{"id":96457,"date":"2026-03-05T14:11:02","date_gmt":"2026-03-05T12:11:02","guid":{"rendered":"https:\/\/greendalehouse.co.za\/?page_id=96457"},"modified":"2026-06-23T13:54:51","modified_gmt":"2026-06-23T11:54:51","slug":"intake-patient-form","status":"publish","type":"page","link":"https:\/\/greendalehouse.co.za\/index.php\/contact-pages\/intake-patient-form\/","title":{"rendered":"Intake Patient Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"96457\" class=\"elementor elementor-96457\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-b748679 elementor-section-stretched elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"b748679\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-9f4330b\" data-id=\"9f4330b\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5d8803ea elementor-widget elementor-widget-heading\" data-id=\"5d8803ea\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Patient Intake Form<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2398d09b elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2398d09b\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-18635687\" data-id=\"18635687\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;none&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-0e51c21\" data-id=\"0e51c21\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;none&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-71433ac2 elementor-section-content-top elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"71433ac2\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-1a081c18\" data-id=\"1a081c18\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-2e36ef1 elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"2e36ef1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Complete the form <\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4f5c918c elementor-widget elementor-widget-heading\" data-id=\"4f5c918c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"elementor-heading-title elementor-size-default\">You can get in touch with us by completing the form on the right. Alternatively please email <u style=\"font-family: Aptos, sans-serif;font-size: 14.6667px;letter-spacing: normal\"><span><a href=\"mailto:intake@greendalehouse.co.za\" title=\"mailto:intake@greendalehouse.co.za\" data-outlook-id=\"600555da-475f-4744-9a8a-b93e78a02773\" style=\"color: purple\"><span><span data-markjs=\"true\" class=\"outlook-search-highlight\"><span data-markjs=\"true\" class=\"outlook-search-highlight\">intake<\/span><\/span>@greendalehouse.co.za<\/span><\/a><\/span><\/u><br><br><br><b>Please make sure to follow us on social media.<\/b> <\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-61479f8 elementor-shape-rounded elementor-grid-0 e-grid-align-center elementor-widget elementor-widget-social-icons\" data-id=\"61479f8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"social-icons.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-social-icons-wrapper elementor-grid\" role=\"list\">\n\t\t\t\t\t\t\t<span class=\"elementor-grid-item\" role=\"listitem\">\n\t\t\t\t\t<a class=\"elementor-icon elementor-social-icon elementor-social-icon-facebook elementor-repeater-item-192cb17\" href=\"https:\/\/www.facebook.com\/greendalehousecare\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-screen-only\">Facebook<\/span>\n\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fab-facebook\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M504 256C504 119 393 8 256 8S8 119 8 256c0 123.78 90.69 226.38 209.25 245V327.69h-63V256h63v-54.64c0-62.15 37-96.48 93.67-96.48 27.14 0 55.52 4.84 55.52 4.84v61h-31.28c-30.8 0-40.41 19.12-40.41 38.73V256h68.78l-11 71.69h-57.78V501C413.31 482.38 504 379.78 504 256z\"><\/path><\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/span>\n\t\t\t\t\t\t\t<span class=\"elementor-grid-item\" role=\"listitem\">\n\t\t\t\t\t<a class=\"elementor-icon elementor-social-icon elementor-social-icon-youtube elementor-repeater-item-e687692\" href=\"https:\/\/www.youtube.com\/@GreendaleHouse\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-screen-only\">Youtube<\/span>\n\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fab-youtube\" viewBox=\"0 0 576 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M549.655 124.083c-6.281-23.65-24.787-42.276-48.284-48.597C458.781 64 288 64 288 64S117.22 