{"id":1176,"date":"2020-01-08T17:31:04","date_gmt":"2020-01-08T17:31:04","guid":{"rendered":"https:\/\/indianahearingspecialists.com\/?page_id=1176"},"modified":"2020-01-08T19:00:03","modified_gmt":"2020-01-08T19:00:03","slug":"hearing-supplies-request","status":"publish","type":"page","link":"https:\/\/indianahearingspecialists.com\/patient-resources\/hearing-supplies-request\/","title":{"rendered":"Hearing Supplies Request"},"content":{"rendered":"\n<p><code><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 e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script><div class=\"fuel-gf-wrapper\">\n                <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' ><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/wp-json\/wp\/v2\/pages\/1176\/#gf_2' data-formid='2' novalidate><div class=\"fuel-gf-alert\" role=\"alert\"><\/div>\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_1\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\" ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_1'><li class='gchoice gchoice_2_1_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.1' type='checkbox'  value='I need more batteries for my hearing aid(s).'  id='choice_2_1_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_1_1' id='label_2_1_1' class='gform-field-label gform-field-label--type-inline'>I need more batteries for my hearing aid(s).<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_1_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.2' type='checkbox'  value='I need more domes for my hearing aid(s).'  id='choice_2_1_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_1_2' id='label_2_1_2' class='gform-field-label gform-field-label--type-inline'>I need more domes for my hearing aid(s).<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_1_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.3' type='checkbox'  value='I need more wax guards.'  id='choice_2_1_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_1_3' id='label_2_1_3' class='gform-field-label gform-field-label--type-inline'>I need more wax guards.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_3\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below 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 gfield_label_before_complex' >I am interested in purchasing the following assistive listening device(s):<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_3'><li class='gchoice gchoice_2_3_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.1' type='checkbox'  value='Tinnitus Bedside Masker'  id='choice_2_3_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_3_1' id='label_2_3_1' class='gform-field-label gform-field-label--type-inline'>Tinnitus Bedside Masker<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_3_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.2' type='checkbox'  value='Television Amplifying Headset'  id='choice_2_3_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_3_2' id='label_2_3_2' class='gform-field-label gform-field-label--type-inline'>Television Amplifying Headset<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_3_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.3' type='checkbox'  value='Pocket Talker'  id='choice_2_3_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_3_3' id='label_2_3_3' class='gform-field-label gform-field-label--type-inline'>Pocket Talker<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_4\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_4\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_4'>\n                            \n              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value='https:\/\/indianahearingspecialists.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_8\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\" ><p>Our team will review your purchase request and follow up with you<\/p><\/li><li id=\"field_2_9\" class=\"gfield gfield--type-gfic field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\" ><label class='gfield_label gform-field-label screen-reader-text' for='input_2_9'><\/label><span class=\"wpcf7-form-control-wrap kc_captcha gfic-loader\"><span class=\"wpcf7-form-control wpcf7-cf7ic\"><span class=\"captcha-image\"><span class=\"cf7ic_instructions\">\r\n\t\t\t\t\tPlease prove you are human by selecting the <span 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