">
<option value="">Select One </option>
<option value="Dermatology">Dermatology </option>
<option value="Gastroenterology">Gastroenterology </option>
<option value="Heart Screening">Heart Screening </option>
<option value="Lung Cancer Screening">Lung Cancer Screening </option>
<option value="Orthopedic Surgery Consultation">Orthopedic Surgery Consultation </option>
<option value="Skin Cancer Screening">Skin Cancer Screening </option>
<option value="Weight Loss Surgery Consultation">Weight Loss Surgery Consultation </option>
<option value="Surgery - Other">Surgery - Other </option>
</select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement11" class="elq-field-style form-element-layout row">
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div>
<div class="single-checkbox-row row">
<input type="checkbox" name="singleCheckbox2" id="fe4837">
<label class="checkbox-aligned elq-item-label" for="fe4837">I am interested in learning about robotic surgery. </label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement12" class="elq-field-style form-element-layout row">
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div>
<div class="single-checkbox-row row">
<input type="checkbox" name="singleCheckbox" id="fe3094" class="required">
<label class="checkbox-aligned elq-item-label" for="fe3094"><strong>I have read the <a href="/notice-privacy-practices">Notice of Privacy Practices.</a></strong>
<span class="elq-required">* </span>
</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="grid-layout-col">
<div class="layout-col col-sm-12 col-xs-12">
<div id="formElement13" class="elq-field-style form-element-layout row">
<div class="col-sm-12 col-xs-12">
<div class="row">
<div class="col-xs-12">
<div>
<input type="Submit" class="submit-button-style btn btn-outline" value="Submit" id="fe2015">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
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// Remove white space from text areas
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$(".HealthGradeForm .elq-required").parents(".form-element-layout").find("input, select").addClass("required");
$('label.checkbox-aligned').each(function(idx, el) {
$(el).click(function(e) {
e.preventDefault();
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event.stopPropagation();
event.preventDefault();
window.open($(this).attr('href'), $(this).attr('target'));
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});
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})
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event.stopPropagation();
event.preventDefault();
return false;
}
});
});
</script>
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SCHEDULE AN APPOINTMENT × COVID-19 Get Vaccinated Symptomatic? Get Tested IN-PERSON Adult Primary Care OBGYN Pediatrics Routine Mammogram CARE NOW Express Virtual Care Urgent Care/Express Clinic With My Own Doctor Skip to Document Content COVID-19 Information: Learn about testing, vaccines and more. × SCHEDULE NOW Berlin, Berlin MyChart Careers Donate Search for: Search Doctors Locations * Cardiology * Emergency Room * Family Medicine * Hospital * Imaging and Radiology * Internal Medicine * Lab Services * Mental and Behavioral Health * Obstetrics and Gynecology * Orthopedics * Pediatrics * Pharmacy * Physical Therapy * Primary Care * Urgent Care and Express Clinics See more locations * Our love for kids just keeps growing! Learn More Now Services * Cancer Care * Emergency and Trauma * Health at Home * Heart & Vascular * Imaging * Maternity * Men’s Health * Neurosciences * Orthopedics * Pediatrics * Pharmacy * Primary care * Senior Health * Therapy and Rehabilitation * Transplant * Weight Management * Women’s Health See more services * Express Virtual Care SSM Health Express Virtual Care offers two convenient virtual care options. Learn More Now Resources * Patients & Visitors * Bill Pay * Classes & Events * Financial Assistance * Medical Records * Price Transparency * About Us * Blog * Leadership * Mission & Values * News * Volunteer * Health Professionals * Admissions & Referrals * Nurses * Physicians * Employees * Connect to Citrix * Culture & Communications * Employee COVID-19 Site * Employee Health Plan * MyWorkday MyChart Search for: SCHEDULE NOW Berlin, Berlin REQUEST AN APPOINTMENT WITH A SPECIALIST St. Anthony physicians provide health screenings and expert care for a variety of medical issues. Request your appointment today! We'll be in touch within 48 hours or by the end of the next business day. First Name * Last Name * Email Address * Birth Date * Address * Address 2 City * State * Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Please Select... ZIP * Phone * What type of care do you need? * Select One Dermatology Gastroenterology Heart Screening Lung Cancer Screening Orthopedic Surgery Consultation Skin Cancer Screening Weight Loss Surgery Consultation Surgery - Other I am interested in learning about robotic surgery. I have read the Notice of Privacy Practices. * -------------------------------------------------------------------------------- About SSM Health Our Mission, Vision & Values Quality & Outcomes Serving Our Community Supply Chain Management Volunteer Patients & Visitors Classes & Events Financial Assistance & Bill Pay Get a Price Estimate Medical Records Price Transparency Health Professionals Admissions & Referrals Employees Culture & Communications Employee COVID-19 Site Contact Our Locations | Call Us | Write Us Connect With Us Choose Font Size A A A * Privacy * Terms and Conditions * Notice of Non-Discrimination * Copyright© 2022 SSM Health * Language Assistance Services: * Español * Hmoob * 简体中文 * Deutsch * ગુજરાતી * Русский * 한국어 * Tiếng Việt * Français * Polski * Pennsylvaanisch Deitsch * HRVATSKI * Tagalog * Hindi * العربية × SELECT LOCATION Enter your location to receive information about nearby SSM Health services. My location is: No location suggestions. Why do we ask? Why do we ask? SSM Health uses your location to provide you with relevant content, like doctor suggestions and local services. We will never share this information. Carousel items will not render as a carousel Carousel items will not be accessibility friendly CONTINUING TO CARDINAL GLENNON × You are now leaving SSM Health.com and continuing to the Cardinal Glennon Children's Hospital's section of our website. Cancel Continue