{"id":140,"date":"2023-03-07T15:30:41","date_gmt":"2023-03-07T15:30:41","guid":{"rendered":"https:\/\/hytechdemo.com\/cdfold\/?page_id=140"},"modified":"2023-03-30T06:38:50","modified_gmt":"2023-03-30T06:38:50","slug":"patient-form","status":"publish","type":"page","link":"https:\/\/hytechdemo.com\/cdfold\/patient-form\/","title":{"rendered":"Patient Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"140\" class=\"elementor elementor-140\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-3c507db elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"3c507db\" data-element_type=\"section\" data-e-type=\"section\">\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-100 elementor-top-column elementor-element elementor-element-201342f\" data-id=\"201342f\" 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-5b85f48 elementor-widget elementor-widget-heading\" data-id=\"5b85f48\" 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\">New Patient 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-191739e elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"191739e\" data-element_type=\"section\" data-e-type=\"section\">\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-100 elementor-top-column elementor-element elementor-element-e8085d0\" data-id=\"e8085d0\" 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-ecb61b1 elementor-widget elementor-widget-shortcode\" data-id=\"ecb61b1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework pa_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1' class='pa' action='\/cdfold\/wp-json\/wp\/v2\/pages\/140#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>9<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_11' style='width:11%;'><span>11%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_2\" class=\"gfield gfield--type-html heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>New Patient Information<\/h2><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--width-third gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-text gfield--width-third gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-email gfield--width-third gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_1_7' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_82\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_82'>Your Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_1_82' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Birth Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_1_6' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_6_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_6_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_6' class='gform_hidden' value='https:\/\/hytechdemo.com\/cdfold\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>Main Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_1_8' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Cell Phone (If different than main)<\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_1_9' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_1' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-1' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_3\" class=\"gfield gfield--type-html heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Patient Information<\/h2><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Mailing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-text gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-select gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_1_12' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Manitoba' >Manitoba<\/option><option value='Ontario' >Ontario<\/option><option value='Quebec' >Quebec<\/option><option value='Newfoundland' >Newfoundland<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='PEI' >PEI<\/option><option value='NWT' >NWT<\/option><option value='Nunavut' >Nunavut<\/option><option value='Yukon' >Yukon<\/option><\/select><\/div><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-text gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>Postal Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_84\" class=\"gfield gfield--type-text gfield--width-full gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_84'>Occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_1_84' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_83\" class=\"gfield gfield--type-text gfield--width-full gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_83'>Place of Business<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_1_83' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_14' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_14' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-14' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_15\" class=\"gfield gfield--type-html heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Emergency Contact Details<\/h2><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-text gf_left_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Your Spouse\/Parent\/Guardian\u2019s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='medium'    placeholder='Full Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_86\" class=\"gfield gfield--type-text gfield--width-full gf_middle_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_86'>His\/Her Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_1_86' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_85\" class=\"gfield gfield--type-text gfield--width-full gf_middle_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_85'>His\/Her Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_1_85' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_88\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_88'>Name of family member responsible for payment of your account<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_1_88' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_87\" class=\"gfield gfield--type-text gfield--width-third gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_87'>How did you hear about our office?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_1_87' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-text gfield--width-third gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>Emergency Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-phone gfield--width-third gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>Emergency Contact Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_18' id='input_1_18' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_19' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_19' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-19' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_92\" class=\"gfield gfield--type-html gfield--width-full heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Insurance Information<\/h2><\/div><fieldset id=\"field_1_100\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have insurance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_100'>\n\t\t\t<div class='gchoice gchoice_1_100_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='Yes'  id='choice_1_100_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_100_0' id='label_1_100_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_100_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='No'  id='choice_1_100_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_100_1' id='label_1_100_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_98\" class=\"gfield gfield--type-html gfield--width-full heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Primary Insurance<\/h4><\/div><div id=\"field_1_93\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_93'>Insurance