{"id":34,"date":"2026-09-25T17:21:58","date_gmt":"2026-09-25T17:21:58","guid":{"rendered":"https:\/\/signatureoms.wpenginepowered.com\/?page_id=34"},"modified":"2026-09-25T17:21:58","modified_gmt":"2026-09-25T17:21:58","slug":"patient-intake-form","status":"publish","type":"page","link":"https:\/\/signature-oms.com\/?page_id=34","title":{"rendered":"Online Patient Intake Form"},"content":{"rendered":"\n<p class=\"has-clinical-blue-color has-text-color has-jetbrains-mono-font-family wp-block-paragraph\" style=\"font-size:12px;font-style:normal;font-weight:600;letter-spacing:0.15em;text-transform:uppercase\">New Patient Registration<\/p>\n\n\n\n<h1 class=\"wp-block-heading has-primary-color has-text-color has-manrope-font-family\">Online Patient Intake Form<\/h1>\n\n\n\n<p class=\"has-on-surface-variant-color has-text-color wp-block-paragraph\" style=\"font-size:20px;line-height:1.6\">Please complete this form before your first visit to Signature Oral Surgery. It covers your contact and insurance details, health history, medications and our office policies, and takes about 15\u201320 minutes.<\/p>\n\n\n\n<div id=\"intake-pdf\" class=\"wp-block-group sos-pdf-card has-border-color has-procedures-bg-background-color has-background is-content-justification-space-between is-layout-flex wp-container-core-group-is-layout-f3dc8872 wp-block-group-is-layout-flex\" style=\"border-color:#E2E8F0;border-width:1px;border-radius:16px;margin-top:32px;margin-bottom:48px;padding-top:24px;padding-right:28px;padding-bottom:24px;padding-left:28px\">\n<p class=\"has-primary-color has-text-color wp-block-paragraph\" style=\"font-size:17px\"><strong>Prefer paper?<\/strong> Download a printable PDF of this form and bring it to your appointment.<\/p>\n\n\n\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button sos-pdf-download\"><a class=\"wp-block-button__link has-on-primary-color has-primary-background-color has-text-color has-background has-manrope-font-family has-custom-font-size wp-element-button\" href=\"#PDF-LINK-HERE\" style=\"border-radius:12px;font-size:12px;font-style:normal;font-weight:700;letter-spacing:0.05em;text-transform:uppercase\">Download PDF Version<\/a><\/div>\n<\/div>\n<\/div>\n\n\n<div class='fluentform ff-default fluentform_wrapper_3 ffs_default_wrap'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-top ff_form_instance_3_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Signature Oral Surgery \u2013 New Patient Intake Form<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='34' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"5b5f955e64\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F34\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_1\" ><h2>Demographic Information<\/h2><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_2\" ><h3 class='ff-el-section-title'>Patient Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Prefix\">Prefix<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='patient_prefix_0f57e1a7d4f27d92ca38e2a40033c18f'><input  type=\"radio\" name=\"patient_prefix\" data-name=\"patient_prefix\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mr.\"  id='patient_prefix_0f57e1a7d4f27d92ca38e2a40033c18f' aria-label='Mr.' aria-invalid='false' aria-required=false> <span>Mr.<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='patient_prefix_f5593b0178541a786b11577ba897d438'><input  type=\"radio\" name=\"patient_prefix\" data-name=\"patient_prefix\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mrs.\"  id='patient_prefix_f5593b0178541a786b11577ba897d438' aria-label='Mrs.' aria-invalid='false' aria-required=false> <span>Mrs.<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='patient_prefix_29de6f3de9d53b161fb1934cc9d18e57'><input  type=\"radio\" name=\"patient_prefix\" data-name=\"patient_prefix\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Ms.\"  id='patient_prefix_29de6f3de9d53b161fb1934cc9d18e57' aria-label='Ms.' aria-invalid='false' aria-required=false> <span>Ms.<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='patient_prefix_4a0c9d94376c5cce996d86fbde43b7e8'><input  type=\"radio\" name=\"patient_prefix\" data-name=\"patient_prefix\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Dr.\"  id='patient_prefix_4a0c9d94376c5cce996d86fbde43b7e8' aria-label='Dr.' aria-invalid='false' aria-required=false> <span>Dr.<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_patient_first_name' id='label_ff_3_patient_first_name' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_first_name\" data-name=\"patient_first_name\" class=\"ff-el-form-control\" id=\"ff_3_patient_first_name\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_middle_initial' id='label_ff_3_patient_middle_initial' aria-label=\"M.I.\">M.I.<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_middle_initial\" data-name=\"patient_middle_initial\" class=\"ff-el-form-control\" id=\"ff_3_patient_middle_initial\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_patient_last_name' id='label_ff_3_patient_last_name' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_last_name\" data-name=\"patient_last_name\" class=\"ff-el-form-control\" id=\"ff_3_patient_last_name\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_3\" ><p><em><strong>Please do not input special characters into your name, including hyphens.<\/strong><\/em><\/p><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_maiden_name' id='label_ff_3_patient_maiden_name' >Maiden Name (if applicable, e.g., previous patient)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_maiden_name\" data-name=\"patient_maiden_name\" class=\"ff-el-form-control\" id=\"ff_3_patient_maiden_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_patient_dob' id='label_ff_3_patient_dob' aria-label=\"Birth Date\">Birth Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Birth Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"patient_dob\" placeholder=\"MM\/DD\/YYYY\" data-name=\"patient_dob\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_3_patient_dob\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_age' id='label_ff_3_patient_age' aria-label=\"Age\">Age<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_age\" data-name=\"patient_age\" class=\"ff-el-form-control\" id=\"ff_3_patient_age\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_ssn' id='label_ff_3_patient_ssn' aria-label=\"Social Security Number\">Social Security Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_ssn\" placeholder=\"XXX-XX-XXXX\" data-mask=\"000-00-0000\" data-name=\"patient_ssn\" class=\"ff-el-form-control\" id=\"ff_3_patient_ssn\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Sex\">Sex<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='patient_sex_51970aeb0acc3ab27587e8061c72a3b9'><input  type=\"radio\" name=\"patient_sex\" data-name=\"patient_sex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Male\"  id='patient_sex_51970aeb0acc3ab27587e8061c72a3b9' aria-label='Male' aria-invalid='false' aria-required=false> <span>Male<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='patient_sex_0595ba7e8df25aaea9ce25235ff77c52'><input  type=\"radio\" name=\"patient_sex\" data-name=\"patient_sex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Female\"  id='patient_sex_0595ba7e8df25aaea9ce25235ff77c52' aria-label='Female' aria-invalid='false' aria-required=false> <span>Female<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='patient_sex_3c43db863bf335c19029194171b1c371'><input  type=\"radio\" name=\"patient_sex\" data-name=\"patient_sex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Decline to say\"  id='patient_sex_3c43db863bf335c19029194171b1c371' aria-label='Decline to say' aria-invalid='false' aria-required=false> <span>Decline to say<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_street' id='label_ff_3_patient_street' aria-label=\"Mailing Address\">Mailing Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_street\" data-name=\"patient_street\" class=\"ff-el-form-control\" id=\"ff_3_patient_street\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_apt' id='label_ff_3_patient_apt' aria-label=\"Apt.\">Apt.<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_apt\" data-name=\"patient_apt\" class=\"ff-el-form-control\" id=\"ff_3_patient_apt\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_city' id='label_ff_3_patient_city' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_city\" data-name=\"patient_city\" class=\"ff-el-form-control\" id=\"ff_3_patient_city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_state' id='label_ff_3_patient_state' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_state\" data-name=\"patient_state\" class=\"ff-el-form-control\" id=\"ff_3_patient_state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_zip' id='label_ff_3_patient_zip' aria-label=\"ZIP Code\">ZIP Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_zip\" data-mask=\"00000\" data-name=\"patient_zip\" class=\"ff-el-form-control\" id=\"ff_3_patient_zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_dl_number' id='label_ff_3_patient_dl_number' aria-label=\"Driver\u2019s License Number\">Driver\u2019s License Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_dl_number\" data-name=\"patient_dl_number\" class=\"ff-el-form-control\" id=\"ff_3_patient_dl_number\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_dl_state' id='label_ff_3_patient_dl_state' aria-label=\"Issuing State\">Issuing State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_dl_state\" data-name=\"patient_dl_state\" class=\"ff-el-form-control\" id=\"ff_3_patient_dl_state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_email' id='label_ff_3_patient_email' aria-label=\"E-mail Address\">E-mail Address<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"patient_email\" placeholder=\"name@example.com\" data-name=\"patient_email\" class=\"ff-el-form-control\" id=\"ff_3_patient_email\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_phone_primary' id='label_ff_3_patient_phone_primary' aria-label=\"Primary Phone\">Primary Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_phone_primary\" placeholder=\"(555) 555-5555\" data-mask=\"(000) 000-0000\" data-name=\"patient_phone_primary\" class=\"ff-el-form-control\" id=\"ff_3_patient_phone_primary\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"May we send text messages to this phone?\">May we send text messages to this phone?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='patient_phone_primary_sms_d849efc8047193b2ce098e883d29016e'><input  type=\"radio\" name=\"patient_phone_primary_sms\" data-name=\"patient_phone_primary_sms\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='patient_phone_primary_sms_d849efc8047193b2ce098e883d29016e' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='patient_phone_primary_sms_005f55c3acbe4494fecdb509a21250d0'><input  type=\"radio\" name=\"patient_phone_primary_sms\" data-name=\"patient_phone_primary_sms\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='patient_phone_primary_sms_005f55c3acbe4494fecdb509a21250d0' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_phone_secondary' id='label_ff_3_patient_phone_secondary' aria-label=\"Secondary Phone\">Secondary Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_phone_secondary\" placeholder=\"(555) 555-5555\" data-mask=\"(000) 000-0000\" data-name=\"patient_phone_secondary\" class=\"ff-el-form-control\" id=\"ff_3_patient_phone_secondary\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"May we send text messages to this phone?\">May we send text messages to this phone?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='patient_phone_secondary_sms_683e5e52d1ea1ebb4cf5ced4e3589019'><input  type=\"radio\" name=\"patient_phone_secondary_sms\" data-name=\"patient_phone_secondary_sms\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='patient_phone_secondary_sms_683e5e52d1ea1ebb4cf5ced4e3589019' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='patient_phone_secondary_sms_b42c121c0de5eba1e820ea9d30d807b3'><input  type=\"radio\" name=\"patient_phone_secondary_sms\" data-name=\"patient_phone_secondary_sms\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='patient_phone_secondary_sms_b42c121c0de5eba1e820ea9d30d807b3' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Were you referred to our practice by your dentist?\">Were you referred to our practice by your dentist?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='referred_by_dentist_fa7348e5ddcb957e259ea4faf76e5510'><input  type=\"radio\" name=\"referred_by_dentist\" data-name=\"referred_by_dentist\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='referred_by_dentist_fa7348e5ddcb957e259ea4faf76e5510' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='referred_by_dentist_0096a8afb28cb658eaf49cf51b3d499a'><input  type=\"radio\" name=\"referred_by_dentist\" data-name=\"referred_by_dentist\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='referred_by_dentist_0096a8afb28cb658eaf49cf51b3d499a' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If no, how did you hear about us?\">If no, how did you hear about us?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='heard_about_us_5fbc3e9684b6a9525db50958fb33eb12'><input  type=\"radio\" name=\"heard_about_us\" data-name=\"heard_about_us\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Medical Doctor\"  id='heard_about_us_5fbc3e9684b6a9525db50958fb33eb12' aria-label='Medical Doctor' aria-invalid='false' aria-required=false> <span>Medical Doctor<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='heard_about_us_39402ea2756ebe6402e76a81adf96bd5'><input  type=\"radio\" name=\"heard_about_us\" data-name=\"heard_about_us\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other Dental Specialist\"  id='heard_about_us_39402ea2756ebe6402e76a81adf96bd5' aria-label='Other Dental Specialist' aria-invalid='false' aria-required=false> <span>Other Dental Specialist<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='heard_about_us_56c7da5367dee84e9d6c008144a924a6'><input  type=\"radio\" name=\"heard_about_us\" data-name=\"heard_about_us\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Family Member\"  id='heard_about_us_56c7da5367dee84e9d6c008144a924a6' aria-label='Family Member' aria-invalid='false' aria-required=false> <span>Family Member<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='heard_about_us_473b78bfb986242ca92fbebd49e15cc3'><input  type=\"radio\" name=\"heard_about_us\" data-name=\"heard_about_us\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Friend\"  id='heard_about_us_473b78bfb986242ca92fbebd49e15cc3' aria-label='Friend' aria-invalid='false' aria-required=false> <span>Friend<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='heard_about_us_07ac3612e0b1e9d96d854c661464b518'><input  type=\"radio\" name=\"heard_about_us\" data-name=\"heard_about_us\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Social Media\"  id='heard_about_us_07ac3612e0b1e9d96d854c661464b518' aria-label='Social Media' aria-invalid='false' aria-required=false> <span>Social Media<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='heard_about_us_8510eb58884f3243965ab54cb67dc84d'><input  type=\"radio\" name=\"heard_about_us\" data-name=\"heard_about_us\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Advertising\"  id='heard_about_us_8510eb58884f3243965ab54cb67dc84d' aria-label='Advertising' aria-invalid='false' aria-required=false> <span>Advertising<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='heard_about_us_89a1cf54177637749d8c1cbc1100ab4c'><input  type=\"radio\" name=\"heard_about_us\" data-name=\"heard_about_us\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other\"  id='heard_about_us_89a1cf54177637749d8c1cbc1100ab4c' aria-label='Other' aria-invalid='false' aria-required=false> <span>Other<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_heard_about_us_other' id='label_ff_3_heard_about_us_other' aria-label=\"If other, please specify\">If other, please specify<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"heard_about_us_other\" data-name=\"heard_about_us_other\" class=\"ff-el-form-control\" id=\"ff_3_heard_about_us_other\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Have you ever been a patient of our practice?\">Have you ever been a patient of our practice?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='former_patient_54214746edf112d53b987ddc14981ad3'><input  type=\"radio\" name=\"former_patient\" data-name=\"former_patient\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='former_patient_54214746edf112d53b987ddc14981ad3' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='former_patient_0ee7c71806c848cafc2bdfb15d95e6e6'><input  type=\"radio\" name=\"former_patient\" data-name=\"former_patient\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='former_patient_0ee7c71806c848cafc2bdfb15d95e6e6' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_former_patient_when' id='label_ff_3_former_patient_when' aria-label=\"If yes, approximately when?\">If yes, approximately when?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"former_patient_when\" data-name=\"former_patient_when\" class=\"ff-el-form-control\" id=\"ff_3_former_patient_when\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dentist_first' id='label_ff_3_dentist_first' aria-label=\"Dentist First Name\">Dentist First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dentist_first\" data-name=\"dentist_first\" class=\"ff-el-form-control\" id=\"ff_3_dentist_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dentist_last' id='label_ff_3_dentist_last' aria-label=\"Dentist Last Name\">Dentist Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dentist_last\" data-name=\"dentist_last\" class=\"ff-el-form-control\" id=\"ff_3_dentist_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dentist_city' id='label_ff_3_dentist_city' aria-label=\"Dentist Office City\">Dentist Office City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dentist_city\" data-name=\"dentist_city\" class=\"ff-el-form-control\" id=\"ff_3_dentist_city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dentist_phone' id='label_ff_3_dentist_phone' aria-label=\"Dentist Phone\">Dentist Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dentist_phone\" placeholder=\"(555) 555-5555\" data-mask=\"(000) 000-0000\" data-name=\"dentist_phone\" class=\"ff-el-form-control\" id=\"ff_3_dentist_phone\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dentist_last_visit' id='label_ff_3_dentist_last_visit' aria-label=\"When were you last there?