64 74.629 75.486c-23.497 6.322-42.003 24.947-48.284 48.597-11.412 42.867-11.412 132.305-11.412 132.305s0 89.438 11.412 132.305c6.281 23.65 24.787 41.5 48.284 47.821C117.22 448 288 448 288 448s170.78 0 213.371-11.486c23.497-6.321 42.003-24.171 48.284-47.821 11.412-42.867 11.412-132.305 11.412-132.305s0-89.438-11.412-132.305zm-317.51 213.508V175.185l142.739 81.205-142.739 81.201z\"><\/path><\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/span>\n\t\t\t\t\t\t\t<span class=\"elementor-grid-item\" role=\"listitem\">\n\t\t\t\t\t<a class=\"elementor-icon elementor-social-icon elementor-social-icon-instagram elementor-repeater-item-d1a3dca\" href=\"https:\/\/www.instagram.com\/greendalehousecare\/\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-screen-only\">Instagram<\/span>\n\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fab-instagram\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M224.1 141c-63.6 0-114.9 51.3-114.9 114.9s51.3 114.9 114.9 114.9S339 319.5 339 255.9 287.7 141 224.1 141zm0 189.6c-41.1 0-74.7-33.5-74.7-74.7s33.5-74.7 74.7-74.7 74.7 33.5 74.7 74.7-33.6 74.7-74.7 74.7zm146.4-194.3c0 14.9-12 26.8-26.8 26.8-14.9 0-26.8-12-26.8-26.8s12-26.8 26.8-26.8 26.8 12 26.8 26.8zm76.1 27.2c-1.7-35.9-9.9-67.7-36.2-93.9-26.2-26.2-58-34.4-93.9-36.2-37-2.1-147.9-2.1-184.9 0-35.8 1.7-67.6 9.9-93.9 36.1s-34.4 58-36.2 93.9c-2.1 37-2.1 147.9 0 184.9 1.7 35.9 9.9 67.7 36.2 93.9s58 34.4 93.9 36.2c37 2.1 147.9 2.1 184.9 0 35.9-1.7 67.7-9.9 93.9-36.2 26.2-26.2 34.4-58 36.2-93.9 2.1-37 2.1-147.8 0-184.8zM398.8 388c-7.8 19.6-22.9 34.7-42.6 42.6-29.5 11.7-99.5 9-132.1 9s-102.7 2.6-132.1-9c-19.6-7.8-34.7-22.9-42.6-42.6-11.7-29.5-9-99.5-9-132.1s-2.6-102.7 9-132.1c7.8-19.6 22.9-34.7 42.6-42.6 29.5-11.7 99.5-9 132.1-9s102.7-2.6 132.1 9c19.6 7.8 34.7 22.9 42.6 42.6 11.7 29.5 9 99.5 9 132.1s2.7 102.7-9 132.1z\"><\/path><\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/span>\n\t\t\t\t\t\t\t<span class=\"elementor-grid-item\" role=\"listitem\">\n\t\t\t\t\t<a class=\"elementor-icon elementor-social-icon elementor-social-icon-linkedin elementor-repeater-item-2088d16\" href=\"https:\/\/www.linkedin.com\/company\/greendalehousecare\/?viewAsMember=true\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-screen-only\">Linkedin<\/span>\n\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fab-linkedin\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M416 32H31.9C14.3 32 0 46.5 0 64.3v383.4C0 465.5 14.3 480 31.9 480H416c17.6 0 32-14.5 32-32.3V64.3c0-17.8-14.4-32.3-32-32.3zM135.4 416H69V202.2h66.5V416zm-33.2-243c-21.3 0-38.5-17.3-38.5-38.5S80.9 96 102.2 96c21.2 0 38.5 17.3 38.5 38.5 0 21.3-17.2 38.5-38.5 38.5zm282.1 243h-66.4V312c0-24.8-.5-56.7-34.5-56.7-34.6 0-39.9 27-39.9 54.9V416h-66.4V202.2h63.7v29.2h.9c8.9-16.8 30.6-34.5 62.9-34.5 67.2 0 79.7 44.3 79.7 101.9V416z\"><\/path><\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/span>\n\t\t\t\t\t\t\t<span class=\"elementor-grid-item\" role=\"listitem\">\n\t\t\t\t\t<a class=\"elementor-icon elementor-social-icon elementor-social-icon-tiktok elementor-repeater-item-22f2a70\" href=\"https:\/\/www.tiktok.com\/@greendalehousecares\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-screen-only\">Tiktok<\/span>\n\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fab-tiktok\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M448,209.91a210.06,210.06,0,0,1-122.77-39.25V349.38A162.55,162.55,0,1,1,185,188.31V278.2a74.62,74.62,0,1,0,52.23,71.18V0l88,0a121.18,121.18,0,0,0,1.86,22.17h0A122.18,122.18,0,0,0,381,102.39a121.43,121.43,0,0,0,67,20.14Z\"><\/path><\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/span>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-37e476f9\" data-id=\"37e476f9\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-65bbc309 elementor-widget elementor-widget-cf7\" data-id=\"65bbc309\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"cf7.