Company<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_1_93' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_96\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_96'>Group\/Plan Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_1_96' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_95\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_95'>Certificate\/Subscriber ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_1_95' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_99\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_99'>Subscriber Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_1_99' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_97\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Subscriber Birthdate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_1_97' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_97_1_container'>\n                                            <input type='number' maxlength='2' name='input_97[]' id='input_1_97_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_97_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_97_2_container'>\n                                            <input type='number' maxlength='2' name='input_97[]' id='input_1_97_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_97_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_97_3_container'>\n                                            <input type='number' maxlength='4' name='input_97[]' id='input_1_97_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_97_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_91\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have secondary insurance?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_91'>\n\t\t\t<div class='gchoice gchoice_1_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='Yes'  id='choice_1_91_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_91_0' id='label_1_91_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='No'  id='choice_1_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_91_1' id='label_1_91_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_138\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_138'>Insurance Company<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_1_138' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_139\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_139'>Group\/Plan Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_1_139' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_142\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_142'>Certificate\/Subscriber ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_1_142' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_140\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_140'>Subscriber Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_1_140' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_141\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Subscriber Birthdate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_1_141' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_141_1_container'>\n                                            <input type='number' maxlength='2' name='input_141[]' id='input_1_141_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_141_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_141_2_container'>\n                                            <input type='number' maxlength='2' name='input_141[]' id='input_1_141_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_141_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_141_3_container'>\n                                            <input type='number' maxlength='4' name='input_141[]' id='input_1_141_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_141_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_105\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you interested in a payment plan for dental services?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_105'>\n\t\t\t<div class='gchoice gchoice_1_105_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Yes'  id='choice_1_105_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_105_0' id='label_1_105_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_105_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='No'  id='choice_1_105_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_105_1' id='label_1_105_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_106\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please inform one of our staff members during your next visit and we will be happy to assist you in starting your payment plan.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_89' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_89' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-89' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_90\" class=\"gfield gfield--type-html gfield--width-full heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Patient Dental History<\/h2><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_25'>Is there a dental problem you would like treated immediately?<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_1_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>Are there any other dental condition that concern you at present?<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_107\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_107'>Are there any dental issues that you want addressed in the future?<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_1_107' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_108\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_108'>How frequently do you see your dentist?<\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_1_108' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_110\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_110'>Date of Your Last Dental Visit?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_110' id='input_1_110' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_110_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_110_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_110' class='gform_hidden' value='https:\/\/hytechdemo.com\/cdfold\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gf_right_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>Date of Last X-rays<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_30' id='input_1_30' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_30_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_30_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_30' class='gform_hidden' value='https:\/\/hytechdemo.com\/cdfold\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gf_middle_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>Date of Last Cleaning<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_29' id='input_1_29' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_29_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_29_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_29' class='gform_hidden' value='https:\/\/hytechdemo.com\/cdfold\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_31\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you feel any pain in your teeth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_31'>\n\t\t\t<div class='gchoice gchoice_1_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_1_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_31_0' id='label_1_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_1_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_31_1' id='label_1_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_32\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do your gums bleed when brushing or eating, or do you suffer from pain or swelling of your gums?