\">When were you last there?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dentist_last_visit\" data-name=\"dentist_last_visit\" class=\"ff-el-form-control\" id=\"ff_3_dentist_last_visit\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_md_first' id='label_ff_3_md_first' aria-label=\"Medical Doctor First Name\">Medical Doctor First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"md_first\" data-name=\"md_first\" class=\"ff-el-form-control\" id=\"ff_3_md_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_md_last' id='label_ff_3_md_last' aria-label=\"Medical Doctor Last Name\">Medical Doctor Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"md_last\" data-name=\"md_last\" class=\"ff-el-form-control\" id=\"ff_3_md_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_md_city' id='label_ff_3_md_city' aria-label=\"Medical Doctor Office City\">Medical Doctor Office City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"md_city\" data-name=\"md_city\" class=\"ff-el-form-control\" id=\"ff_3_md_city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_md_phone' id='label_ff_3_md_phone' aria-label=\"Medical Doctor Phone\">Medical Doctor Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"md_phone\" placeholder=\"(555) 555-5555\" data-mask=\"(000) 000-0000\" data-name=\"md_phone\" class=\"ff-el-form-control\" id=\"ff_3_md_phone\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_md_last_visit' id='label_ff_3_md_last_visit' aria-label=\"When were you last there?\">When were you last there?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"md_last_visit\" data-name=\"md_last_visit\" class=\"ff-el-form-control\" id=\"ff_3_md_last_visit\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_pharmacy_name' id='label_ff_3_pharmacy_name' >Preferred Pharmacy<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"pharmacy_name\" data-name=\"pharmacy_name\" class=\"ff-el-form-control\" id=\"ff_3_pharmacy_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_pharmacy_phone' id='label_ff_3_pharmacy_phone' aria-label=\"Pharmacy Phone\">Pharmacy Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"pharmacy_phone\" placeholder=\"(555) 555-5555\" data-mask=\"(000) 000-0000\" data-name=\"pharmacy_phone\" class=\"ff-el-form-control\" id=\"ff_3_pharmacy_phone\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_pharmacy_street' id='label_ff_3_pharmacy_street' aria-label=\"Pharmacy Street\">Pharmacy Street<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"pharmacy_street\" data-name=\"pharmacy_street\" class=\"ff-el-form-control\" id=\"ff_3_pharmacy_street\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_pharmacy_city' id='label_ff_3_pharmacy_city' aria-label=\"Pharmacy City\">Pharmacy City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"pharmacy_city\" data-name=\"pharmacy_city\" class=\"ff-el-form-control\" id=\"ff_3_pharmacy_city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_employer' id='label_ff_3_patient_employer' aria-label=\"Employer \/ Business Name\">Employer \/ Business Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_employer\" data-name=\"patient_employer\" class=\"ff-el-form-control\" id=\"ff_3_patient_employer\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_patient_work_phone' id='label_ff_3_patient_work_phone' aria-label=\"Business Phone\">Business Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patient_work_phone\" placeholder=\"(555) 555-5555\" data-mask=\"(000) 000-0000\" data-name=\"patient_work_phone\" class=\"ff-el-form-control\" id=\"ff_3_patient_work_phone\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Does the patient have a legal guardian?\">Does the patient have a legal guardian?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='has_legal_guardian_c933e30fab0cdcd29ba40150d0b748c8'><input  type=\"radio\" name=\"has_legal_guardian\" data-name=\"has_legal_guardian\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='has_legal_guardian_c933e30fab0cdcd29ba40150d0b748c8' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='has_legal_guardian_33475c3de624fccfd316534952128744'><input  type=\"radio\" name=\"has_legal_guardian\" data-name=\"has_legal_guardian\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='has_legal_guardian_33475c3de624fccfd316534952128744' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_15\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_guardian_first' id='label_ff_3_guardian_first' aria-label=\"Guardian First Name\">Guardian First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"guardian_first\" data-name=\"guardian_first\" class=\"ff-el-form-control\" id=\"ff_3_guardian_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_guardian_last' id='label_ff_3_guardian_last' aria-label=\"Guardian Last Name\">Guardian Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"guardian_last\" data-name=\"guardian_last\" class=\"ff-el-form-control\" id=\"ff_3_guardian_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Does the patient require an interpreter?\">Does the patient require an interpreter?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='interpreter_required_a2280931dfc34359bbfb5883029301a5'><input  type=\"radio\" name=\"interpreter_required\" data-name=\"interpreter_required\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='interpreter_required_a2280931dfc34359bbfb5883029301a5' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='interpreter_required_5ad314cad7694f84f02489ab5eb338f5'><input  type=\"radio\" name=\"interpreter_required\" data-name=\"interpreter_required\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='interpreter_required_5ad314cad7694f84f02489ab5eb338f5' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_16\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_interpreter_language' id='label_ff_3_interpreter_language' aria-label=\"If yes, what language?\">If yes, what language?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"interpreter_language\" data-name=\"interpreter_language\" class=\"ff-el-form-control\" id=\"ff_3_interpreter_language\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Interpreter\">Interpreter<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='interpreter_bring_own_85a3f13e81e982c229e55ed46895f17e'><input  type=\"checkbox\" name=\"interpreter_bring_own[]\" data-name=\"interpreter_bring_own\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Patient will bring their own interpreter\"  id='interpreter_bring_own_85a3f13e81e982c229e55ed46895f17e' aria-label='Patient will bring their own interpreter' aria-invalid='false' aria-required=false> <span>Patient will bring their own interpreter<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_4\" ><h3 class='ff-el-section-title'>Emergency Contact<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_emergency_name' id='label_ff_3_emergency_name' >Please Contact<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"emergency_name\" data-name=\"emergency_name\" class=\"ff-el-form-control\" id=\"ff_3_emergency_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_17\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_emergency_phone' id='label_ff_3_emergency_phone' aria-label=\"Phone\">Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"emergency_phone\" placeholder=\"(555) 555-5555\" data-mask=\"(000) 000-0000\" data-name=\"emergency_phone\" class=\"ff-el-form-control\" id=\"ff_3_emergency_phone\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_emergency_relation' id='label_ff_3_emergency_relation' aria-label=\"Relation to Patient\">Relation to Patient<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"emergency_relation\" data-name=\"emergency_relation\" class=\"ff-el-form-control\" id=\"ff_3_emergency_relation\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_5\" ><h3 class='ff-el-section-title'>Who will be responsible for your account?<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Who will be responsible for your account?\">Who will be responsible for your account?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='guarantor_27438a1564ffdbf531983e8b5a87fce1'><input  type=\"radio\" name=\"guarantor\" data-name=\"guarantor\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Self\"  id='guarantor_27438a1564ffdbf531983e8b5a87fce1' aria-label='Self' aria-invalid='false' aria-required=false> <span>Self<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='guarantor_765e3359ab135be12a44002b7a2ff737'><input  type=\"radio\" name=\"guarantor\" data-name=\"guarantor\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Spouse\"  id='guarantor_765e3359ab135be12a44002b7a2ff737' aria-label='Spouse' aria-invalid='false' aria-required=false> <span>Spouse<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='guarantor_3a38a8fc1e029ec7177061b457c41037'><input  type=\"radio\" name=\"guarantor\" data-name=\"guarantor\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Father\"  id='guarantor_3a38a8fc1e029ec7177061b457c41037' aria-label='Father' aria-invalid='false' aria-required=false> <span>Father<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='guarantor_8cd8f394b46a2160d6924ef6f3cb51e6'><input  type=\"radio\" name=\"guarantor\" data-name=\"guarantor\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mother\"  id='guarantor_8cd8f394b46a2160d6924ef6f3cb51e6' aria-label='Mother' aria-invalid='false' aria-required=false> <span>Mother<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='guarantor_8874b3ca24cbb184993b5e2cbd671151'><input  type=\"radio\" name=\"guarantor\" data-name=\"guarantor\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Legal Guardian\"  id='guarantor_8874b3ca24cbb184993b5e2cbd671151' aria-label='Legal Guardian' aria-invalid='false' aria-required=false> <span>Legal Guardian<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='guarantor_fbf7f62d177596fecbe6cde5b85d20f3'><input  type=\"radio\" name=\"guarantor\" data-name=\"guarantor\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other\"  id='guarantor_fbf7f62d177596fecbe6cde5b85d20f3' aria-label='Other' aria-invalid='false' aria-required=false> <span>Other<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_guarantor_guardian_name' id='label_ff_3_guarantor_guardian_name' >Legal Guardian\u2019s Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"guarantor_guardian_name\" data-name=\"guarantor_guardian_name\" class=\"ff-el-form-control\" id=\"ff_3_guarantor_guardian_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_guarantor_other_desc' id='label_ff_3_guarantor_other_desc' aria-label=\"Other \u2014 please describe\">Other \u2014 please describe<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"guarantor_other_desc\" data-name=\"guarantor_other_desc\" class=\"ff-el-form-control\" id=\"ff_3_guarantor_other_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_18\"  class='ff-t-container ff-column-container ff_columns_total_3 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_first' id='label_ff_3_rp_first' aria-label=\"First Name\">First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"rp_first\" data-name=\"rp_first\" class=\"ff-el-form-control\" id=\"ff_3_rp_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_mi' id='label_ff_3_rp_mi' aria-label=\"M.I.\">M.I.<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"rp_mi\" data-name=\"rp_mi\" class=\"ff-el-form-control\" id=\"ff_3_rp_mi\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_last' id='label_ff_3_rp_last' aria-label=\"Last Name\">Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"rp_last\" data-name=\"rp_last\" class=\"ff-el-form-control\" id=\"ff_3_rp_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_19\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_dob' id='label_ff_3_rp_dob' aria-label=\"Birth Date\">Birth Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Birth Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"rp_dob\" placeholder=\"MM\/DD\/YYYY\" data-name=\"rp_dob\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_3_rp_dob\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_ssn' id='label_ff_3_rp_ssn' aria-label=\"Social Security Number\">Social Security Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"rp_ssn\" placeholder=\"XXX-XX-XXXX\" data-mask=\"000-00-0000\" data-name=\"rp_ssn\" class=\"ff-el-form-control\" id=\"ff_3_rp_ssn\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_email' id='label_ff_3_rp_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"rp_email\" placeholder=\"name@example.com\" data-name=\"rp_email\" class=\"ff-el-form-control\" id=\"ff_3_rp_email\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_20\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_street' id='label_ff_3_rp_street' aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"rp_street\" data-name=\"rp_street\" class=\"ff-el-form-control\" id=\"ff_3_rp_street\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_apt' id='label_ff_3_rp_apt' aria-label=\"Apt.\">Apt.<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"rp_apt\" data-name=\"rp_apt\" class=\"ff-el-form-control\" id=\"ff_3_rp_apt\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_21\"  class='ff-t-container ff-column-container ff_columns_total_3 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_city' id='label_ff_3_rp_city' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"rp_city\" data-name=\"rp_city\" class=\"ff-el-form-control\" id=\"ff_3_rp_city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_state' id='label_ff_3_rp_state' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"rp_state\" data-name=\"rp_state\" class=\"ff-el-form-control\" id=\"ff_3_rp_state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_zip' id='label_ff_3_rp_zip' aria-label=\"ZIP Code\">ZIP Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"rp_zip\" data-mask=\"00000\" data-name=\"rp_zip\" class=\"ff-el-form-control\" id=\"ff_3_rp_zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_phone' id='label_ff_3_rp_phone' aria-label=\"Responsible Party\u2019s Phone\">Responsible Party\u2019s Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"rp_phone\" placeholder=\"(555) 555-5555\" data-mask=\"(000) 000-0000\" data-name=\"rp_phone\" class=\"ff-el-form-control\" id=\"ff_3_rp_phone\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rp_employer' id='label_ff_3_rp_employer' aria-label=\"Employer\">Employer<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"rp_employer\" data-name=\"rp_employer\" class=\"ff-el-form-control\" id=\"ff_3_rp_employer\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_6\" ><h3 class='ff-el-section-title'>Is this related to an accident?<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Is this visit related to an accident?\">Is this visit related to an accident?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='accident_related_bfd956e7e40c969320b323ac328d6144'><input  type=\"radio\" name=\"accident_related\" data-name=\"accident_related\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='accident_related_bfd956e7e40c969320b323ac328d6144' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='accident_related_2393931a8bfcf670328e5955f339d6b3'><input  type=\"radio\" name=\"accident_related\" data-name=\"accident_related\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='accident_related_2393931a8bfcf670328e5955f339d6b3' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, indicate type of accident\">If yes, indicate type of accident<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='accident_type_b6b46598166aece4470d0fe6303aecc9'><input  type=\"checkbox\" name=\"accident_type[]\" data-name=\"accident_type\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Automobile\"  id='accident_type_b6b46598166aece4470d0fe6303aecc9' aria-label='Automobile' aria-invalid='false' aria-required=false> <span>Automobile<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='accident_type_18e36657872916e9cf9c37b14566ac0f'><input  type=\"checkbox\" name=\"accident_type[]\" data-name=\"accident_type\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Work related\"  id='accident_type_18e36657872916e9cf9c37b14566ac0f' aria-label='Work related' aria-invalid='false' aria-required=false> <span>Work related<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='accident_type_a5e8b1c24bc662bcb542c2ab7694628d'><input  type=\"checkbox\" name=\"accident_type[]\" data-name=\"accident_type\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Other\"  id='accident_type_a5e8b1c24bc662bcb542c2ab7694628d' aria-label='Other' aria-invalid='false' aria-required=false> <span>Other<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_accident_other_desc' id='label_ff_3_accident_other_desc' aria-label=\"If other, please specify\">If other, please specify<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"accident_other_desc\" data-name=\"accident_other_desc\" class=\"ff-el-form-control\" id=\"ff_3_accident_other_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_injury_date' id='label_ff_3_injury_date' aria-label=\"Date of Injury\">Date of Injury<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of Injury Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"injury_date\" placeholder=\"MM\/DD\/YYYY\" data-name=\"injury_date\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_3_injury_date\"  aria-invalid='false' aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_22\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_injury_ins_company' id='label_ff_3_injury_ins_company' aria-label=\"Insurance company handling this claim\">Insurance company handling this claim<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"injury_ins_company\" data-name=\"injury_ins_company\" class=\"ff-el-form-control\" id=\"ff_3_injury_ins_company\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_injury_claim_number' id='label_ff_3_injury_claim_number' aria-label=\"Insurance Claim Number\">Insurance Claim Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"injury_claim_number\" data-name=\"injury_claim_number\" class=\"ff-el-form-control\" id=\"ff_3_injury_claim_number\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_23\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_injury_attorney' id='label_ff_3_injury_attorney' aria-label=\"Name of Attorney \/ Adjustor\">Name of Attorney \/ Adjustor<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"injury_attorney\" data-name=\"injury_attorney\" class=\"ff-el-form-control\" id=\"ff_3_injury_attorney\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_injury_attorney_phone' id='label_ff_3_injury_attorney_phone' aria-label=\"Attorney \/ Adjustor Phone\">Attorney \/ Adjustor Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"injury_attorney_phone\" placeholder=\"(555) 555-5555\" data-mask=\"(000) 000-0000\" data-name=\"injury_attorney_phone\" class=\"ff-el-form-control\" id=\"ff_3_injury_attorney_phone\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_7\" ><h2>Insurance Information<\/h2><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_8\" ><h3 class='ff-el-section-title'>General Insurance Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Please select one\">Please select one<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='has_insurance_dfce1bb8863d6f9e6c15c499377b9ad2'><input  type=\"radio\" name=\"has_insurance\" data-name=\"has_insurance\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, there is insurance.