By this I understand the form HTML:
[response]
<fieldset>
<legend style=”font-weight: bold;”>Client Information</legend>
- Date: [date date-382 id:date size:10 placeholder “mm/dd/YYYY”]
- DOB: [date date-382 id:dob size:10 placeholder “mm/dd/yyyy”]
- Client’s Name: [text cf7s-name size:20 placeholder "client's Full name"]
- Street Address: [text text-674 id:st_address size:20 placeholder "123 Any Street"]
- City: [text text-674 maxlength:15 id:city size:10 city placeholder "New York"]
- State: [text text-674 id:state size:3 placeholder "CA"]
- Zip: [text text-674 id:zip size:6 placeholder "10011"]
- Home Phone: [tel tel-643 id:home_tel size:14 placeholder “(555) 555-1212”]
- Cell Phone: [tel tel-643 id:cel_tel size:14 placeholder “(555) 555-1212”]
- SS#: [number number-735 id:ss size:16 placeholder “555-55-5555”]
<fieldset>
<legend style=”font-weight: bold;”>Referral info</legend>
- Referred by: [text text-886 id:ref_name size:20 placeholder "referrer Full name"]
- Phone: [tel tel-843 id:ref_phone placeholder size:14 “(555) 555-1212”]
- Agency Name: [text text-349 id:agency size:15 placeholder "agency name"]
- Fax: [tel tel-843 id:ref_fax placeholder size:14 “(555) 555-1212”]
<li style=”font-style: italic;”>Please email me your newsletter – Email: [email email-239 id:nl-email placeholder “email”]
<p>We are interested in a presentation. Email us at?[email protected]</p>
</fieldset>
<fieldset>
<legend style=”font-weight: bold;”>Required for Psychological Testing:</legend>
- Referring MD name:[text text-571 id:refMD size:20 placeholder "referring MD"]
- Phone:[tel tel-488 id:refTel placeholder “(555) 555-1212”]
<p style=”font-style: italic;”>Chart ? Notes ? Are? Required ?? Fax? To?? 858-244-0990.</p>
</fieldset>
<fieldset>
<legend style=”font-weight: bold;”>Insurance Information Required Below:</legend>
- Medicare number: [number number-698 id:mc-num size:15 placeholder “Medicare #”]
- Primary Insurance Name: [text text-783 id:p-ins-name size:20 placeholder "primary ins"]
- ID#: [number number-698 id:p-id-num size:15 placeholder “ID #”]
- Group#: [number number-698 id:p-gp-num size:20 placeholder “group #”]
- Secondary Insurance Name: [text text-783 id:s-ins-name size:20 placeholder "second ins name"]
- ID#: [number number-698 id:s-id-num size:15 placeholder “ID #”]
- Group#: [number number-698 id:s-gp-num size:20 placeholder “group #”]
<p>Primary Insured: [checkbox cf7s-checkbox-02 “self” “spouse” “other”]</p>
</fieldset>
<fieldset>
<legend style=”font-weight: bold;”>MD Information</legend>
- Primary Physician Name: [text text-840 id:p-doc-name size:20 placeholder "primary MD name"]
- Phone: [tel tel-906 size:14 id:p-doc-tel placeholder “(555) 555-1212”]
- Psychiatrist Name: [text text-840 id:psyc-doc-name size:20 placeholder "psych MD name"]
- Phone: [tel tel-906 size:14 id:psyc-doc-tel placeholder “(555) 555-1212”]
- Psychiatric Medication: [text text-840 id:psyc-med size:25 placeholder "psychiatric medication"]
</fieldset>
<fieldset>
<legend style=”font-weight: bold;”>Support System: </legend>
<p>[text text-196 id:support size:30 maxlength:30 placeholder "support"]<p/>
</fieldset>
<p style= “clear:both;”></p>
<fieldset>
<legend style=”font-weight: bold;”>Reason for Referral</legend>
- [textarea cf7s-message 40×10 placeholder “reason for referral”]
</fieldset>
<fieldset>
<legend style=”font-weight: bold;”>Requested Place of Service</legend>
<li style=”font-weight: bold;”>[checkbox cf7s-checkbox-01 “Office” “Home” “Facility””Video”] Email:<b style=”color:red;”>*</b> [email* label_first email-893 id:place_email 20 placeholder “email”]
<p style=”font-style: italic;”> Special Needs: [checkbox cf7s-checkbox-03 “Elevator” “Sightedness” “Hearing Issues” “Suicidal Ideation “]</p>
</fieldset>
<p>
</p>
<p>
[submit “Submit”]
</p>
[response]
<p>Lorem ipsum dolor sit amet, consectetur adipiscing elit. Vestibulum tempus pharetra vehicula. Aliquam pellentesque mi non scelerisque placerat.</p>