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_32'>\n\t\t\t<div class='gchoice gchoice_1_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Yes'  id='choice_1_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_32_0' id='label_1_32_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_1_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_32_1' id='label_1_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_33\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are there any growths or sore spots in your mouth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_33'>\n\t\t\t<div class='gchoice gchoice_1_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_1_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_0' id='label_1_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_1_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_1' id='label_1_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_34\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been given oral hygiene instruction in brushing, flossing or other instructions?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_34'>\n\t\t\t<div class='gchoice gchoice_1_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_1_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_0' id='label_1_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_1_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_1' id='label_1_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_35\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does food catch between your teeth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_35'>\n\t\t\t<div class='gchoice gchoice_1_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_1_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_0' id='label_1_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_1_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_1' id='label_1_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_36\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are any of your teeth sensitive to heat, cold, sweets or pressure?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_36'>\n\t\t\t<div class='gchoice gchoice_1_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_1_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_36_0' id='label_1_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_1_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_36_1' id='label_1_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever had local anesthetics (freezing)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_37'>\n\t\t\t<div class='gchoice gchoice_1_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes'  id='choice_1_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_0' id='label_1_37_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_1_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_1' id='label_1_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you missing any teeth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_39'>\n\t\t\t<div class='gchoice gchoice_1_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Yes'  id='choice_1_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_39_0' id='label_1_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_1_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_39_1' id='label_1_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_111\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you dissatisfied with the appearance of your teeth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_111'>\n\t\t\t<div class='gchoice gchoice_1_111_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Yes'  id='choice_1_111_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_111_0' id='label_1_111_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_111_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='No'  id='choice_1_111_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_111_1' id='label_1_111_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_112\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you had dental x-rays taken in the last 5 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_112'>\n\t\t\t<div class='gchoice gchoice_1_112_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Yes'  id='choice_1_112_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_112_0' id='label_1_112_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_112_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='No'  id='choice_1_112_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_112_1' id='label_1_112_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_73\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have any of the following habits? Please check all that apply: (Choose as many as you like)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_73'><div class='gchoice gchoice_1_73_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.1' type='checkbox'  value='Clenching or grinding your teeth while awake or asleep?'  id='choice_1_73_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_73_1' id='label_1_73_1' class='gform-field-label gform-field-label--type-inline'>Clenching or grinding your teeth while awake or asleep?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_73_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.2' type='checkbox'  value='Mouth breathing while awake or asleep?'  id='choice_1_73_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_73_2' id='label_1_73_2' class='gform-field-label gform-field-label--type-inline'>Mouth breathing while awake or asleep?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_73_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.3' type='checkbox'  value='Biting your cheeks or lips?'  id='choice_1_73_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_73_3' id='label_1_73_3' class='gform-field-label gform-field-label--type-inline'>Biting your cheeks or lips?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_73_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.4' type='checkbox'  value='Gag reflex?'  id='choice_1_73_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_73_4' id='label_1_73_4' class='gform-field-label gform-field-label--type-inline'>Gag reflex?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_73_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.5' type='checkbox'  value='None of the above.'  id='choice_1_73_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_73_5' id='label_1_73_5' class='gform-field-label gform-field-label--type-inline'>None of the above.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you ever experienced any of the following jaw problems: Please check all that apply: (Choose as many as you like)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_43'><div class='gchoice gchoice_1_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Popping\/clicking in your jaw joints.'  id='choice_1_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_1' id='label_1_43_1' class='gform-field-label gform-field-label--type-inline'>Popping\/clicking in your jaw joints.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='Difficulty opening or closing.'  id='choice_1_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_2' id='label_1_43_2' class='gform-field-label gform-field-label--type-inline'>Difficulty opening or closing.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.3' type='checkbox'  value='Pain or difficulty while chewing.'  id='choice_1_43_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_3' id='label_1_43_3' class='gform-field-label gform-field-label--type-inline'>Pain or difficulty while chewing.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.4' type='checkbox'  value='Pain in your jaw joints, around your ear or side of your face.'  id='choice_1_43_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_4' id='label_1_43_4' class='gform-field-label gform-field-label--type-inline'>Pain in your jaw joints, around your ear or side of your face.