\"  id='has_insurance_dfce1bb8863d6f9e6c15c499377b9ad2' aria-label='Yes, there is insurance.' aria-invalid='false' aria-required=false> <span>Yes, there is insurance.<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='has_insurance_c82daf02ee691b96a220d3759d6261f6'><input  type=\"radio\" name=\"has_insurance\" data-name=\"has_insurance\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"NO INSURANCE\"  id='has_insurance_c82daf02ee691b96a220d3759d6261f6' aria-label='NO INSURANCE' aria-invalid='false' aria-required=false> <span>NO INSURANCE<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Student\">Student<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='student_status_bc20de4f2cad3802a2f44e945491fc52'><input  type=\"radio\" name=\"student_status\" data-name=\"student_status\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Full-time\"  id='student_status_bc20de4f2cad3802a2f44e945491fc52' aria-label='Full-time' aria-invalid='false' aria-required=false> <span>Full-time<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='student_status_f1aa900e1fc1aa86ede736cf2598a25d'><input  type=\"radio\" name=\"student_status\" data-name=\"student_status\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Part-time\"  id='student_status_f1aa900e1fc1aa86ede736cf2598a25d' aria-label='Part-time' aria-invalid='false' aria-required=false> <span>Part-time<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='student_status_3e345b8b81bc1d99ee85c91ec171a3a4'><input  type=\"radio\" name=\"student_status\" data-name=\"student_status\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not a student\"  id='student_status_3e345b8b81bc1d99ee85c91ec171a3a4' aria-label='Not a student' aria-invalid='false' aria-required=false> <span>Not a student<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Marital Status\">Marital Status<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='marital_status_9d1a592a24db5ed5b01b598e1b11791e'><input  type=\"radio\" name=\"marital_status\" data-name=\"marital_status\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Married\"  id='marital_status_9d1a592a24db5ed5b01b598e1b11791e' aria-label='Married' aria-invalid='false' aria-required=false> <span>Married<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='marital_status_aff8f736537600690fcfbb8a6d891da6'><input  type=\"radio\" name=\"marital_status\" data-name=\"marital_status\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Divorced\"  id='marital_status_aff8f736537600690fcfbb8a6d891da6' aria-label='Divorced' aria-invalid='false' aria-required=false> <span>Divorced<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='marital_status_587f0c510964fb13cd94936946a4a0d8'><input  type=\"radio\" name=\"marital_status\" data-name=\"marital_status\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Widow\"  id='marital_status_587f0c510964fb13cd94936946a4a0d8' aria-label='Widow' aria-invalid='false' aria-required=false> <span>Widow<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='marital_status_bcfcadd168a7038305ebf08fd0a4b0e2'><input  type=\"radio\" name=\"marital_status\" data-name=\"marital_status\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Single\"  id='marital_status_bcfcadd168a7038305ebf08fd0a4b0e2' aria-label='Single' aria-invalid='false' aria-required=false> <span>Single<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='marital_status_49860a48fbb666cebadbd8991c4504c4'><input  type=\"radio\" name=\"marital_status\" data-name=\"marital_status\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Legally Separated\"  id='marital_status_49860a48fbb666cebadbd8991c4504c4' aria-label='Legally Separated' aria-invalid='false' aria-required=false> <span>Legally Separated<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Employed\">Employed<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='employment_status_5d4fd7fcc9181fd4548d43dc1010cf70'><input  type=\"radio\" name=\"employment_status\" data-name=\"employment_status\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Full Time\"  id='employment_status_5d4fd7fcc9181fd4548d43dc1010cf70' aria-label='Full Time' aria-invalid='false' aria-required=false> <span>Full Time<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='employment_status_b30ddb3a1af0586528e9f86659a4ec48'><input  type=\"radio\" name=\"employment_status\" data-name=\"employment_status\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Part Time\"  id='employment_status_b30ddb3a1af0586528e9f86659a4ec48' aria-label='Part Time' aria-invalid='false' aria-required=false> <span>Part Time<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='employment_status_78ea8a2202bffe396597a4f56d2b801f'><input  type=\"radio\" name=\"employment_status\" data-name=\"employment_status\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Retired\"  id='employment_status_78ea8a2202bffe396597a4f56d2b801f' aria-label='Retired' aria-invalid='false' aria-required=false> <span>Retired<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='employment_status_8a70461fad79d4c2eb8fe2859aa63781'><input  type=\"radio\" name=\"employment_status\" data-name=\"employment_status\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not employed\"  id='employment_status_8a70461fad79d4c2eb8fe2859aa63781' aria-label='Not employed' aria-invalid='false' aria-required=false> <span>Not employed<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group  has-conditions ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_9\" ><h3 class='ff-el-section-title'>Primary Dental Insurance Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental1_none_d5f04ec9481b12121ca3275d0deee41d'><input  type=\"checkbox\" name=\"dental1_none[]\" data-name=\"dental1_none\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"NONE\"  id='dental1_none_d5f04ec9481b12121ca3275d0deee41d' aria-label='NONE' aria-invalid='false' aria-required=false> <span>NONE<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_company' id='label_ff_3_dental1_company' aria-label=\"Insurance Company Name\">Insurance Company Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental1_company\" data-name=\"dental1_company\" class=\"ff-el-form-control\" id=\"ff_3_dental1_company\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_24\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_policy_id' id='label_ff_3_dental1_policy_id' aria-label=\"Policy I.D. Number\">Policy I.D. Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental1_policy_id\" data-name=\"dental1_policy_id\" class=\"ff-el-form-control\" id=\"ff_3_dental1_policy_id\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_group' id='label_ff_3_dental1_group' aria-label=\"Group Number\">Group Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental1_group\" data-name=\"dental1_group\" class=\"ff-el-form-control\" id=\"ff_3_dental1_group\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_employer' id='label_ff_3_dental1_employer' aria-label=\"Employer \/ Business\">Employer \/ Business<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental1_employer\" data-name=\"dental1_employer\" class=\"ff-el-form-control\" id=\"ff_3_dental1_employer\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Subscriber\">Subscriber<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental1_subscriber_2a8d439632bece1c2ddcbc9ef7f6539e'><input  type=\"radio\" name=\"dental1_subscriber\" data-name=\"dental1_subscriber\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Self\"  id='dental1_subscriber_2a8d439632bece1c2ddcbc9ef7f6539e' aria-label='Self' aria-invalid='false' aria-required=false> <span>Self<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental1_subscriber_47c27dd22fde504532154bf7d712200d'><input  type=\"radio\" name=\"dental1_subscriber\" data-name=\"dental1_subscriber\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Non-Self (please complete subscriber information)\"  id='dental1_subscriber_47c27dd22fde504532154bf7d712200d' aria-label='Non-Self (please complete subscriber information)' aria-invalid='false' aria-required=false> <span>Non-Self (please complete subscriber information)<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_25\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_sub_first' id='label_ff_3_dental1_sub_first' aria-label=\"Subscriber\u2019s First Name\">Subscriber\u2019s First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental1_sub_first\" data-name=\"dental1_sub_first\" class=\"ff-el-form-control\" id=\"ff_3_dental1_sub_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_sub_last' id='label_ff_3_dental1_sub_last' aria-label=\"Subscriber\u2019s Last Name\">Subscriber\u2019s Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental1_sub_last\" data-name=\"dental1_sub_last\" class=\"ff-el-form-control\" id=\"ff_3_dental1_sub_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_26\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_sub_relation' id='label_ff_3_dental1_sub_relation' aria-label=\"Relation\">Relation<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental1_sub_relation\" data-name=\"dental1_sub_relation\" class=\"ff-el-form-control\" id=\"ff_3_dental1_sub_relation\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_sub_dob' id='label_ff_3_dental1_sub_dob' aria-label=\"Subscriber Birth Date\">Subscriber Birth Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Subscriber Birth Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"dental1_sub_dob\" placeholder=\"MM\/DD\/YYYY\" data-name=\"dental1_sub_dob\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_3_dental1_sub_dob\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Subscriber Sex\">Subscriber Sex<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental1_sub_sex_f0c22f7ea297489033f35c883b324c8f'><input  type=\"radio\" name=\"dental1_sub_sex\" data-name=\"dental1_sub_sex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Male\"  id='dental1_sub_sex_f0c22f7ea297489033f35c883b324c8f' aria-label='Male' aria-invalid='false' aria-required=false> <span>Male<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental1_sub_sex_4152789b2a976893c4023e1430189d34'><input  type=\"radio\" name=\"dental1_sub_sex\" data-name=\"dental1_sub_sex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Female\"  id='dental1_sub_sex_4152789b2a976893c4023e1430189d34' aria-label='Female' aria-invalid='false' aria-required=false> <span>Female<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_sub_ssn' id='label_ff_3_dental1_sub_ssn' aria-label=\"Subscriber S.S. #\">Subscriber S.S. #<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental1_sub_ssn\" placeholder=\"XXX-XX-XXXX\" data-mask=\"000-00-0000\" data-name=\"dental1_sub_ssn\" class=\"ff-el-form-control\" id=\"ff_3_dental1_sub_ssn\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Subscriber Address\">Subscriber Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental1_sub_address_6281619036da736c15110aa92f92af60'><input  type=\"radio\" name=\"dental1_sub_address\" data-name=\"dental1_sub_address\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Same\"  id='dental1_sub_address_6281619036da736c15110aa92f92af60' aria-label='Same' aria-invalid='false' aria-required=false> <span>Same<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental1_sub_address_ba04134d2466f8f9ddd7f4853847f8cd'><input  type=\"radio\" name=\"dental1_sub_address\" data-name=\"dental1_sub_address\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Different\"  id='dental1_sub_address_ba04134d2466f8f9ddd7f4853847f8cd' aria-label='Different' aria-invalid='false' aria-required=false> <span>Different<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_sub_street' id='label_ff_3_dental1_sub_street' aria-label=\"Street Address\">Street Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental1_sub_street\" data-name=\"dental1_sub_street\" class=\"ff-el-form-control\" id=\"ff_3_dental1_sub_street\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_27\"  class='ff-t-container ff-column-container ff_columns_total_3 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_sub_city' id='label_ff_3_dental1_sub_city' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental1_sub_city\" data-name=\"dental1_sub_city\" class=\"ff-el-form-control\" id=\"ff_3_dental1_sub_city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_sub_state' id='label_ff_3_dental1_sub_state' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental1_sub_state\" data-name=\"dental1_sub_state\" class=\"ff-el-form-control\" id=\"ff_3_dental1_sub_state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental1_sub_zip' id='label_ff_3_dental1_sub_zip' aria-label=\"ZIP Code\">ZIP Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental1_sub_zip\" data-mask=\"00000\" data-name=\"dental1_sub_zip\" class=\"ff-el-form-control\" id=\"ff_3_dental1_sub_zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group  has-conditions ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_10\" ><h3 class='ff-el-section-title'>Primary Medical Insurance Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical1_none_5470b8995d72527a41dc1d7564c4924e'><input  type=\"checkbox\" name=\"medical1_none[]\" data-name=\"medical1_none\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"NONE\"  id='medical1_none_5470b8995d72527a41dc1d7564c4924e' aria-label='NONE' aria-invalid='false' aria-required=false> <span>NONE<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_company' id='label_ff_3_medical1_company' aria-label=\"Insurance Company Name\">Insurance Company Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical1_company\" data-name=\"medical1_company\" class=\"ff-el-form-control\" id=\"ff_3_medical1_company\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_28\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_policy_id' id='label_ff_3_medical1_policy_id' aria-label=\"Policy I.D. Number\">Policy I.D. Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical1_policy_id\" data-name=\"medical1_policy_id\" class=\"ff-el-form-control\" id=\"ff_3_medical1_policy_id\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_group' id='label_ff_3_medical1_group' aria-label=\"Group Number\">Group Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical1_group\" data-name=\"medical1_group\" class=\"ff-el-form-control\" id=\"ff_3_medical1_group\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_employer' id='label_ff_3_medical1_employer' aria-label=\"Employer \/ Business\">Employer \/ Business<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical1_employer\" data-name=\"medical1_employer\" class=\"ff-el-form-control\" id=\"ff_3_medical1_employer\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Subscriber\">Subscriber<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical1_subscriber_d4c3b7e24f41a6e58f8bf56321feccfa'><input  type=\"radio\" name=\"medical1_subscriber\" data-name=\"medical1_subscriber\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Self\"  id='medical1_subscriber_d4c3b7e24f41a6e58f8bf56321feccfa' aria-label='Self' aria-invalid='false' aria-required=false> <span>Self<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical1_subscriber_7006639e321994a4b375561c89309822'><input  type=\"radio\" name=\"medical1_subscriber\" data-name=\"medical1_subscriber\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Non-Self (please complete subscriber information)\"  id='medical1_subscriber_7006639e321994a4b375561c89309822' aria-label='Non-Self (please complete subscriber information)' aria-invalid='false' aria-required=false> <span>Non-Self (please complete subscriber information)<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_29\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_sub_first' id='label_ff_3_medical1_sub_first' aria-label=\"Subscriber\u2019s First Name\">Subscriber\u2019s First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical1_sub_first\" data-name=\"medical1_sub_first\" class=\"ff-el-form-control\" id=\"ff_3_medical1_sub_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_sub_last' id='label_ff_3_medical1_sub_last' aria-label=\"Subscriber\u2019s Last Name\">Subscriber\u2019s Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical1_sub_last\" data-name=\"medical1_sub_last\" class=\"ff-el-form-control\" id=\"ff_3_medical1_sub_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_30\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_sub_relation' id='label_ff_3_medical1_sub_relation' aria-label=\"Relation\">Relation<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical1_sub_relation\" data-name=\"medical1_sub_relation\" class=\"ff-el-form-control\" id=\"ff_3_medical1_sub_relation\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_sub_dob' id='label_ff_3_medical1_sub_dob' aria-label=\"Subscriber Birth Date\">Subscriber Birth Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Subscriber