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n\t\t<div class=\"nd_elements_cf7_component\">\n\t\t\t\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f96458-o1\" lang=\"en-ZA\" dir=\"ltr\" data-wpcf7-id=\"96458\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/96457#wpcf7-f96458-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"96458\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_ZA\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f96458-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p><br \/>\n<label for=\"contact-name\">Contact Name<\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"contact-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"contact-name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Full Name\" value=\"\" type=\"text\" name=\"contact-name\" \/><\/span>\n<\/p>\n<p><br \/>\n<label for=\"contact-number\">Contact Number<\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"contact-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" id=\"contact-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Primary Contact Number\" value=\"\" type=\"tel\" name=\"contact-number\" \/><\/span>\n<\/p>\n<p><br \/>\n<label for=\"alternate-contact-number\">Alternate Contact Number<\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"alternate-contact-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" id=\"alternate-contact-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Alternate Contact Number\" value=\"\" type=\"tel\" name=\"alternate-contact-number\" \/><\/span>\n<\/p>\n<p><br \/>\n<label for=\"contact-email\">Contact Email Address<\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"contact-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" id=\"contact-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email Address\" value=\"\" type=\"email\" name=\"contact-email\" \/><\/span>\n<\/p>\n<p><br \/>\n<label for=\"patient-name\">Patient Name & Surname<\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"patient-name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient Full Name\" value=\"\" type=\"text\" name=\"patient-name\" \/><\/span>\n<\/p>\n<hr \/>\n<p><br \/>\n<label for=\"patient-area\">Area: Suburb \/ Residential Address of Patient<\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-area\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"patient-area\" aria-invalid=\"false\" placeholder=\"Suburb \/ Residential Address\" value=\"\" type=\"text\" name=\"patient-area\" \/><\/span>\n<\/p>\n<p><br \/>\n<label>Medical Aid<\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"medical-aid\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"medical-aid\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"medical-aid\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><br \/>\n<label for=\"patient-condition\">Message: Description of Patient\u2019s Condition<\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-condition\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" id=\"patient-condition\" aria-invalid=\"false\" placeholder=\"Please describe the patient\u2019s condition in detail\" name=\"patient-condition\"><\/textarea><\/span>\n<\/p>\n<p><br \/>\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"126\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n\t\t<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Patient Intake Form Complete the form You can get in touch with us by completing the form on the right. Alternatively please email intake@greendalehouse.co.za Please make sure to follow us [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":9015,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"give_campaign_id":0,"footnotes":""},"class_list":["post-96457","page","type-page","status-publish","hentry"],"campaignId":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/greendalehouse.co.za\/index.php\/wp-json\/wp\/v2\/pages\/96457","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/greendalehouse.co.za\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/greendalehouse.co.za\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/greendalehouse.co.za\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/greendalehouse.co.za\/index.php\/wp-json\/wp\/v2\/comments?post=96457"}],"version-history":[{"count":10,"href":"https:\/\/greendalehouse.co.za\/index.php\/wp-json\/wp\/v2\/pages\/96457\/revisions"}],"predecessor-version":[{"id":96588,"href":"https:\/\/greendalehouse.co.za\/index.php\/wp-json\/wp\/v2\/pages\/96457\/revisions\/96588"}],"up":[{"embeddable":true,"href":"https:\/\/greendalehouse.co.za\/index.php\/wp-json\/wp\/v2\/pages\/9015"}],"wp:attachment":[{"href":"https:\/\/greendalehouse.co.za\/index.php\/wp-json\/wp\/v2\/media?parent=96457"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}