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.5' type='checkbox'  value='Pain when teeth are clenched.'  id='choice_1_43_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_5' id='label_1_43_5' class='gform-field-label gform-field-label--type-inline'>Pain when teeth are clenched.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.6' type='checkbox'  value='None of the above.'  id='choice_1_43_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_6' id='label_1_43_6' class='gform-field-label gform-field-label--type-inline'>None of the above.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are you interested in discussing any of the following with the dentist or hygienist?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_44'><div class='gchoice gchoice_1_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Teeth whitening or bleaching?'  id='choice_1_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_1' id='label_1_44_1' class='gform-field-label gform-field-label--type-inline'>Teeth whitening or bleaching?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='Cosmetic dentistry?'  id='choice_1_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_2' id='label_1_44_2' class='gform-field-label gform-field-label--type-inline'>Cosmetic dentistry?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.3' type='checkbox'  value='Orthodontic treatment?'  id='choice_1_44_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_3' id='label_1_44_3' class='gform-field-label gform-field-label--type-inline'>Orthodontic treatment?<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_113\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_113'>Have you ever had an upsetting experience in a dental office, or any complications during or following dental treatment, or, do you have any questions or concerns?<\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_1_113' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_22' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_22' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-22' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_23\" class=\"gfield gfield--type-html heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Patient Medical History<\/h2><\/div><div id=\"field_1_45\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_45'>Family Doctor<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_1_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_114\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you in good health now?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_114'>\n\t\t\t<div class='gchoice gchoice_1_114_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Yes'  id='choice_1_114_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_114_0' id='label_1_114_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_114_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='No'  id='choice_1_114_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_114_1' id='label_1_114_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_115\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you presently being treated by a physicians?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_115'>\n\t\t\t<div class='gchoice gchoice_1_115_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Yes'  id='choice_1_115_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_115_0' id='label_1_115_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_115_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='No'  id='choice_1_115_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_115_1' id='label_1_115_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you taking any medication(s) including non-prescription medicine?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_50'>\n\t\t\t<div class='gchoice gchoice_1_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Yes'  id='choice_1_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_50_0' id='label_1_50_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='No'  id='choice_1_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_50_1' id='label_1_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_76\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_76'>what medication(s) are you taking? Please provide a complete list of medication?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_76' id='input_1_76' class='textarea medium'    placeholder='Please provide details of all medications here...'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have any allergies? Or have you ever had a reaction to any of the following: Penicillin, Codeine, General Anesthetic, Aspirin, Local Anesthetic (Freezing).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_52'>\n\t\t\t<div class='gchoice gchoice_1_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Yes'  id='choice_1_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_52_0' id='label_1_52_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='No'  id='choice_1_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_52_1' id='label_1_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_77\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_77'>please provide details.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_77' id='input_1_77' class='textarea medium'    placeholder='Please provide details...'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_54'>\n\t\t\t<div class='gchoice gchoice_1_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Yes'  id='choice_1_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_54_0' id='label_1_54_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='No'  id='choice_1_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_54_1' id='label_1_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_78\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_78'>please provide details.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_78' id='input_1_78' class='textarea medium'    placeholder='Please provide details...'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_56\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you smoke?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_56'>\n\t\t\t<div class='gchoice gchoice_1_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Yes'  id='choice_1_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_56_0' id='label_1_56_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='No'  id='choice_1_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_56_1' id='label_1_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_57\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you get chest pains upon exertion or shortness of breath after mild exercise?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_57'>\n\t\t\t<div class='gchoice gchoice_1_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes'  id='choice_1_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_57_0' id='label_1_57_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_1_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_57_1' id='label_1_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_117\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you get swelling of your ankles or have difficulty lying flat on your back?