[et_pb_section admin_label=”section”][et_pb_row admin_label=”row”][et_pb_column type=”4_4″][et_pb_contact_form admin_label=”Appointment Rescheduling Request” captcha=”on” title=”Reschedule My Appointment” custom_message=”The following patient is requesting to be contacted to reschedule their appointment. Please contact them immediately for available rescheduling date and time options: Name of Patient: %%Name%% Date of Original Appointment: %%Original Appointment Date%% Phone Number: %%Phone Number%% Email Address: %%Email%% Thank-you! Ear and Hearing Clinic Team” use_redirect=”off” success_message=”Thank-you for rescheduling your appointment. A member of our team will contact you within 24 hours with some options for dates and time to reschedule your appointment.” input_border_radius=”0″ use_border_color=”off” border_color=”#ffffff” border_style=”solid” custom_button=”off” button_letter_spacing=”0″ button_use_icon=”default” button_icon_placement=”right” button_on_hover=”on” button_letter_spacing_hover=”0″ email=”[email protected]”] [et_pb_contact_field field_title=”Name” field_type=”input” field_id=”Name” required_mark=”on” fullwidth_field=”off” form_field_font_select=”default” form_field_font=”||||” use_border_color=”off” border_style=”solid”] [/et_pb_contact_field][et_pb_contact_field field_title=”Email Address” field_type=”email” field_id=”Email” required_mark=”on” fullwidth_field=”off”] [/et_pb_contact_field][et_pb_contact_field field_id=”Phone Number” field_title=”Phone Number” field_type=”input” required_mark=”on” fullwidth_field=”on” form_field_font_select=”default” form_field_font=”||||” use_border_color=”off” border_style=”solid” /][et_pb_contact_field field_id=”Original Appointment Date” field_title=”Original Appointment Date” field_type=”input” required_mark=”on” fullwidth_field=”on” form_field_font_select=”default” form_field_font=”||||” use_border_color=”off” border_style=”solid” /] [/et_pb_contact_form][/et_pb_column][/et_pb_row][/et_pb_section]