Birth Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"medical1_sub_dob\" placeholder=\"MM\/DD\/YYYY\" data-name=\"medical1_sub_dob\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_3_medical1_sub_dob\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Subscriber Sex\">Subscriber Sex<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical1_sub_sex_6f38c299aa60d6775da568ecfbe8cd0d'><input  type=\"radio\" name=\"medical1_sub_sex\" data-name=\"medical1_sub_sex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Male\"  id='medical1_sub_sex_6f38c299aa60d6775da568ecfbe8cd0d' aria-label='Male' aria-invalid='false' aria-required=false> <span>Male<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical1_sub_sex_6bcab5cf77d6626534a66849c83b32be'><input  type=\"radio\" name=\"medical1_sub_sex\" data-name=\"medical1_sub_sex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Female\"  id='medical1_sub_sex_6bcab5cf77d6626534a66849c83b32be' aria-label='Female' aria-invalid='false' aria-required=false> <span>Female<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_sub_ssn' id='label_ff_3_medical1_sub_ssn' aria-label=\"Subscriber S.S. #\">Subscriber S.S. #<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical1_sub_ssn\" placeholder=\"XXX-XX-XXXX\" data-mask=\"000-00-0000\" data-name=\"medical1_sub_ssn\" class=\"ff-el-form-control\" id=\"ff_3_medical1_sub_ssn\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Subscriber Address\">Subscriber Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical1_sub_address_774a5afebc53bcae0eb98a681d72ef92'><input  type=\"radio\" name=\"medical1_sub_address\" data-name=\"medical1_sub_address\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Same\"  id='medical1_sub_address_774a5afebc53bcae0eb98a681d72ef92' aria-label='Same' aria-invalid='false' aria-required=false> <span>Same<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical1_sub_address_70c3d07f7d324c9c00e1a8bf3c0ae365'><input  type=\"radio\" name=\"medical1_sub_address\" data-name=\"medical1_sub_address\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Different\"  id='medical1_sub_address_70c3d07f7d324c9c00e1a8bf3c0ae365' aria-label='Different' aria-invalid='false' aria-required=false> <span>Different<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_sub_street' id='label_ff_3_medical1_sub_street' aria-label=\"Street Address\">Street Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical1_sub_street\" data-name=\"medical1_sub_street\" class=\"ff-el-form-control\" id=\"ff_3_medical1_sub_street\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_31\"  class='ff-t-container ff-column-container ff_columns_total_3 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_sub_city' id='label_ff_3_medical1_sub_city' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical1_sub_city\" data-name=\"medical1_sub_city\" class=\"ff-el-form-control\" id=\"ff_3_medical1_sub_city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_sub_state' id='label_ff_3_medical1_sub_state' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical1_sub_state\" data-name=\"medical1_sub_state\" class=\"ff-el-form-control\" id=\"ff_3_medical1_sub_state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical1_sub_zip' id='label_ff_3_medical1_sub_zip' aria-label=\"ZIP Code\">ZIP Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical1_sub_zip\" data-mask=\"00000\" data-name=\"medical1_sub_zip\" class=\"ff-el-form-control\" id=\"ff_3_medical1_sub_zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Do you have secondary dental or medical insurance?\">Do you have secondary dental or medical insurance?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='has_secondary_insurance_f8162ab0e9fbb610fda704ce844a8de0'><input  type=\"radio\" name=\"has_secondary_insurance\" data-name=\"has_secondary_insurance\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='has_secondary_insurance_f8162ab0e9fbb610fda704ce844a8de0' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='has_secondary_insurance_b0329ffd9db541cf50a419ae5bee8f92'><input  type=\"radio\" name=\"has_secondary_insurance\" data-name=\"has_secondary_insurance\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='has_secondary_insurance_b0329ffd9db541cf50a419ae5bee8f92' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group  has-conditions ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_11\" ><h3 class='ff-el-section-title'>Secondary Dental Insurance Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental2_none_ede73bcaafd45b3a22742ebd270d3ca3'><input  type=\"checkbox\" name=\"dental2_none[]\" data-name=\"dental2_none\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"NONE\"  id='dental2_none_ede73bcaafd45b3a22742ebd270d3ca3' aria-label='NONE' aria-invalid='false' aria-required=false> <span>NONE<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_company' id='label_ff_3_dental2_company' aria-label=\"Insurance Company Name\">Insurance Company Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental2_company\" data-name=\"dental2_company\" class=\"ff-el-form-control\" id=\"ff_3_dental2_company\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_32\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_policy_id' id='label_ff_3_dental2_policy_id' aria-label=\"Policy I.D. Number\">Policy I.D. Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental2_policy_id\" data-name=\"dental2_policy_id\" class=\"ff-el-form-control\" id=\"ff_3_dental2_policy_id\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_group' id='label_ff_3_dental2_group' aria-label=\"Group Number\">Group Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental2_group\" data-name=\"dental2_group\" class=\"ff-el-form-control\" id=\"ff_3_dental2_group\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_employer' id='label_ff_3_dental2_employer' aria-label=\"Employer \/ Business\">Employer \/ Business<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental2_employer\" data-name=\"dental2_employer\" class=\"ff-el-form-control\" id=\"ff_3_dental2_employer\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Subscriber\">Subscriber<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental2_subscriber_0803a64e4f1a06c681c0c28c64db17ff'><input  type=\"radio\" name=\"dental2_subscriber\" data-name=\"dental2_subscriber\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Self\"  id='dental2_subscriber_0803a64e4f1a06c681c0c28c64db17ff' aria-label='Self' aria-invalid='false' aria-required=false> <span>Self<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental2_subscriber_66dc672dc0bb996f023799b4c30143e0'><input  type=\"radio\" name=\"dental2_subscriber\" data-name=\"dental2_subscriber\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Non-Self (please complete subscriber information)\"  id='dental2_subscriber_66dc672dc0bb996f023799b4c30143e0' aria-label='Non-Self (please complete subscriber information)' aria-invalid='false' aria-required=false> <span>Non-Self (please complete subscriber information)<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_33\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_sub_first' id='label_ff_3_dental2_sub_first' aria-label=\"Subscriber\u2019s First Name\">Subscriber\u2019s First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental2_sub_first\" data-name=\"dental2_sub_first\" class=\"ff-el-form-control\" id=\"ff_3_dental2_sub_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_sub_last' id='label_ff_3_dental2_sub_last' aria-label=\"Subscriber\u2019s Last Name\">Subscriber\u2019s Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental2_sub_last\" data-name=\"dental2_sub_last\" class=\"ff-el-form-control\" id=\"ff_3_dental2_sub_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_34\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_sub_relation' id='label_ff_3_dental2_sub_relation' aria-label=\"Relation\">Relation<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental2_sub_relation\" data-name=\"dental2_sub_relation\" class=\"ff-el-form-control\" id=\"ff_3_dental2_sub_relation\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_sub_dob' id='label_ff_3_dental2_sub_dob' aria-label=\"Subscriber Birth Date\">Subscriber Birth Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Subscriber Birth Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"dental2_sub_dob\" placeholder=\"MM\/DD\/YYYY\" data-name=\"dental2_sub_dob\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_3_dental2_sub_dob\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Subscriber Sex\">Subscriber Sex<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental2_sub_sex_08bffa035fdc47ffb9ae3ffaacb64f11'><input  type=\"radio\" name=\"dental2_sub_sex\" data-name=\"dental2_sub_sex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Male\"  id='dental2_sub_sex_08bffa035fdc47ffb9ae3ffaacb64f11' aria-label='Male' aria-invalid='false' aria-required=false> <span>Male<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental2_sub_sex_eb41bab3b9791e31b668bd80801eec7f'><input  type=\"radio\" name=\"dental2_sub_sex\" data-name=\"dental2_sub_sex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Female\"  id='dental2_sub_sex_eb41bab3b9791e31b668bd80801eec7f' aria-label='Female' aria-invalid='false' aria-required=false> <span>Female<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_sub_ssn' id='label_ff_3_dental2_sub_ssn' aria-label=\"Subscriber S.S. #\">Subscriber S.S. #<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental2_sub_ssn\" placeholder=\"XXX-XX-XXXX\" data-mask=\"000-00-0000\" data-name=\"dental2_sub_ssn\" class=\"ff-el-form-control\" id=\"ff_3_dental2_sub_ssn\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Subscriber Address\">Subscriber Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental2_sub_address_f22fd3de55f7cc3f85e0d92649c33a5a'><input  type=\"radio\" name=\"dental2_sub_address\" data-name=\"dental2_sub_address\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Same\"  id='dental2_sub_address_f22fd3de55f7cc3f85e0d92649c33a5a' aria-label='Same' aria-invalid='false' aria-required=false> <span>Same<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dental2_sub_address_269920cd228fb2ae36b9e9ac77cd80c5'><input  type=\"radio\" name=\"dental2_sub_address\" data-name=\"dental2_sub_address\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Different\"  id='dental2_sub_address_269920cd228fb2ae36b9e9ac77cd80c5' aria-label='Different' aria-invalid='false' aria-required=false> <span>Different<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_sub_street' id='label_ff_3_dental2_sub_street' aria-label=\"Street Address\">Street Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental2_sub_street\" data-name=\"dental2_sub_street\" class=\"ff-el-form-control\" id=\"ff_3_dental2_sub_street\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_35\"  class='ff-t-container ff-column-container ff_columns_total_3 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_sub_city' id='label_ff_3_dental2_sub_city' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental2_sub_city\" data-name=\"dental2_sub_city\" class=\"ff-el-form-control\" id=\"ff_3_dental2_sub_city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_sub_state' id='label_ff_3_dental2_sub_state' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental2_sub_state\" data-name=\"dental2_sub_state\" class=\"ff-el-form-control\" id=\"ff_3_dental2_sub_state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dental2_sub_zip' id='label_ff_3_dental2_sub_zip' aria-label=\"ZIP Code\">ZIP Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"dental2_sub_zip\" data-mask=\"00000\" data-name=\"dental2_sub_zip\" class=\"ff-el-form-control\" id=\"ff_3_dental2_sub_zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group  has-conditions ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_12\" ><h3 class='ff-el-section-title'>Secondary Medical Insurance Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical2_none_c1f5adb5bfc0c42e15950a1865bc1b2d'><input  type=\"checkbox\" name=\"medical2_none[]\" data-name=\"medical2_none\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"NONE\"  id='medical2_none_c1f5adb5bfc0c42e15950a1865bc1b2d' aria-label='NONE' aria-invalid='false' aria-required=false> <span>NONE<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_company' id='label_ff_3_medical2_company' aria-label=\"Insurance Company Name\">Insurance Company Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical2_company\" data-name=\"medical2_company\" class=\"ff-el-form-control\" id=\"ff_3_medical2_company\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_36\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_policy_id' id='label_ff_3_medical2_policy_id' aria-label=\"Policy I.D. Number\">Policy I.D. Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical2_policy_id\" data-name=\"medical2_policy_id\" class=\"ff-el-form-control\" id=\"ff_3_medical2_policy_id\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_group' id='label_ff_3_medical2_group' aria-label=\"Group Number\">Group Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical2_group\" data-name=\"medical2_group\" class=\"ff-el-form-control\" id=\"ff_3_medical2_group\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_employer' id='label_ff_3_medical2_employer' aria-label=\"Employer \/ Business\">Employer \/ Business<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical2_employer\" data-name=\"medical2_employer\" class=\"ff-el-form-control\" id=\"ff_3_medical2_employer\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Subscriber\">Subscriber<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical2_subscriber_2f454a4d273095322d9f6e94f7c815ba'><input  type=\"radio\" name=\"medical2_subscriber\" data-name=\"medical2_subscriber\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Self\"  id='medical2_subscriber_2f454a4d273095322d9f6e94f7c815ba' aria-label='Self' aria-invalid='false' aria-required=false> <span>Self<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical2_subscriber_41c5918a483ba677f8134234af93e3fa'><input  type=\"radio\" name=\"medical2_subscriber\" data-name=\"medical2_subscriber\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Non-Self (please complete subscriber information)\"  id='medical2_subscriber_41c5918a483ba677f8134234af93e3fa' aria-label='Non-Self (please complete subscriber information)' aria-invalid='false' aria-required=false> <span>Non-Self (please complete subscriber information)<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_37\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_sub_first' id='label_ff_3_medical2_sub_first' aria-label=\"Subscriber\u2019s First Name\">Subscriber\u2019s First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical2_sub_first\" data-name=\"medical2_sub_first\" class=\"ff-el-form-control\" id=\"ff_3_medical2_sub_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_sub_last' id='label_ff_3_medical2_sub_last' aria-label=\"Subscriber\u2019s Last Name\">Subscriber\u2019s Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical2_sub_last\" data-name=\"medical2_sub_last\" class=\"ff-el-form-control\" id=\"ff_3_medical2_sub_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_38\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_sub_relation' id='label_ff_3_medical2_sub_relation' aria-label=\"Relation\">Relation<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical2_sub_relation\" data-name=\"medical2_sub_relation\" class=\"ff-el-form-control\" id=\"ff_3_medical2_sub_relation\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_sub_dob' id='label_ff_3_medical2_sub_dob' aria-label=\"Subscriber Birth Date\">Subscriber Birth Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Subscriber Birth Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"medical2_sub_dob\" placeholder=\"MM\/DD\/YYYY\" data-name=\"medical2_sub_dob\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_3_medical2_sub_dob\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Subscriber Sex\">Subscriber Sex<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical2_sub_sex_e6734772609b40823d15561c8813f2dc'><input  type=\"radio\" name=\"medical2_sub_sex\" data-name=\"medical2_sub_sex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Male\"  id='medical2_sub_sex_e6734772609b40823d15561c8813f2dc' aria-label='Male' aria-invalid='false' aria-required=false> <span>Male<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical2_sub_sex_ca440e0be61f5d0b2636c3e9fece4fbd'><input  type=\"radio\" name=\"medical2_sub_sex\" data-name=\"medical2_sub_sex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Female\"  id='medical2_sub_sex_ca440e0be61f5d0b2636c3e9fece4fbd' aria-label='Female' aria-invalid='false' aria-required=false> <span>Female<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_sub_ssn' id='label_ff_3_medical2_sub_ssn' aria-label=\"Subscriber S.S. #\">Subscriber S.S. #<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical2_sub_ssn\" placeholder=\"XXX-XX-XXXX\" data-mask=\"000-00-0000\" data-name=\"medical2_sub_ssn\" class=\"ff-el-form-control\" id=\"ff_3_medical2_sub_ssn\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Subscriber Address\">Subscriber Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical2_sub_address_64e4c95e27b3be5ef0722adf4f5006f6'><input  type=\"radio\" name=\"medical2_sub_address\" data-name=\"medical2_sub_address\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Same\"  id='medical2_sub_address_64e4c95e27b3be5ef0722adf4f5006f6' aria-label='Same' aria-invalid='false' aria-required=false> <span>Same<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical2_sub_address_9795e4220b24c8ed3b384fd33b873870'><input  type=\"radio\" name=\"medical2_sub_address\" data-name=\"medical2_sub_address\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Different\"  id='medical2_sub_address_9795e4220b24c8ed3b384fd33b873870' aria-label='Different' aria-invalid='false' aria-required=false> <span>Different<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_sub_street' id='label_ff_3_medical2_sub_street' aria-label=\"Street Address\">Street Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical2_sub_street\" data-name=\"medical2_sub_street\" class=\"ff-el-form-control\" id=\"ff_3_medical2_sub_street\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_39\"  class='ff-t-container ff-column-container ff_columns_total_3 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_sub_city' id='label_ff_3_medical2_sub_city' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical2_sub_city\" data-name=\"medical2_sub_city\" class=\"ff-el-form-control\" id=\"ff_3_medical2_sub_city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_sub_state' id='label_ff_3_medical2_sub_state' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical2_sub_state\" data-name=\"medical2_sub_state\" class=\"ff-el-form-control\" id=\"ff_3_medical2_sub_state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical2_sub_zip' id='label_ff_3_medical2_sub_zip' aria-label=\"ZIP Code\">ZIP Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"medical2_sub_zip\" data-mask=\"00000\" data-name=\"medical2_sub_zip\" class=\"ff-el-form-control\" id=\"ff_3_medical2_sub_zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_13\" ><h2>Health History<\/h2><\/div><div data-name=\"ff_cn_id_40\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_legal_first' id='label_ff_3_hh_legal_first' aria-label=\"Patient Legal First Name\">Patient Legal First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_legal_first\" data-name=\"hh_legal_first\" class=\"ff-el-form-control\" id=\"ff_3_hh_legal_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_legal_mi' id='label_ff_3_hh_legal_mi' aria-label=\"M.I.