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_117'>\n\t\t\t<div class='gchoice gchoice_1_117_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='Yes'  id='choice_1_117_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_117_0' id='label_1_117_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_117_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='No'  id='choice_1_117_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_117_1' id='label_1_117_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_116\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you use controlled substances (cocaine, barbiturates, other)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_116'>\n\t\t\t<div class='gchoice gchoice_1_116_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_116' type='radio' value='Yes'  id='choice_1_116_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_116_0' id='label_1_116_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_116_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_116' type='radio' value='No'  id='choice_1_116_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_116_1' id='label_1_116_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_118\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever had any excessive bleeding requiring treatment?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_118'>\n\t\t\t<div class='gchoice gchoice_1_118_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_118' type='radio' value='Yes'  id='choice_1_118_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_118_0' id='label_1_118_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_118_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_118' type='radio' value='No'  id='choice_1_118_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_118_1' id='label_1_118_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_58\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you ever had any of the following? (Please check all the applicable boxes)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_58'><div class='gchoice gchoice_1_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='AIDS or HIV Infection'  id='choice_1_58_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_1' id='label_1_58_1' class='gform-field-label gform-field-label--type-inline'>AIDS or HIV Infection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.2' type='checkbox'  value='Anemia'  id='choice_1_58_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_2' id='label_1_58_2' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.3' type='checkbox'  value='Angina'  id='choice_1_58_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_3' id='label_1_58_3' class='gform-field-label gform-field-label--type-inline'>Angina<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.4' type='checkbox'  value='Mental Disorder'  id='choice_1_58_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_4' id='label_1_58_4' class='gform-field-label gform-field-label--type-inline'>Mental Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.5' type='checkbox'  value='Nervous Disorder'  id='choice_1_58_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_5' id='label_1_58_5' class='gform-field-label gform-field-label--type-inline'>Nervous Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.6' type='checkbox'  value='Arthritis'  id='choice_1_58_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_6' id='label_1_58_6' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.7' type='checkbox'  value='Asthma\/COPD'  id='choice_1_58_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_7' id='label_1_58_7' class='gform-field-label gform-field-label--type-inline'>Asthma\/COPD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.8' type='checkbox'  value='Bleeding Problems'  id='choice_1_58_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_8' id='label_1_58_8' class='gform-field-label gform-field-label--type-inline'>Bleeding Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.9' type='checkbox'  value='Cancer'  id='choice_1_58_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_9' id='label_1_58_9' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.11' type='checkbox'  value='Cardiac Pacemaker'  id='choice_1_58_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_11' id='label_1_58_11' class='gform-field-label gform-field-label--type-inline'>Cardiac Pacemaker<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.12' type='checkbox'  value='Cleft Lip or Palate'  id='choice_1_58_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_12' id='label_1_58_12' class='gform-field-label gform-field-label--type-inline'>Cleft Lip or Palate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.13' type='checkbox'  value='Chest Pains'  id='choice_1_58_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_13' id='label_1_58_13' class='gform-field-label gform-field-label--type-inline'>Chest Pains<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.14' type='checkbox'  value='Cirrhosis'  id='choice_1_58_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_14' id='label_1_58_14' class='gform-field-label gform-field-label--type-inline'>Cirrhosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.15' type='checkbox'  value='Cystic Fibrosis'  id='choice_1_58_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_15' id='label_1_58_15' class='gform-field-label gform-field-label--type-inline'>Cystic Fibrosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.16' type='checkbox'  value='Diabetes'  id='choice_1_58_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_16' id='label_1_58_16' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.17' type='checkbox'  value='Eating Disorder'  id='choice_1_58_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_17' id='label_1_58_17' class='gform-field-label gform-field-label--type-inline'>Eating Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.18' type='checkbox'  value='Emphysema'  id='choice_1_58_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_18' id='label_1_58_18' class='gform-field-label gform-field-label--type-inline'>Emphysema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.19' type='checkbox'  value='Epilepsy\/Convulsions'  id='choice_1_58_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_19' id='label_1_58_19' class='gform-field-label gform-field-label--type-inline'>Epilepsy\/Convulsions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.21' type='checkbox'  value='Fainting\/Seizures'  id='choice_1_58_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_21' id='label_1_58_21' class='gform-field-label gform-field-label--type-inline'>Fainting\/Seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.22' type='checkbox'  value='Fibromyalgia'  id='choice_1_58_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_22' id='label_1_58_22' class='gform-field-label gform-field-label--type-inline'>Fibromyalgia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.23' type='checkbox'  value='Glaucoma'  id='choice_1_58_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_23' id='label_1_58_23' class='gform-field-label gform-field-label--type-inline'>Glaucoma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.24' type='checkbox'  value='Heart Attack'  id='choice_1_58_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_24' id='label_1_58_24' class='gform-field-label gform-field-label--type-inline'>Heart Attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.25' type='checkbox'  value='Heart Disease'  id='choice_1_58_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_25' id='label_1_58_25' class='gform-field-label gform-field-label--type-inline'>Heart Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.26' type='checkbox'  value='Heart Murmur'  id='choice_1_58_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_26' id='label_1_58_26' class='gform-field-label gform-field-label--type-inline'>Heart Murmur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.27' type='checkbox'  value='Heart Surgery or Transplant'  id='choice_1_58_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_27' id='label_1_58_27' class='gform-field-label gform-field-label--type-inline'>Heart Surgery or Transplant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.28' type='checkbox'  value='Hepatitis'  id='choice_1_58_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_28' id='label_1_58_28' class='gform-field-label gform-field-label--type-inline'>Hepatitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.29' type='checkbox'  value='High Blood Pressure'  id='choice_1_58_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_29' id='label_1_58_29' class='gform-field-label gform-field-label--type-inline'>High Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.31' type='checkbox'  value='Low Blood Pressure'  id='choice_1_58_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_31' id='label_1_58_31' class='gform-field-label gform-field-label--type-inline'>Low Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.32' type='checkbox'  value='Joint Replacement'  id='choice_1_58_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_32' id='label_1_58_32' class='gform-field-label gform-field-label--type-inline'>Joint Replacement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.33' type='checkbox'  value='Kidney Disease'  id='choice_1_58_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_33' id='label_1_58_33' class='gform-field-label gform-field-label--type-inline'>Kidney Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.34' type='checkbox'  value='Leukemia'  id='choice_1_58_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_34' id='label_1_58_34' class='gform-field-label gform-field-label--type-inline'>Leukemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.35' type='checkbox'  value='Liver Disease'  id='choice_1_58_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_35' id='label_1_58_35' class='gform-field-label gform-field-label--type-inline'>Liver Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.36' type='checkbox'  value='Osteoporosis\/Osteopenia'  id='choice_1_58_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_36' id='label_1_58_36' class='gform-field-label gform-field-label--type-inline'>Osteoporosis\/Osteopenia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_37'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.37' type='checkbox'  value='Radiation\/Chemo Therapy'  id='choice_1_58_37'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_37' id='label_1_58_37' class='gform-field-label gform-field-label--type-inline'>Radiation\/Chemo Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_38'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.38' type='checkbox'  value='Respiratory Problems'  id='choice_1_58_38'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_38' id='label_1_58_38' class='gform-field-label gform-field-label--type-inline'>Respiratory Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_39'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.39' type='checkbox'  value='STD'  id='choice_1_58_39'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_39' id='label_1_58_39' class='gform-field-label gform-field-label--type-inline'>STD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_41'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.41' type='checkbox'  value='Sinus Trouble'  id='choice_1_58_41'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_41' id='label_1_58_41' class='gform-field-label gform-field-label--type-inline'>Sinus Trouble<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_42'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.42' type='checkbox'  value='Stomach Troubles\/Ulcers'  id='choice_1_58_42'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_42' id='label_1_58_42' class='gform-field-label gform-field-label--type-inline'>Stomach Troubles\/Ulcers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_43'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.43' type='checkbox'  value='Stroke'  id='choice_1_58_43'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_43' id='label_1_58_43' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_58_44'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.44' type='checkbox'  value='Thyroid Disease'  id='choice_1_58_44'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_44' id='label_1_58_44' class='gform-field-label gform-field-label--type-inline'>Thyroid Disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_46\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_46'>Is there anything else we should know about your health?<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-html women_only gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Women Only<\/h3><\/div><fieldset id=\"field_1_60\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you pregnant or think you may be pregnant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_60'>\n\t\t\t<div class='gchoice gchoice_1_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Yes'  id='choice_1_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_60_0' id='label_1_60_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='No'  id='choice_1_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_60_1' id='label_1_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_61\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you nursing?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_61'>\n\t\t\t<div class='gchoice gchoice_1_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Yes'  id='choice_1_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_61_0' id='label_1_61_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='No'  id='choice_1_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_61_1' id='label_1_61_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_62\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you taking oral contraceptives?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_62'>\n\t\t\t<div class='gchoice gchoice_1_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Yes'  id='choice_1_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_62_0' id='label_1_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_1_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_62_1' id='label_1_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_63\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have allergies?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_63'>\n\t\t\t<div class='gchoice gchoice_1_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Yes'  id='choice_1_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_0' id='label_1_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='No'  id='choice_1_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_1' id='label_1_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_79\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_79'>please provide details.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_79' id='input_1_79' class='textarea medium'    placeholder='Please provide details...'