\">M.I.<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_legal_mi\" data-name=\"hh_legal_mi\" class=\"ff-el-form-control\" id=\"ff_3_hh_legal_mi\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_legal_last' id='label_ff_3_hh_legal_last' aria-label=\"Patient Legal Last Name\">Patient Legal Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_legal_last\" data-name=\"hh_legal_last\" class=\"ff-el-form-control\" id=\"ff_3_hh_legal_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Person Filling Out\">Person Filling Out<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_person_filling_44ee892ee7c832327530cb0bf5df697d'><input  type=\"checkbox\" name=\"hh_person_filling[]\" data-name=\"hh_person_filling\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Self \/ Patient\"  id='hh_person_filling_44ee892ee7c832327530cb0bf5df697d' aria-label='Self \/ Patient' aria-invalid='false' aria-required=false> <span>Self \/ Patient<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_person_filling_d55b8521fffbfc7c0e0b47f5543cb8d8'><input  type=\"checkbox\" name=\"hh_person_filling[]\" data-name=\"hh_person_filling\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Guardian \/ Other\"  id='hh_person_filling_d55b8521fffbfc7c0e0b47f5543cb8d8' aria-label='Guardian \/ Other' aria-invalid='false' aria-required=false> <span>Guardian \/ Other<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_person_filling_e99686d55ffda370947cae9497220054'><input  type=\"checkbox\" name=\"hh_person_filling[]\" data-name=\"hh_person_filling\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Medical Power of Attorney\"  id='hh_person_filling_e99686d55ffda370947cae9497220054' aria-label='Medical Power of Attorney' aria-invalid='false' aria-required=false> <span>Medical Power of Attorney<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_person_relationship' id='label_ff_3_hh_person_relationship' aria-label=\"If not patient, relationship\">If not patient, relationship<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_person_relationship\" data-name=\"hh_person_relationship\" class=\"ff-el-form-control\" id=\"ff_3_hh_person_relationship\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_14\" ><p><strong>Health History Questionnaire<\/strong><br>Health problems that you may have or medications that you may be taking could have an important interrelationship with the care you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.<\/p><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_reason_for_visit' id='label_ff_3_hh_reason_for_visit' aria-label=\"Reason for today\u2019s office visit?\">Reason for today\u2019s office visit?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_reason_for_visit\" data-name=\"hh_reason_for_visit\" class=\"ff-el-form-control\" id=\"ff_3_hh_reason_for_visit\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_41\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_height' id='label_ff_3_hh_height' aria-label=\"Height\">Height<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_height\" data-name=\"hh_height\" class=\"ff-el-form-control\" id=\"ff_3_hh_height\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_weight' id='label_ff_3_hh_weight' aria-label=\"Weight\">Weight<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_weight\" data-name=\"hh_weight\" class=\"ff-el-form-control\" id=\"ff_3_hh_weight\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_15\" ><h3 class='ff-el-section-title'>Please indicate any health issues that apply for the patient<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Patient has been hospitalized in the past year?\">Patient has been hospitalized in the past year?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_hospitalized_549cc47fc9ada9de30d40aacc3525d6d'><input  type=\"radio\" name=\"hh_hospitalized\" data-name=\"hh_hospitalized\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_hospitalized_549cc47fc9ada9de30d40aacc3525d6d' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_hospitalized_6ae2a16f84c71f0f144c497ac8672321'><input  type=\"radio\" name=\"hh_hospitalized\" data-name=\"hh_hospitalized\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_hospitalized_6ae2a16f84c71f0f144c497ac8672321' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_hospitalized_desc' id='label_ff_3_hh_hospitalized_desc' aria-label=\"If so, describe\">If so, describe<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_hospitalized_desc\" data-name=\"hh_hospitalized_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_hospitalized_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Patient has a prosthetic joint or heart valve replacement?\">Patient has a prosthetic joint or heart valve replacement?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_prosthetic_joint_d24b0554deeda1766f5f42699b70ac35'><input  type=\"radio\" name=\"hh_prosthetic_joint\" data-name=\"hh_prosthetic_joint\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_prosthetic_joint_d24b0554deeda1766f5f42699b70ac35' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_prosthetic_joint_48669739846dc7df7f35aeacfad56945'><input  type=\"radio\" name=\"hh_prosthetic_joint\" data-name=\"hh_prosthetic_joint\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_prosthetic_joint_48669739846dc7df7f35aeacfad56945' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_prosthetic_joint_desc' id='label_ff_3_hh_prosthetic_joint_desc' aria-label=\"If so, describe\">If so, describe<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_prosthetic_joint_desc\" data-name=\"hh_prosthetic_joint_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_prosthetic_joint_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Patient or a family member has had an unusual or serious reaction to general anesthesia?\">Patient or a family member has had an unusual or serious reaction to general anesthesia?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_anesthesia_reaction_6cb4bf8c54ae086907694e0bcac024d3'><input  type=\"radio\" name=\"hh_anesthesia_reaction\" data-name=\"hh_anesthesia_reaction\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_anesthesia_reaction_6cb4bf8c54ae086907694e0bcac024d3' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_anesthesia_reaction_c96c81b0d1490424099bc56c25563e60'><input  type=\"radio\" name=\"hh_anesthesia_reaction\" data-name=\"hh_anesthesia_reaction\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_anesthesia_reaction_c96c81b0d1490424099bc56c25563e60' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_anesthesia_reaction_desc' id='label_ff_3_hh_anesthesia_reaction_desc' aria-label=\"If so, describe\">If so, describe<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_anesthesia_reaction_desc\" data-name=\"hh_anesthesia_reaction_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_anesthesia_reaction_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Patient under the care of a pain management or addiction specialist?\">Patient under the care of a pain management or addiction specialist?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_pain_mgmt_specialist_845236c0747b48b371e93e93009106df'><input  type=\"radio\" name=\"hh_pain_mgmt_specialist\" data-name=\"hh_pain_mgmt_specialist\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_pain_mgmt_specialist_845236c0747b48b371e93e93009106df' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_pain_mgmt_specialist_f57badef1dcc513e1c69ac25a506751d'><input  type=\"radio\" name=\"hh_pain_mgmt_specialist\" data-name=\"hh_pain_mgmt_specialist\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_pain_mgmt_specialist_f57badef1dcc513e1c69ac25a506751d' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_pain_mgmt_specialist_desc' id='label_ff_3_hh_pain_mgmt_specialist_desc' aria-label=\"If so, describe\">If so, describe<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_pain_mgmt_specialist_desc\" data-name=\"hh_pain_mgmt_specialist_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_pain_mgmt_specialist_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_16\" ><h2>Health History Part 2<\/h2><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_17\" ><p><strong>If any of the following categories is YES, please indicate the condition.<\/strong><\/p><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_18\" ><h3 class='ff-el-section-title'>Cardiac History<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Cardiac History\">Cardiac History<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_a9dcf6f878153df74da7c15804f0871d'><input  type=\"radio\" name=\"hh_cardiac\" data-name=\"hh_cardiac\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_cardiac_a9dcf6f878153df74da7c15804f0871d' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_1f909008d6b15b21357d5e8f5205ca8b'><input  type=\"radio\" name=\"hh_cardiac\" data-name=\"hh_cardiac\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_cardiac_1f909008d6b15b21357d5e8f5205ca8b' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_conditions_f8a874b850849c7b84d2735aa65dc497'><input  type=\"checkbox\" name=\"hh_cardiac_conditions[]\" data-name=\"hh_cardiac_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"High Cholesterol\"  id='hh_cardiac_conditions_f8a874b850849c7b84d2735aa65dc497' aria-label='High Cholesterol' aria-invalid='false' aria-required=false> <span>High Cholesterol<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_conditions_afac5a55ec1a59885b77fddad4b3552f'><input  type=\"checkbox\" name=\"hh_cardiac_conditions[]\" data-name=\"hh_cardiac_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"High Blood Pressure (Hypertension)\"  id='hh_cardiac_conditions_afac5a55ec1a59885b77fddad4b3552f' aria-label='High Blood Pressure (Hypertension)' aria-invalid='false' aria-required=false> <span>High Blood Pressure (Hypertension)<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_conditions_dccc370654493be9eb750fd467b3e8e1'><input  type=\"checkbox\" name=\"hh_cardiac_conditions[]\" data-name=\"hh_cardiac_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Heart Attack (Myocardial Infarction)\"  id='hh_cardiac_conditions_dccc370654493be9eb750fd467b3e8e1' aria-label='Heart Attack (Myocardial Infarction)' aria-invalid='false' aria-required=false> <span>Heart Attack (Myocardial Infarction)<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_conditions_89423bd767c36d9d323518781c7628bc'><input  type=\"checkbox\" name=\"hh_cardiac_conditions[]\" data-name=\"hh_cardiac_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Angina (Chest pain on exertion)\"  id='hh_cardiac_conditions_89423bd767c36d9d323518781c7628bc' aria-label='Angina (Chest pain on exertion)' aria-invalid='false' aria-required=false> <span>Angina (Chest pain on exertion)<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_conditions_9064fd66839fecc4ded81215d56d85c1'><input  type=\"checkbox\" name=\"hh_cardiac_conditions[]\" data-name=\"hh_cardiac_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Irregular Heartbeat\"  id='hh_cardiac_conditions_9064fd66839fecc4ded81215d56d85c1' aria-label='Irregular Heartbeat' aria-invalid='false' aria-required=false> <span>Irregular Heartbeat<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_conditions_d15ca7ed04c33782cc13bc799abffa92'><input  type=\"checkbox\" name=\"hh_cardiac_conditions[]\" data-name=\"hh_cardiac_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"ICD (Implanted Cardiac Defibrillator)\"  id='hh_cardiac_conditions_d15ca7ed04c33782cc13bc799abffa92' aria-label='ICD (Implanted Cardiac Defibrillator)' aria-invalid='false' aria-required=false> <span>ICD (Implanted Cardiac Defibrillator)<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_conditions_44994a844d2d0c3c9a05104e708513f9'><input  type=\"checkbox\" name=\"hh_cardiac_conditions[]\" data-name=\"hh_cardiac_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pacemaker\"  id='hh_cardiac_conditions_44994a844d2d0c3c9a05104e708513f9' aria-label='Pacemaker' aria-invalid='false' aria-required=false> <span>Pacemaker<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_conditions_ea5e1aee4a5987d8670d5d1651f0f8b6'><input  type=\"checkbox\" name=\"hh_cardiac_conditions[]\" data-name=\"hh_cardiac_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Heart Surgery\"  id='hh_cardiac_conditions_ea5e1aee4a5987d8670d5d1651f0f8b6' aria-label='Heart Surgery' aria-invalid='false' aria-required=false> <span>Heart Surgery<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_conditions_4d6a8671be6f207d7b7dbba5ee724271'><input  type=\"checkbox\" name=\"hh_cardiac_conditions[]\" data-name=\"hh_cardiac_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Heart Valve Replacement\"  id='hh_cardiac_conditions_4d6a8671be6f207d7b7dbba5ee724271' aria-label='Heart Valve Replacement' aria-invalid='false' aria-required=false> <span>Heart Valve Replacement<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_conditions_f5e42c5024f3f2776bf07026484ae80a'><input  type=\"checkbox\" name=\"hh_cardiac_conditions[]\" data-name=\"hh_cardiac_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Congestive Heart Failure (CHF)\"  id='hh_cardiac_conditions_f5e42c5024f3f2776bf07026484ae80a' aria-label='Congestive Heart Failure (CHF)' aria-invalid='false' aria-required=false> <span>Congestive Heart Failure (CHF)<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_conditions_7e1b161eadfd143dcd906f865ab9c6d2'><input  type=\"checkbox\" name=\"hh_cardiac_conditions[]\" data-name=\"hh_cardiac_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Atrial Fibrillation\"  id='hh_cardiac_conditions_7e1b161eadfd143dcd906f865ab9c6d2' aria-label='Atrial Fibrillation' aria-invalid='false' aria-required=false> <span>Atrial Fibrillation<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_conditions_1599036b3957b1e2ce34afd63c18da6b'><input  type=\"checkbox\" name=\"hh_cardiac_conditions[]\" data-name=\"hh_cardiac_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Bundle Branch Block or other arrhythmia (irregular heartbeat)\"  id='hh_cardiac_conditions_1599036b3957b1e2ce34afd63c18da6b' aria-label='Bundle Branch Block or other arrhythmia (irregular heartbeat)' aria-invalid='false' aria-required=false> <span>Bundle Branch Block or other arrhythmia (irregular heartbeat)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Other\">Other<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_other_77d125dc49ed22f6d162776af5df875f'><input  type=\"radio\" name=\"hh_cardiac_other\" data-name=\"hh_cardiac_other\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_cardiac_other_77d125dc49ed22f6d162776af5df875f' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cardiac_other_57f2ab93d7329b735fe45795f18adb79'><input  type=\"radio\" name=\"hh_cardiac_other\" data-name=\"hh_cardiac_other\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_cardiac_other_57f2ab93d7329b735fe45795f18adb79' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_cardiac_other_desc' id='label_ff_3_hh_cardiac_other_desc' aria-label=\"Please specify\">Please specify<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_cardiac_other_desc\" data-name=\"hh_cardiac_other_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_cardiac_other_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_19\" ><h3 class='ff-el-section-title'>Diabetes<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Diabetes\">Diabetes<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_diabetes_b4a80e914835da8609e54c5151aac520'><input  type=\"radio\" name=\"hh_diabetes\" data-name=\"hh_diabetes\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_diabetes_b4a80e914835da8609e54c5151aac520' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_diabetes_64e52d174d375112b74e0e10dcf11cef'><input  type=\"radio\" name=\"hh_diabetes\" data-name=\"hh_diabetes\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_diabetes_64e52d174d375112b74e0e10dcf11cef' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_diabetes_conditions_334c124a4b672532aa5e6bb2b5c05d04'><input  type=\"checkbox\" name=\"hh_diabetes_conditions[]\" data-name=\"hh_diabetes_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Type 1\"  id='hh_diabetes_conditions_334c124a4b672532aa5e6bb2b5c05d04' aria-label='Type 1' aria-invalid='false' aria-required=false> <span>Type 1<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_diabetes_conditions_83d0c814d037de348b82fd75596cf48b'><input  type=\"checkbox\" name=\"hh_diabetes_conditions[]\" data-name=\"hh_diabetes_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Type 2\"  id='hh_diabetes_conditions_83d0c814d037de348b82fd75596cf48b' aria-label='Type 2' aria-invalid='false' aria-required=false> <span>Type 2<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_diabetes_conditions_7df3425fd541ac2a443ee212c1618d5b'><input  type=\"checkbox\" name=\"hh_diabetes_conditions[]\" data-name=\"hh_diabetes_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pre-diabetic\"  id='hh_diabetes_conditions_7df3425fd541ac2a443ee212c1618d5b' aria-label='Pre-diabetic' aria-invalid='false' aria-required=false> <span>Pre-diabetic<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_20\" ><h3 class='ff-el-section-title'>Lung Disease<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Lung Disease\">Lung Disease<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_lung_723545d5a5adf77388a0a93666a944b5'><input  type=\"radio\" name=\"hh_lung\" data-name=\"hh_lung\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_lung_723545d5a5adf77388a0a93666a944b5' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_lung_8cc468d3d7426268cee2f1e1fedbcc76'><input  type=\"radio\" name=\"hh_lung\" data-name=\"hh_lung\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_lung_8cc468d3d7426268cee2f1e1fedbcc76' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_lung_conditions_19b381724ee083b13ee55a07bc064a91'><input  type=\"checkbox\" name=\"hh_lung_conditions[]\" data-name=\"hh_lung_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Asthma\"  id='hh_lung_conditions_19b381724ee083b13ee55a07bc064a91' aria-label='Asthma' aria-invalid='false' aria-required=false> <span>Asthma<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_lung_conditions_8968237000a9c8b18c966d803702b747'><input  type=\"checkbox\" name=\"hh_lung_conditions[]\" data-name=\"hh_lung_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Chronic Bronchitis\"  id='hh_lung_conditions_8968237000a9c8b18c966d803702b747' aria-label='Chronic Bronchitis' aria-invalid='false' aria-required=false> <span>Chronic Bronchitis<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_lung_conditions_7c4f051ff4a1bf030aa97a82f4754027'><input  type=\"checkbox\" name=\"hh_lung_conditions[]\" data-name=\"hh_lung_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Sarcoidosis\"  id='hh_lung_conditions_7c4f051ff4a1bf030aa97a82f4754027' aria-label='Sarcoidosis' aria-invalid='false' aria-required=false> <span>Sarcoidosis<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_lung_conditions_c90437c5ec7e11ae819022e6d222e821'><input  type=\"checkbox\" name=\"hh_lung_conditions[]\" data-name=\"hh_lung_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pulmonary Embolism\"  id='hh_lung_conditions_c90437c5ec7e11ae819022e6d222e821' aria-label='Pulmonary Embolism' aria-invalid='false' aria-required=false> <span>Pulmonary Embolism<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_lung_conditions_3e1466f8e558fe64a1b1d44e1c972154'><input  type=\"checkbox\" name=\"hh_lung_conditions[]\" data-name=\"hh_lung_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"COPD Emphysema\"  id='hh_lung_conditions_3e1466f8e558fe64a1b1d44e1c972154' aria-label='COPD Emphysema' aria-invalid='false' aria-required=false> <span>COPD Emphysema<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Other\">Other<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_lung_other_c615961d5bae46e032a3bd5d2add6039'><input  type=\"radio\" name=\"hh_lung_other\" data-name=\"hh_lung_other\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_lung_other_c615961d5bae46e032a3bd5d2add6039' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_lung_other_122c9f815ab7649a09adff73bbbe32e6'><input  type=\"radio\" name=\"hh_lung_other\" data-name=\"hh_lung_other\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_lung_other_122c9f815ab7649a09adff73bbbe32e6' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_lung_other_desc' id='label_ff_3_hh_lung_other_desc' aria-label=\"Please specify\">Please specify<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_lung_other_desc\" data-name=\"hh_lung_other_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_lung_other_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_21\" ><h3 class='ff-el-section-title'>Sleep Apnea<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Sleep Apnea\">Sleep Apnea<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_sleep_apnea_6de3bae762ffa8c5c9bce0f29b14f0bd'><input  type=\"radio\" name=\"hh_sleep_apnea\" data-name=\"hh_sleep_apnea\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_sleep_apnea_6de3bae762ffa8c5c9bce0f29b14f0bd' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_sleep_apnea_bbcb8c97c3299aaea66a6d667190edc0'><input  type=\"radio\" name=\"hh_sleep_apnea\" data-name=\"hh_sleep_apnea\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_sleep_apnea_bbcb8c97c3299aaea66a6d667190edc0' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_sleep_apnea_conditions_9f2362bdc86e98d751eaf9c2ada057d0'><input  type=\"checkbox\" name=\"hh_sleep_apnea_conditions[]\" data-name=\"hh_sleep_apnea_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Positive Sleep Study\"  id='hh_sleep_apnea_conditions_9f2362bdc86e98d751eaf9c2ada057d0' aria-label='Positive Sleep Study' aria-invalid='false' aria-required=false> <span>Positive Sleep Study<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_sleep_apnea_conditions_3eb9636abdf65ca7ef68d78178eb17e6'><input  type=\"checkbox\" name=\"hh_sleep_apnea_conditions[]\" data-name=\"hh_sleep_apnea_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"CPAP\"  id='hh_sleep_apnea_conditions_3eb9636abdf65ca7ef68d78178eb17e6' aria-label='CPAP' aria-invalid='false' aria-required=false> <span>CPAP<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_sleep_apnea_conditions_b1b8c6ca6ac06cc43a56eb25a470fc18'><input  type=\"checkbox\" name=\"hh_sleep_apnea_conditions[]\" data-name=\"hh_sleep_apnea_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Sleep Appliance\"  id='hh_sleep_apnea_conditions_b1b8c6ca6ac06cc43a56eb25a470fc18' aria-label='Sleep Appliance' aria-invalid='false' aria-required=false> <span>Sleep Appliance<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_22\" ><h3 class='ff-el-section-title'>Liver Disease<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Liver Disease\">Liver Disease<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_liver_a0b1fec3cb03e40f028b3ad72b884855'><input  type=\"radio\" name=\"hh_liver\" data-name=\"hh_liver\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_liver_a0b1fec3cb03e40f028b3ad72b884855' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_liver_46055e70b86e24ad96b16757d83e61ab'><input  type=\"radio\" name=\"hh_liver\" data-name=\"hh_liver\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_liver_46055e70b86e24ad96b16757d83e61ab' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_liver_conditions_ab3b241051128b0492c82ca6d4098840'><input  type=\"checkbox\" name=\"hh_liver_conditions[]\" data-name=\"hh_liver_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Hepatitis\"  id='hh_liver_conditions_ab3b241051128b0492c82ca6d4098840' aria-label='Hepatitis' aria-invalid='false' aria-required=false> <span>Hepatitis<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_liver_conditions_99e90f8fdcec044c1288dbfeaf22b886'><input  type=\"checkbox\" name=\"hh_liver_conditions[]\" data-name=\"hh_liver_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Fatty Liver\"  id='hh_liver_conditions_99e90f8fdcec044c1288dbfeaf22b886' aria-label='Fatty Liver' aria-invalid='false' aria-required=false> <span>Fatty Liver<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_liver_conditions_69c4ee53a69d61ca9b439d5cfc409417'><input  type=\"checkbox\" name=\"hh_liver_conditions[]\" data-name=\"hh_liver_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cirrhosis\"  id='hh_liver_conditions_69c4ee53a69d61ca9b439d5cfc409417' aria-label='Cirrhosis' aria-invalid='false' aria-required=false> <span>Cirrhosis<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_liver_conditions_9cc095be451507e0ffa9f7a50eaa0baa'><input  type=\"checkbox\" name=\"hh_liver_conditions[]\" data-name=\"hh_liver_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Liver Failure\"  id='hh_liver_conditions_9cc095be451507e0ffa9f7a50eaa0baa' aria-label='Liver Failure' aria-invalid='false' aria-required=false> <span>Liver Failure<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Other\">Other<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_liver_other_349bff0f410f6de84bdb5ecb63bdc442'><input  type=\"radio\" name=\"hh_liver_other\" data-name=\"hh_liver_other\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_liver_other_349bff0f410f6de84bdb5ecb63bdc442' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_liver_other_86f32ffa600a8912e5f594c8d9406948'><input  type=\"radio\" name=\"hh_liver_other\" data-name=\"hh_liver_other\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_liver_other_86f32ffa600a8912e5f594c8d9406948' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_liver_other_desc' id='label_ff_3_hh_liver_other_desc' aria-label=\"Please specify\">Please specify<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_liver_other_desc\" data-name=\"hh_liver_other_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_liver_other_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_23\" ><h3 class='ff-el-section-title'>Kidney Disease<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Kidney Disease\">Kidney Disease<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_kidney_bef8328ccae38381deb51cef2281d54e'><input  type=\"radio\" name=\"hh_kidney\" data-name=\"hh_kidney\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_kidney_bef8328ccae38381deb51cef2281d54e' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_kidney_fd9cc73ba55fd17ad841f589bc833073'><input  type=\"radio\" name=\"hh_kidney\" data-name=\"hh_kidney\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_kidney_fd9cc73ba55fd17ad841f589bc833073' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_kidney_conditions_4bad47f9d9424ddb1a550df808134e8e'><input  type=\"checkbox\" name=\"hh_kidney_conditions[]\" data-name=\"hh_kidney_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Dialysis\"  id='hh_kidney_conditions_4bad47f9d9424ddb1a550df808134e8e' aria-label='Dialysis' aria-invalid='false' aria-required=false> <span>Dialysis<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_kidney_conditions_20845f5976e2a9f1fc3b02d54f38aa70'><input  type=\"checkbox\" name=\"hh_kidney_conditions[]\" data-name=\"hh_kidney_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Chronic Kidney Failure\"  id='hh_kidney_conditions_20845f5976e2a9f1fc3b02d54f38aa70' aria-label='Chronic Kidney Failure' aria-invalid='false' aria-required=false> <span>Chronic Kidney Failure<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Other\">Other<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_kidney_other_c07379831446e81037d1fc6bcdbb9dbe'><input  type=\"radio\" name=\"hh_kidney_other\" data-name=\"hh_kidney_other\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_kidney_other_c07379831446e81037d1fc6bcdbb9dbe' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_kidney_other_eda0f6347ffd2b7af88d3726193b0286'><input  type=\"radio\" name=\"hh_kidney_other\" data-name=\"hh_kidney_other\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_kidney_other_eda0f6347ffd2b7af88d3726193b0286' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_kidney_other_desc' id='label_ff_3_hh_kidney_other_desc' aria-label=\"Please specify\">Please specify<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_kidney_other_desc\" data-name=\"hh_kidney_other_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_kidney_other_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_24\" ><h3 class='ff-el-section-title'>Thyroid Disease<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Thyroid Disease\">Thyroid Disease<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_thyroid_b3f13822569d0b5b4cc3b18e984632f4'><input  type=\"radio\" name=\"hh_thyroid\" data-name=\"hh_thyroid\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_thyroid_b3f13822569d0b5b4cc3b18e984632f4' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_thyroid_0da86704a1d6c9bb3072b2978fa89b32'><input  type=\"radio\" name=\"hh_thyroid\" data-name=\"hh_thyroid\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_thyroid_0da86704a1d6c9bb3072b2978fa89b32' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_thyroid_conditions_26b52e3ea4a4e1890ccbb741b4e4e9c9'><input  type=\"checkbox\" name=\"hh_thyroid_conditions[]\" data-name=\"hh_thyroid_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Hypothyroid\"  id='hh_thyroid_conditions_26b52e3ea4a4e1890ccbb741b4e4e9c9' aria-label='Hypothyroid' aria-invalid='false' aria-required=false> <span>Hypothyroid<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_thyroid_conditions_2de2a0575415c0c39c41e70f428f499f'><input  type=\"checkbox\" name=\"hh_thyroid_conditions[]\" data-name=\"hh_thyroid_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Hashimoto\u2019s Disease\"  id='hh_thyroid_conditions_2de2a0575415c0c39c41e70f428f499f' aria-label='Hashimoto\u2019s Disease' aria-invalid='false' aria-required=false> <span>Hashimoto\u2019s Disease<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_thyroid_conditions_ae6e69645997c3eb2e2add4392a445fd'><input  type=\"checkbox\" name=\"hh_thyroid_conditions[]\" data-name=\"hh_thyroid_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Thyroid Removal\"  id='hh_thyroid_conditions_ae6e69645997c3eb2e2add4392a445fd' aria-label='Thyroid Removal' aria-invalid='false' aria-required=false> <span>Thyroid Removal<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_thyroid_conditions_f27b3ecbc940008df51edef27c5933f6'><input  type=\"checkbox\" name=\"hh_thyroid_conditions[]\" data-name=\"hh_thyroid_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Hyperthyroid\"  id='hh_thyroid_conditions_f27b3ecbc940008df51edef27c5933f6' aria-label='Hyperthyroid' aria-invalid='false' aria-required=false> <span>Hyperthyroid<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_25\" ><h3 class='ff-el-section-title'>Neurologic Disease<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Neurologic Disease\">Neurologic Disease<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_neuro_b00c56087f598381fffe6b66cbf009ab'><input  type=\"radio\" name=\"hh_neuro\" data-name=\"hh_neuro\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_neuro_b00c56087f598381fffe6b66cbf009ab' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_neuro_d9210bfaabd697b0db72654fcae03943'><input  type=\"radio\" name=\"hh_neuro\" data-name=\"hh_neuro\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_neuro_d9210bfaabd697b0db72654fcae03943' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_neuro_conditions_9ddf5e3fb5929600d2feab2d7b5319fc'><input  type=\"checkbox\" name=\"hh_neuro_conditions[]\" data-name=\"hh_neuro_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Epilepsy \/ Seizures\"  id='hh_neuro_conditions_9ddf5e3fb5929600d2feab2d7b5319fc' aria-label='Epilepsy \/ Seizures' aria-invalid='false' aria-required=false> <span>Epilepsy \/ Seizures<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_neuro_conditions_ece51a11001769b51f1590307bfc2df2'><input  type=\"checkbox\" name=\"hh_neuro_conditions[]\" data-name=\"hh_neuro_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Stroke \/ TIA\"  id='hh_neuro_conditions_ece51a11001769b51f1590307bfc2df2' aria-label='Stroke \/ TIA' aria-invalid='false' aria-required=false> <span>Stroke \/ TIA<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_neuro_conditions_738d9d818db314912913a6f542d6580d'><input  type=\"checkbox\" name=\"hh_neuro_conditions[]\" data-name=\"hh_neuro_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Traumatic Brain Injury\"  id='hh_neuro_conditions_738d9d818db314912913a6f542d6580d' aria-label='Traumatic Brain Injury' aria-invalid='false' aria-required=false> <span>Traumatic Brain Injury<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_neuro_conditions_1f25f0e3e725da077fe3ed402efa08ba'><input  type=\"checkbox\" name=\"hh_neuro_conditions[]\" data-name=\"hh_neuro_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Brain Tumors \/ Surgery\"  id='hh_neuro_conditions_1f25f0e3e725da077fe3ed402efa08ba' aria-label='Brain Tumors \/ Surgery' aria-invalid='false' aria-required=false> <span>Brain Tumors \/ Surgery<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_neuro_conditions_a0ef70ef734ad70bdaf31267afd66ab3'><input  type=\"checkbox\" name=\"hh_neuro_conditions[]\" data-name=\"hh_neuro_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Parkinson\u2019s\"  id='hh_neuro_conditions_a0ef70ef734ad70bdaf31267afd66ab3' aria-label='Parkinson\u2019s' aria-invalid='false' aria-required=false> <span>Parkinson\u2019s<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_neuro_conditions_0cfe55cf2ee46575f49d5463676f34a7'><input  type=\"checkbox\" name=\"hh_neuro_conditions[]\" data-name=\"hh_neuro_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Myasthenia Gravis\"  id='hh_neuro_conditions_0cfe55cf2ee46575f49d5463676f34a7' aria-label='Myasthenia Gravis' aria-invalid='false' aria-required=false> <span>Myasthenia Gravis<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_neuro_conditions_07ad1b628a315d08275c3a302c429ff6'><input  type=\"checkbox\" name=\"hh_neuro_conditions[]\" data-name=\"hh_neuro_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Guillain-Barre\"  id='hh_neuro_conditions_07ad1b628a315d08275c3a302c429ff6' aria-label='Guillain-Barre' aria-invalid='false' aria-required=false> <span>Guillain-Barre<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_neuro_conditions_ba3de39231c3f8b87231cebc56849634'><input  type=\"checkbox\" name=\"hh_neuro_conditions[]\" data-name=\"hh_neuro_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Multiple Sclerosis\"  id='hh_neuro_conditions_ba3de39231c3f8b87231cebc56849634' aria-label='Multiple Sclerosis' aria-invalid='false' aria-required=false> <span>Multiple Sclerosis<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_26\" ><h3 class='ff-el-section-title'>Bleeding Issues<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Bleeding Issues\">Bleeding Issues<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_bleeding_5901c25b7f43838d9c5d7a5de0ce2332'><input  type=\"radio\" name=\"hh_bleeding\" data-name=\"hh_bleeding\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_bleeding_5901c25b7f43838d9c5d7a5de0ce2332' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_bleeding_18dcf09e6a355b9c3154ebd231eb920a'><input  type=\"radio\" name=\"hh_bleeding\" data-name=\"hh_bleeding\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_bleeding_18dcf09e6a355b9c3154ebd231eb920a' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_bleeding_conditions_6775d02833bed523f28a7746ddbd2e8b'><input  