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_49' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_49' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_7' class='gform_page' data-js='page-field-id-49' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_48\" class=\"gfield gfield--type-html gfield--width-full heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>X-ray And Record Release<\/h2><\/div><div id=\"field_1_121\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_121'>Patient Name<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_1_121' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_122\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I, consent to the release and transfer of my;<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_122'><div class='gchoice gchoice_1_122_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.1' type='checkbox'  value='X-rays'  id='choice_1_122_1'   aria-describedby=\"gfield_description_1_122\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_122_1' id='label_1_122_1' class='gform-field-label gform-field-label--type-inline'>X-rays<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_122_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.2' type='checkbox'  value='Medical History (including medications)'  id='choice_1_122_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_122_2' id='label_1_122_2' class='gform-field-label gform-field-label--type-inline'>Medical History (including medications)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_122_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.3' type='checkbox'  value='Full Chart (including specialist letters and requisitions)'  id='choice_1_122_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_122_3' id='label_1_122_3' class='gform-field-label gform-field-label--type-inline'>Full Chart (including specialist letters and requisitions)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_122'>to Central Dental Family Dentistry for the purpose of aiding in diagnostic procedures and to supplement the medical and dental history in my records. <\/div><\/fieldset><div id=\"field_1_123\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_123'>As well as the same information and records for my dependent(s);<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_123' id='input_1_123' class='textarea large'    placeholder='Please provide full printed names of dependents'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_124\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_124'>Please transfer my records from:<\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_1_124' type='text' value='' class='large'    placeholder='Previous Dental Office'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_126\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >I acknowledge that I have been made aware of the reasons for the disclosure of the above information, and the risks and benefits associated with consenting or not consenting to its release. \n\nI understand that I make revoke my consent at any time, by providing a signed, written statement to my dental service provider. <\/div><div id=\"field_1_127\" class=\"gfield gfield--type-signature gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_127'>Signature<\/label><input type='hidden' value='' name='input_127' id='input_1_127_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_127_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_1_127' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/hytechdemo.com\/cdfold\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_127_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_1_127_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_1_127_data' name='input_1_127_data' value=''><\/div><\/div><div id=\"field_1_128\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_128'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_128' id='input_1_128' type='text' value='06\/27\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_128_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_128_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_128' class='gform_hidden' value='https:\/\/hytechdemo.com\/cdfold\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_131\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_131'>Valid Until:<\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_1_131' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_132\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please forward digital records to: info@centraldentalfamily.com  \n\nOr physical records to: \n\nCentral Dental Family Dentistry\n10705 107 St. NW\nEdmonton, AB T5H 2Y9<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_119' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_119' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_8' class='gform_page' data-js='page-field-id-119' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_120\" class=\"gfield gfield--type-html gfield--width-full heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Personal Information Consent Form<\/h2><\/div><div id=\"field_1_133\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >We are committed to protecting the privacy of our patients\u2019 personal information. Collecting, using and disclosing all personal information will be done in a responsible and professional manner and in accordance with The Personal Information Protection and Electronic Documents Act and Health Information Act. <\/div><div id=\"field_1_137\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >We are committed to protecting the privacy of our patients\u2019 personal information. Collecting, using and disclosing all personal information will be done in a responsible and professional manner and in accordance with The Personal Information Protection and Electronic Documents Act and Health Information Act. \n<br><\/br>\nWe collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, cell phone numbers, and e-mail addresses. (Collectively referred to as \u201cContact information\u201d) Contact Information is collected, shared with all family members and used for the following purposes: \n<br><\/br>\n\u2022 To open and update patient files. \n<br><\/br>\n\u2022 To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts. \n<br><\/br>\n\u2022 To process claims for payment or reimbursement from third-party health benefit providers and insurance companies. \n<br><\/br>\n\u2022 To send reminders to patients concerning the need for further dental examination or treatment. \n<br><\/br>\n\u2022 To send patients informational material about our dental practice. \n<br><\/br>\n\u2022 To confirm appointments \n<br><\/br>\nContact Information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient\u2019s behalf. \n<br><\/br>\nFinancial information may be collected in order to make arrangement for the payment of dental services. \n<br><\/br>\nWe collect information from our patients about their health history, their family health history, physical condition, and dental treatments. (Collectively referred to as \u201cMedical Information\u201d) Patients\u2019 Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. \n<br><\/br>\nPatients\u2019 Medical Information is disclosed: \n<br><\/br>\nTo third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or bas asked up to submit a claim on the patient\u2019s behalf. \n<br><\/br>\nTo other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion. \n<br><\/br>\nTo other dentists and dental specialists if the patient, with their consent, has been referred to us to the other dentist or dental specialist for treatment. \n<br><\/br>\nTo other dentist and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion. \n<br><\/br>\nTo other health care professionals such as physicians if the patient, with their consent, has been referred to us to the other health care professional for either a second opinion or treatment. \n <br><\/br>\nThe Health Information Act is designed to facilitate the sharing of health information, in a controlled way, within a \u201ccircle of care\u201d. Those that are in the circle of care include; dentists, dental specialists, personal physicians, nursing homes, Alberta Health and Wellness and Alberta Health Services. Disclosure outside of this circle of care is strictly controlled. You may at any time designate any restriction as to whom we may disclose your personal information or restrict the content of disclosure. \n<br><\/br>\nIf we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information. \n<br><\/br>\nDentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest. \n<br><\/br>\nThis is to certify that I, undersigned, consent to the performing of the dental procedures agreed to be necessary or advisable, and I will assume responsibility for fees associated with those procedures. \n<br><\/br>\nIn addition, I consent to the collection, use and disclosure of my personal information as set out above. \n<br><\/br>\nI also agree that any images\/video taken of me, excluding dental records and x-rays, may be used in whole or in part for promotional purposes online or in print. In compliance with Canadian Anti-Spam Laws, you understand that by signing this form, you give us permission to send you information such as appointment reminders, appointment confirmations, news and events. \n<br><\/br>\n<strong>Information retention and destruction<\/strong>\n<br><\/br>\nWe will retain your personal information for the period necessary to continue providing oral health services to you, and for its related administration. We will destroy information in a secure manner when the information is no longer necessary for the provision of oral health services and is not required to be retained for compliance with provincial or federal regulations or statues. \n<br><\/br>\n<strong>Your access to your records<\/strong>\n<br><\/br>\nWe are committed to providing you with open access to your personal information held by us. You may at any time ask (in writing) to see your records held by us and to request amendments to that information. \n<br><\/br>\n<strong>Complaint Process<\/strong>\n<br><\/br>\nShould you wish to make a formal complaint regarding our privacy practice, please do so in writing to our privacy officer, Samantha Bath. \n<br><\/br>\n<strong>Contact<\/strong>\n<br><\/br>\nShould you have any questions, comments or concerns, please bring them to the attention of our privacy officer Samantha Bath. We will be pleased to assist you. \n<br><\/br>\n<strong>Financial Policy and Agreement<\/strong>\n<br><\/br>\nThank you for choosing us for your dental needs. Our financial arrangements are based on an open and honest discussion of recommended treatment options, respective fees and patients\u2019 financial abilities. To confirm your understanding with our policies, please read the following. \n<br><\/br>\n<strong>Dental Treatment<\/strong>\n<br><\/br>\nDental treatment fees given are based on the treatments anticipated at the initial comprehensive examination. Some teeth may have hidden decay, fractures, affected nerves or other unanticipated conditions requiring more extensive dental treatments. In situations where additional charges are involved we will explain the reason for additional treatment and their respective fees prior to the services being rendered. \n<br><\/br>\n<strong>Dental Insurance<\/strong>\n<br><\/br>\nWe wish to stress that the financial responsibility for services rendered rests with the patient and his\/her family; regardless of any insurance coverage. Please understand that dental insurance is a contract between the patient and the insurance carrier, and not between the insurance carrier and the dentist. As a convenience to you, our office will submit charges to your insurance carrier. We urge you to be fully aware of the provisions of your policy since insurance coverage varies dramatically. <\/div><fieldset id=\"field_1_67\" class=\"gfield gfield--type-checkbox gfield--type-choice agreement gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Authorization and Release of Information<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_67'>I (patient, parent or guardian) certify that I have read and understand the above information to the best of my knowledge and that the dental and medical profiles I have provided are complete and accurate. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered during the period of such dental care to third party payers and or health practitioners for the purpose of administering claims. I authorize the release of information contained in claims to be submitted electronically to my insuring company plans administrator.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_67'><div class='gchoice gchoice_1_67_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.1' type='checkbox'  value='I accept'  id='choice_1_67_1'   aria-describedby=\"gfield_description_1_67\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_67_1' id='label_1_67_1' class='gform-field-label gform-field-label--type-inline'>I accept<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_68\" class=\"gfield gfield--type-checkbox gfield--type-choice agreement gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Payment Authorization<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_68'>As a benefit to our patients, our office offers no interest payment plans. Payment plans are not available on initial visits. Our payment plan structure is 35% of balance due on the date of service and the remaining balance split over three months\/or the remainder of treatment. A valid credit card is needed on file before treatment in order to proceed with a payment plan. A $50.00 NSF charge + 8.5% interest will be applied to your account if we are unable to process the payment. \n\nFinancial Consent :\n\nI am aware that any unpaid balances over 90 days without any financial arrangements in place are sent to a third party collection agency. \n\nI give permission for claims and pre-authorizations to be sent manually and\/or electronically to my insurance. \n\nI understand and agree, regardless of my insurance status, I am ultimately responsible for any unpaid balance on my account. <\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_68'><div class='gchoice gchoice_1_68_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.1' type='checkbox'  value='I accept'  id='choice_1_68_1'   aria-describedby=\"gfield_description_1_68\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_68_1' id='label_1_68_1' class='gform-field-label gform-field-label--type-inline'>I accept<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_69\" class=\"gfield gfield--type-checkbox gfield--type-choice agreement gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Short Notice Cancellation and No Show Policy:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_69'>Changes to existing dental appointments are accepted within 2 days\u2019 notice for Monday to Friday appointments and 3 days\u2019 notice for Saturday and Sunday appointments. When less notice is given, this may result in a deposit being required to pre-book any future appointments. Thank you for your understanding of our policy. This question is required. * <\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_69'><div class='gchoice gchoice_1_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='I accept'  id='choice_1_69_1'   aria-describedby=\"gfield_description_1_69\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_69_1' id='label_1_69_1' class='gform-field-label gform-field-label--type-inline'>I accept<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_65' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_65' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_9' class='gform_page' data-js='page-field-id-65' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_66\" class=\"gfield gfield--type-html heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Signature of Approval<\/h2><\/div><div id=\"field_1_70\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_70'>Print Patient\/Guardian Name<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_1_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_71\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_71'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><input type='hidden' value='' name='input_71' id='input_1_71_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_71_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_1_71' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/hytechdemo.com\/cdfold\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_71_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_1_71_resetbutton' 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