type=\"checkbox\" name=\"hh_bleeding_conditions[]\" data-name=\"hh_bleeding_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Anemia\"  id='hh_bleeding_conditions_6775d02833bed523f28a7746ddbd2e8b' aria-label='Anemia' aria-invalid='false' aria-required=false> <span>Anemia<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_bleeding_conditions_fb134515419fff2c52740ff3c7259158'><input  type=\"checkbox\" name=\"hh_bleeding_conditions[]\" data-name=\"hh_bleeding_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Clotting Disorder\"  id='hh_bleeding_conditions_fb134515419fff2c52740ff3c7259158' aria-label='Clotting Disorder' aria-invalid='false' aria-required=false> <span>Clotting Disorder<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_bleeding_conditions_2a8493f46f888d7278054e5e3a3d0a18'><input  type=\"checkbox\" name=\"hh_bleeding_conditions[]\" data-name=\"hh_bleeding_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Von Willebrand\u2019s\"  id='hh_bleeding_conditions_2a8493f46f888d7278054e5e3a3d0a18' aria-label='Von Willebrand\u2019s' aria-invalid='false' aria-required=false> <span>Von Willebrand\u2019s<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_bleeding_conditions_b34d9e67da3444daa00c4bb73b42dd8b'><input  type=\"checkbox\" name=\"hh_bleeding_conditions[]\" data-name=\"hh_bleeding_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Factor 5 Deficiency\"  id='hh_bleeding_conditions_b34d9e67da3444daa00c4bb73b42dd8b' aria-label='Factor 5 Deficiency' aria-invalid='false' aria-required=false> <span>Factor 5 Deficiency<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_bleeding_conditions_f4fa3ce321c65cf92eb0157e16811d05'><input  type=\"checkbox\" name=\"hh_bleeding_conditions[]\" data-name=\"hh_bleeding_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Sickle Cell\"  id='hh_bleeding_conditions_f4fa3ce321c65cf92eb0157e16811d05' aria-label='Sickle Cell' aria-invalid='false' aria-required=false> <span>Sickle Cell<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_bleeding_conditions_a50cda0d01cf20eebfaa8ea320c0e35d'><input  type=\"checkbox\" name=\"hh_bleeding_conditions[]\" data-name=\"hh_bleeding_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Deep Vein Thrombosis (DVT)\"  id='hh_bleeding_conditions_a50cda0d01cf20eebfaa8ea320c0e35d' aria-label='Deep Vein Thrombosis (DVT)' aria-invalid='false' aria-required=false> <span>Deep Vein Thrombosis (DVT)<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_27\" ><h3 class='ff-el-section-title'>Autoimmune Issues<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Autoimmune Issues\">Autoimmune Issues<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_autoimmune_44e8834ed9051a502c3663dab81d357f'><input  type=\"radio\" name=\"hh_autoimmune\" data-name=\"hh_autoimmune\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_autoimmune_44e8834ed9051a502c3663dab81d357f' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_autoimmune_7efb5450e20cbc435d93617df3d7cdff'><input  type=\"radio\" name=\"hh_autoimmune\" data-name=\"hh_autoimmune\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_autoimmune_7efb5450e20cbc435d93617df3d7cdff' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_autoimmune_conditions_91f18149f8234f2170a94afb331d7119'><input  type=\"checkbox\" name=\"hh_autoimmune_conditions[]\" data-name=\"hh_autoimmune_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Lupus\"  id='hh_autoimmune_conditions_91f18149f8234f2170a94afb331d7119' aria-label='Lupus' aria-invalid='false' aria-required=false> <span>Lupus<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_autoimmune_conditions_02d4e50b8af57f98a3740cbd7e7a55bf'><input  type=\"checkbox\" name=\"hh_autoimmune_conditions[]\" data-name=\"hh_autoimmune_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Rheumatoid\"  id='hh_autoimmune_conditions_02d4e50b8af57f98a3740cbd7e7a55bf' aria-label='Rheumatoid' aria-invalid='false' aria-required=false> <span>Rheumatoid<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_autoimmune_conditions_04245c7dadd1fd7d317e8570f8e0a018'><input  type=\"checkbox\" name=\"hh_autoimmune_conditions[]\" data-name=\"hh_autoimmune_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Sjogren\u2019s Syndrome\"  id='hh_autoimmune_conditions_04245c7dadd1fd7d317e8570f8e0a018' aria-label='Sjogren\u2019s Syndrome' aria-invalid='false' aria-required=false> <span>Sjogren\u2019s Syndrome<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_28\" ><h3 class='ff-el-section-title'>Bone Disorder<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Bone Disorder\">Bone Disorder<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_bone_dbe85b2dd4e35257759ca4e4eeb90246'><input  type=\"radio\" name=\"hh_bone\" data-name=\"hh_bone\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_bone_dbe85b2dd4e35257759ca4e4eeb90246' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_bone_c413ac913bedc02e896545f0bda01dcb'><input  type=\"radio\" name=\"hh_bone\" data-name=\"hh_bone\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_bone_c413ac913bedc02e896545f0bda01dcb' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_bone_conditions_8943c43be4f65234b4decb7f58d29028'><input  type=\"checkbox\" name=\"hh_bone_conditions[]\" data-name=\"hh_bone_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Osteoporosis\"  id='hh_bone_conditions_8943c43be4f65234b4decb7f58d29028' aria-label='Osteoporosis' aria-invalid='false' aria-required=false> <span>Osteoporosis<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_bone_conditions_17f33a2e72c435520b4b071730bc4050'><input  type=\"checkbox\" name=\"hh_bone_conditions[]\" data-name=\"hh_bone_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Osteoarthritis\"  id='hh_bone_conditions_17f33a2e72c435520b4b071730bc4050' aria-label='Osteoarthritis' aria-invalid='false' aria-required=false> <span>Osteoarthritis<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_29\" ><h3 class='ff-el-section-title'>Gastrointestinal Issues<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Gastrointestinal Issues\">Gastrointestinal Issues<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_gi_23b2d2e825c96a9ca329c55cc9ac3888'><input  type=\"radio\" name=\"hh_gi\" data-name=\"hh_gi\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_gi_23b2d2e825c96a9ca329c55cc9ac3888' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_gi_b0be37af36f5381cf56a5a612c269b2b'><input  type=\"radio\" name=\"hh_gi\" data-name=\"hh_gi\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_gi_b0be37af36f5381cf56a5a612c269b2b' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_gi_conditions_4494daf73b47a75dde6f61f67c558a14'><input  type=\"checkbox\" name=\"hh_gi_conditions[]\" data-name=\"hh_gi_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Acid Reflux\"  id='hh_gi_conditions_4494daf73b47a75dde6f61f67c558a14' aria-label='Acid Reflux' aria-invalid='false' aria-required=false> <span>Acid Reflux<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_gi_conditions_28756ef370e79b4873ff0e9f37c54dc5'><input  type=\"checkbox\" name=\"hh_gi_conditions[]\" data-name=\"hh_gi_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ulcers\"  id='hh_gi_conditions_28756ef370e79b4873ff0e9f37c54dc5' aria-label='Ulcers' aria-invalid='false' aria-required=false> <span>Ulcers<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_gi_conditions_6aa00e58b4bd18f1ef628c91dd1a1cc5'><input  type=\"checkbox\" name=\"hh_gi_conditions[]\" data-name=\"hh_gi_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Gastric Bypass\"  id='hh_gi_conditions_6aa00e58b4bd18f1ef628c91dd1a1cc5' aria-label='Gastric Bypass' aria-invalid='false' aria-required=false> <span>Gastric Bypass<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_gi_conditions_5100ca382809a396b3a684f1eb80c149'><input  type=\"checkbox\" name=\"hh_gi_conditions[]\" data-name=\"hh_gi_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Gastric Band\"  id='hh_gi_conditions_5100ca382809a396b3a684f1eb80c149' aria-label='Gastric Band' aria-invalid='false' aria-required=false> <span>Gastric Band<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_30\" ><h3 class='ff-el-section-title'>History of Cancer<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"History of Cancer\">History of Cancer<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cancer_fcdd319b8f6e02d7987badd6c422859d'><input  type=\"radio\" name=\"hh_cancer\" data-name=\"hh_cancer\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_cancer_fcdd319b8f6e02d7987badd6c422859d' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_cancer_893de0b99da5c265c0a98f94830a8236'><input  type=\"radio\" name=\"hh_cancer\" data-name=\"hh_cancer\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_cancer_893de0b99da5c265c0a98f94830a8236' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_cancer_desc' id='label_ff_3_hh_cancer_desc' aria-label=\"If yes, describe\">If yes, describe<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_cancer_desc\" data-name=\"hh_cancer_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_cancer_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_31\" ><h3 class='ff-el-section-title'>History of Head and \/ or Neck Radiation<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"History of Head and \/ or Neck Radiation\">History of Head and \/ or Neck Radiation<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_radiation_f2b5b9bac94445462fc18dc1fa6cb4ec'><input  type=\"radio\" name=\"hh_radiation\" data-name=\"hh_radiation\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_radiation_f2b5b9bac94445462fc18dc1fa6cb4ec' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_radiation_c019eaa3269acf6ccd0e7254791c115d'><input  type=\"radio\" name=\"hh_radiation\" data-name=\"hh_radiation\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_radiation_c019eaa3269acf6ccd0e7254791c115d' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_radiation_desc' id='label_ff_3_hh_radiation_desc' aria-label=\"If yes, describe\">If yes, describe<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_radiation_desc\" data-name=\"hh_radiation_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_radiation_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_radiation_where' id='label_ff_3_hh_radiation_where' aria-label=\"Where\">Where<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_radiation_where\" data-name=\"hh_radiation_where\" class=\"ff-el-form-control\" id=\"ff_3_hh_radiation_where\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_32\" ><h3 class='ff-el-section-title'>Developmental Issues<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Developmental Issues\">Developmental Issues<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_developmental_d1cf4c14668dfa5d1fe82ac1026135d3'><input  type=\"radio\" name=\"hh_developmental\" data-name=\"hh_developmental\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_developmental_d1cf4c14668dfa5d1fe82ac1026135d3' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_developmental_152d4b754cca113725a7e3b578242db6'><input  type=\"radio\" name=\"hh_developmental\" data-name=\"hh_developmental\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_developmental_152d4b754cca113725a7e3b578242db6' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_developmental_conditions_269331911b4e6c5a493bd456ca65b338'><input  type=\"checkbox\" name=\"hh_developmental_conditions[]\" data-name=\"hh_developmental_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cerebral Palsy\"  id='hh_developmental_conditions_269331911b4e6c5a493bd456ca65b338' aria-label='Cerebral Palsy' aria-invalid='false' aria-required=false> <span>Cerebral Palsy<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_developmental_conditions_446ba1fbb5d3f94045df882d5fac34d7'><input  type=\"checkbox\" name=\"hh_developmental_conditions[]\" data-name=\"hh_developmental_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Autism\"  id='hh_developmental_conditions_446ba1fbb5d3f94045df882d5fac34d7' aria-label='Autism' aria-invalid='false' aria-required=false> <span>Autism<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_developmental_conditions_8e7480297618df3851d11d2c42319c42'><input  type=\"checkbox\" name=\"hh_developmental_conditions[]\" data-name=\"hh_developmental_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Blindness or other eye disorders\"  id='hh_developmental_conditions_8e7480297618df3851d11d2c42319c42' aria-label='Blindness or other eye disorders' aria-invalid='false' aria-required=false> <span>Blindness or other eye disorders<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_developmental_conditions_1939760d84c426e1eadd486df2995dae'><input  type=\"checkbox\" name=\"hh_developmental_conditions[]\" data-name=\"hh_developmental_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Deafness\"  id='hh_developmental_conditions_1939760d84c426e1eadd486df2995dae' aria-label='Deafness' aria-invalid='false' aria-required=false> <span>Deafness<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_33\" ><h3 class='ff-el-section-title'>Contagious Diseases<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Contagious Diseases\">Contagious Diseases<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_contagious_2fb94a1c2b03eb43ec4268793deeb4e9'><input  type=\"radio\" name=\"hh_contagious\" data-name=\"hh_contagious\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_contagious_2fb94a1c2b03eb43ec4268793deeb4e9' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_contagious_cab38bb3cb06455eacdf5f1ce6fc1eaa'><input  type=\"radio\" name=\"hh_contagious\" data-name=\"hh_contagious\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_contagious_cab38bb3cb06455eacdf5f1ce6fc1eaa' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_contagious_conditions_36545855a2131c9d181e609ee4426638'><input  type=\"checkbox\" name=\"hh_contagious_conditions[]\" data-name=\"hh_contagious_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Hepatitis\"  id='hh_contagious_conditions_36545855a2131c9d181e609ee4426638' aria-label='Hepatitis' aria-invalid='false' aria-required=false> <span>Hepatitis<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_contagious_conditions_abe2d0947c1674774d19ffab33ab5dc2'><input  type=\"checkbox\" name=\"hh_contagious_conditions[]\" data-name=\"hh_contagious_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"HIV\"  id='hh_contagious_conditions_abe2d0947c1674774d19ffab33ab5dc2' aria-label='HIV' aria-invalid='false' aria-required=false> <span>HIV<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_contagious_conditions_dc26f1f87df525c6e4069e77469d573a'><input  type=\"checkbox\" name=\"hh_contagious_conditions[]\" data-name=\"hh_contagious_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"AIDS\"  id='hh_contagious_conditions_dc26f1f87df525c6e4069e77469d573a' aria-label='AIDS' aria-invalid='false' aria-required=false> <span>AIDS<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_contagious_conditions_095776d8a7e279650bae75a43ea02d1d'><input  type=\"checkbox\" name=\"hh_contagious_conditions[]\" data-name=\"hh_contagious_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Tuberculosis\"  id='hh_contagious_conditions_095776d8a7e279650bae75a43ea02d1d' aria-label='Tuberculosis' aria-invalid='false' aria-required=false> <span>Tuberculosis<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_34\" ><h3 class='ff-el-section-title'>Smoke, Vape or Tobacco Use<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Smoke, Vape or Tobacco Use\">Smoke, Vape or Tobacco Use<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_tobacco_c1bd2fbca250ebf80ff837a3d0575e81'><input  type=\"radio\" name=\"hh_tobacco\" data-name=\"hh_tobacco\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_tobacco_c1bd2fbca250ebf80ff837a3d0575e81' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_tobacco_8565c034af8a45cddb0036ee6d84e053'><input  type=\"radio\" name=\"hh_tobacco\" data-name=\"hh_tobacco\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_tobacco_8565c034af8a45cddb0036ee6d84e053' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate type\">If yes, please indicate type<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_tobacco_types_fc98a27b0bc95cf7dfe16322ff547208'><input  type=\"checkbox\" name=\"hh_tobacco_types[]\" data-name=\"hh_tobacco_types\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cigarettes\"  id='hh_tobacco_types_fc98a27b0bc95cf7dfe16322ff547208' aria-label='Cigarettes' aria-invalid='false' aria-required=false> <span>Cigarettes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_tobacco_types_f04f4417ed54869d316c771e6208ffbb'><input  type=\"checkbox\" name=\"hh_tobacco_types[]\" data-name=\"hh_tobacco_types\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cigars \/ Pipe\"  id='hh_tobacco_types_f04f4417ed54869d316c771e6208ffbb' aria-label='Cigars \/ Pipe' aria-invalid='false' aria-required=false> <span>Cigars \/ Pipe<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_tobacco_types_72291e8e21a71ccc483d42fde7a97212'><input  type=\"checkbox\" name=\"hh_tobacco_types[]\" data-name=\"hh_tobacco_types\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Chewing Tobacco \/ Snuff Dipping\"  id='hh_tobacco_types_72291e8e21a71ccc483d42fde7a97212' aria-label='Chewing Tobacco \/ Snuff Dipping' aria-invalid='false' aria-required=false> <span>Chewing Tobacco \/ Snuff Dipping<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_tobacco_types_a7c25140871b0a695e938a13480aba81'><input  type=\"checkbox\" name=\"hh_tobacco_types[]\" data-name=\"hh_tobacco_types\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Vaping\"  id='hh_tobacco_types_a7c25140871b0a695e938a13480aba81' aria-label='Vaping' aria-invalid='false' aria-required=false> <span>Vaping<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_42\"  class='ff-t-container ff-column-container ff_columns_total_2 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_tobacco_how_much' id='label_ff_3_hh_tobacco_how_much' aria-label=\"How many times \/ packs per day\">How many times \/ packs per day<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_tobacco_how_much\" data-name=\"hh_tobacco_how_much\" class=\"ff-el-form-control\" id=\"ff_3_hh_tobacco_how_much\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_tobacco_years' id='label_ff_3_hh_tobacco_years' aria-label=\"How long (years)\">How long (years)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_tobacco_years\" data-name=\"hh_tobacco_years\" class=\"ff-el-form-control\" id=\"ff_3_hh_tobacco_years\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_35\" ><h3 class='ff-el-section-title'>Marijuana Use<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Marijuana \u2014 do you use?\">Marijuana \u2014 do you use?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_marijuana_723e83edfb4365ab011b470f7f58f018'><input  type=\"radio\" name=\"hh_marijuana\" data-name=\"hh_marijuana\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_marijuana_723e83edfb4365ab011b470f7f58f018' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_marijuana_b500c8eca33cd70691fc7f1fa034ef4b'><input  type=\"radio\" name=\"hh_marijuana\" data-name=\"hh_marijuana\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_marijuana_b500c8eca33cd70691fc7f1fa034ef4b' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Medical Marijuana\">Medical Marijuana<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_marijuana_medical_774781de478afdfe8811fbf9e37d4f39'><input  type=\"radio\" name=\"hh_marijuana_medical\" data-name=\"hh_marijuana_medical\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_marijuana_medical_774781de478afdfe8811fbf9e37d4f39' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_marijuana_medical_d4b0143f45f92abea3e7ae4b2de10298'><input  type=\"radio\" name=\"hh_marijuana_medical\" data-name=\"hh_marijuana_medical\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_marijuana_medical_d4b0143f45f92abea3e7ae4b2de10298' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_marijuana_condition' id='label_ff_3_hh_marijuana_condition' aria-label=\"If yes for medical marijuana use, for what condition?\">If yes for medical marijuana use, for what condition?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_marijuana_condition\" data-name=\"hh_marijuana_condition\" class=\"ff-el-form-control\" id=\"ff_3_hh_marijuana_condition\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Recreational Marijuana\">Recreational Marijuana<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_marijuana_recreational_7bf20df1de2feec85c69da6a79bf2a74'><input  type=\"radio\" name=\"hh_marijuana_recreational\" data-name=\"hh_marijuana_recreational\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_marijuana_recreational_7bf20df1de2feec85c69da6a79bf2a74' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_marijuana_recreational_8504785545169c397dfc5b1c7ceb8a4b'><input  type=\"radio\" name=\"hh_marijuana_recreational\" data-name=\"hh_marijuana_recreational\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_marijuana_recreational_8504785545169c397dfc5b1c7ceb8a4b' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, what types?\">If yes, what types?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_marijuana_types_23d595c555c113c5d0c7c481a3bffb60'><input  type=\"checkbox\" name=\"hh_marijuana_types[]\" data-name=\"hh_marijuana_types\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Smoke\"  id='hh_marijuana_types_23d595c555c113c5d0c7c481a3bffb60' aria-label='Smoke' aria-invalid='false' aria-required=false> <span>Smoke<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_marijuana_types_5c8f66ab7eb3f0c5f20875d931cd1639'><input  type=\"checkbox\" name=\"hh_marijuana_types[]\" data-name=\"hh_marijuana_types\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Vape\"  id='hh_marijuana_types_5c8f66ab7eb3f0c5f20875d931cd1639' aria-label='Vape' aria-invalid='false' aria-required=false> <span>Vape<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_marijuana_types_7c4a53fc948411dac9a706a66a6fb858'><input  type=\"checkbox\" name=\"hh_marijuana_types[]\" data-name=\"hh_marijuana_types\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Edibles\"  id='hh_marijuana_types_7c4a53fc948411dac9a706a66a6fb858' aria-label='Edibles' aria-invalid='false' aria-required=false> <span>Edibles<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_marijuana_per_week' id='label_ff_3_hh_marijuana_per_week' aria-label=\"How many times per week?\">How many times per week?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_marijuana_per_week\" data-name=\"hh_marijuana_per_week\" class=\"ff-el-form-control\" id=\"ff_3_hh_marijuana_per_week\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_36\" ><h3 class='ff-el-section-title'>Dependency, Mis-Use or Abuse \u2014 Current or History<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Dependency, Mis-Use or Abuse \u2014 Current or History\">Dependency, Mis-Use or Abuse \u2014 Current or History<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_dependency_0a4126f50b11270cd15870995f46ce6c'><input  type=\"radio\" name=\"hh_dependency\" data-name=\"hh_dependency\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_dependency_0a4126f50b11270cd15870995f46ce6c' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_dependency_4e89ddd174b33db9d2c62424f8b6e788'><input  type=\"radio\" name=\"hh_dependency\" data-name=\"hh_dependency\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_dependency_4e89ddd174b33db9d2c62424f8b6e788' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If yes, please indicate the condition\">If yes, please indicate the condition<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_dependency_conditions_8a59aa139170ef5c1746f99e712e4a94'><input  type=\"checkbox\" name=\"hh_dependency_conditions[]\" data-name=\"hh_dependency_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Alcohol\"  id='hh_dependency_conditions_8a59aa139170ef5c1746f99e712e4a94' aria-label='Alcohol' aria-invalid='false' aria-required=false> <span>Alcohol<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_dependency_conditions_73fe4862d3c25a277ba1fa429c92d4f9'><input  type=\"checkbox\" name=\"hh_dependency_conditions[]\" data-name=\"hh_dependency_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Prescription Meds (e.g., Vicodin, Percocet, Oxycontin)\"  id='hh_dependency_conditions_73fe4862d3c25a277ba1fa429c92d4f9' aria-label='Prescription Meds (e.g., Vicodin, Percocet, Oxycontin)' aria-invalid='false' aria-required=false> <span>Prescription Meds (e.g., Vicodin, Percocet, Oxycontin)<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_dependency_conditions_692c0140ecda899c26a985c6a91fd9f2'><input  type=\"checkbox\" name=\"hh_dependency_conditions[]\" data-name=\"hh_dependency_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Recreational Opioid Drugs (e.g., Heroin, Fentanyl)\"  id='hh_dependency_conditions_692c0140ecda899c26a985c6a91fd9f2' aria-label='Recreational Opioid Drugs (e.g., Heroin, Fentanyl)' aria-invalid='false' aria-required=false> <span>Recreational Opioid Drugs (e.g., Heroin, Fentanyl)<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_dependency_conditions_1217f0f05e7bfef0f8e87c03aaf978b9'><input  type=\"checkbox\" name=\"hh_dependency_conditions[]\" data-name=\"hh_dependency_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cocaine\"  id='hh_dependency_conditions_1217f0f05e7bfef0f8e87c03aaf978b9' aria-label='Cocaine' aria-invalid='false' aria-required=false> <span>Cocaine<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Other\">Other<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_dependency_other_3f9c584e33abb609679e299933a1f83b'><input  type=\"radio\" name=\"hh_dependency_other\" data-name=\"hh_dependency_other\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_dependency_other_3f9c584e33abb609679e299933a1f83b' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_dependency_other_1d26d5b3ac582d43a41bc4e23aeb1662'><input  type=\"radio\" name=\"hh_dependency_other\" data-name=\"hh_dependency_other\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_dependency_other_1d26d5b3ac582d43a41bc4e23aeb1662' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_dependency_other_desc' id='label_ff_3_hh_dependency_other_desc' aria-label=\"Please specify\">Please specify<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_dependency_other_desc\" data-name=\"hh_dependency_other_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_dependency_other_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Are you currently in a care program for this history?\">Are you currently in a care program for this history?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_dependency_program_940695c464d7136cb1bd8a2f72d1f196'><input  type=\"radio\" name=\"hh_dependency_program\" data-name=\"hh_dependency_program\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_dependency_program_940695c464d7136cb1bd8a2f72d1f196' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_dependency_program_8162429fc66ed2810b2b4391f27fd24e'><input  type=\"radio\" name=\"hh_dependency_program\" data-name=\"hh_dependency_program\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_dependency_program_8162429fc66ed2810b2b4391f27fd24e' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Are you under a contract with your treating provider?\">Are you under a contract with your treating provider?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_dependency_contract_0e953b747841f19642f8b09dc7ef67e0'><input  type=\"radio\" name=\"hh_dependency_contract\" data-name=\"hh_dependency_contract\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_dependency_contract_0e953b747841f19642f8b09dc7ef67e0' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_dependency_contract_80eb8ecb93cdbd7f812b03f385aaa806'><input  type=\"radio\" name=\"hh_dependency_contract\" data-name=\"hh_dependency_contract\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_dependency_contract_80eb8ecb93cdbd7f812b03f385aaa806' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_43\"  class='ff-t-container ff-column-container ff_columns_total_3 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_dependency_dr_first' id='label_ff_3_hh_dependency_dr_first' aria-label=\"If yes, with whom \u2014 First Name\">If yes, with whom \u2014 First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_dependency_dr_first\" data-name=\"hh_dependency_dr_first\" class=\"ff-el-form-control\" id=\"ff_3_hh_dependency_dr_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_dependency_dr_last' id='label_ff_3_hh_dependency_dr_last' aria-label=\"Last Name\">Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_dependency_dr_last\" data-name=\"hh_dependency_dr_last\" class=\"ff-el-form-control\" id=\"ff_3_hh_dependency_dr_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_dependency_dr_phone' id='label_ff_3_hh_dependency_dr_phone' aria-label=\"Phone\">Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_dependency_dr_phone\" placeholder=\"(555) 555-5555\" data-mask=\"(000) 000-0000\" data-name=\"hh_dependency_dr_phone\" class=\"ff-el-form-control\" id=\"ff_3_hh_dependency_dr_phone\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_recovery_length' id='label_ff_3_hh_recovery_length' aria-label=\"If no, how long have you been in recovery?\">If no, how long have you been in recovery?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_recovery_length\" data-name=\"hh_recovery_length\" class=\"ff-el-form-control\" id=\"ff_3_hh_recovery_length\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_37\" ><h3 class='ff-el-section-title'>Pain Management Program or Recovery Program<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Pain Management Program or Recovery Program\">Pain Management Program or Recovery Program<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_pain_program_4a8fde7dad56d14deb34e5b7b9ed2ead'><input  type=\"radio\" name=\"hh_pain_program\" data-name=\"hh_pain_program\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_pain_program_4a8fde7dad56d14deb34e5b7b9ed2ead' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_pain_program_af99994bb72fffc13b36489e8b8488a9'><input  type=\"radio\" name=\"hh_pain_program\" data-name=\"hh_pain_program\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_pain_program_af99994bb72fffc13b36489e8b8488a9' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_pain_program_desc' id='label_ff_3_hh_pain_program_desc' aria-label=\"If yes, please define\">If yes, please define<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_pain_program_desc\" data-name=\"hh_pain_program_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_pain_program_desc\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_44\"  class='ff-t-container ff-column-container ff_columns_total_3 has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_pain_dr_first' id='label_ff_3_hh_pain_dr_first' aria-label=\"With whom \u2014 First Name\">With whom \u2014 First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_pain_dr_first\" data-name=\"hh_pain_dr_first\" class=\"ff-el-form-control\" id=\"ff_3_hh_pain_dr_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_pain_dr_last' id='label_ff_3_hh_pain_dr_last' aria-label=\"Last Name\">Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_pain_dr_last\" data-name=\"hh_pain_dr_last\" class=\"ff-el-form-control\" id=\"ff_3_hh_pain_dr_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_pain_dr_phone' id='label_ff_3_hh_pain_dr_phone' aria-label=\"Phone\">Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_pain_dr_phone\" placeholder=\"(555) 555-5555\" data-mask=\"(000) 000-0000\" data-name=\"hh_pain_dr_phone\" class=\"ff-el-form-control\" id=\"ff_3_hh_pain_dr_phone\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_38\" ><h3 class='ff-el-section-title'>Women<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Are you or could you be pregnant?\">Are you or could you be pregnant?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_pregnant_8d842822fd50dfeb0c5f142a02da5bf2'><input  type=\"radio\" name=\"hh_pregnant\" data-name=\"hh_pregnant\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_pregnant_8d842822fd50dfeb0c5f142a02da5bf2' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_pregnant_938521477502251914a6d2cdeb428e27'><input  type=\"radio\" name=\"hh_pregnant\" data-name=\"hh_pregnant\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_pregnant_938521477502251914a6d2cdeb428e27' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_due_date' id='label_ff_3_hh_due_date' aria-label=\"If yes, when is your estimated due date?\">If yes, when is your estimated due date?<\/label><\/div><div class='ff-el-input--content'><input  aria-label='If yes, when is your estimated due date? Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"hh_due_date\" placeholder=\"MM\/DD\/YYYY\" data-name=\"hh_due_date\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_3_hh_due_date\"  aria-invalid='false' aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_last_cycle' id='label_ff_3_hh_last_cycle' aria-label=\"If unsure if you might be pregnant, when was your last menstrual cycle?\">If unsure if you might be pregnant, when was your last menstrual cycle?<\/label><\/div><div class='ff-el-input--content'><input  aria-label='If unsure if you might be pregnant, when was your last menstrual cycle? Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"hh_last_cycle\" placeholder=\"MM\/DD\/YYYY\" data-name=\"hh_last_cycle\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_3_hh_last_cycle\"  aria-invalid='false' aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_39\" ><h3 class='ff-el-section-title'>Other Medical Condition Not Addressed<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Other Medical Condition Not Addressed\">Other Medical Condition Not Addressed<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_other_conditions_66436f27b799a956ec4d58520bc81c19'><input  type=\"radio\" name=\"hh_other_conditions\" data-name=\"hh_other_conditions\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='hh_other_conditions_66436f27b799a956ec4d58520bc81c19' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='hh_other_conditions_e94882c787d889b27274cf446ec3165d'><input  type=\"radio\" name=\"hh_other_conditions\" data-name=\"hh_other_conditions\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='hh_other_conditions_e94882c787d889b27274cf446ec3165d' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_other_conditions_desc' id='label_ff_3_hh_other_conditions_desc' aria-label=\"If yes, describe\">If yes, describe<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_hh_other_conditions_desc\" name=\"hh_other_conditions_desc\" rows=\"4\" cols=\"2\" data-name=\"hh_other_conditions_desc\" class=\"ff-el-form-control\" id=\"ff_3_hh_other_conditions_desc\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_40\" ><h3 class='ff-el-section-title'>Patient \/ Guardian Signature<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_45\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_hh_sig_signature' id='label_ff_3_hh_sig_signature' aria-label=\"Signature \u2014 type your full legal name\">Signature \u2014 type your full legal name<\/label><div class=\"ff-el-tooltip\" data-content=\"Typing your name here serves as your electronic signature.\"><svg width=\"16\" height=\"16\" viewbox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_sig_signature\" data-name=\"hh_sig_signature\" class=\"ff-el-form-control\" id=\"ff_3_hh_sig_signature\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_hh_sig_date' id='label_ff_3_hh_sig_date' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"hh_sig_date\" placeholder=\"MM\/DD\/YYYY\" data-name=\"hh_sig_date\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_3_hh_sig_date\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_hh_sig_relationship' id='label_ff_3_hh_sig_relationship' aria-label=\"Relationship to patient (if signing for a minor or as guardian)\">Relationship to patient (if signing for a minor or as guardian)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"hh_sig_relationship\" data-name=\"hh_sig_relationship\" class=\"ff-el-form-control\" id=\"ff_3_hh_sig_relationship\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_41\" ><h2>Medications \/ Allergies<\/h2><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_42\" ><h3 class='ff-el-section-title'>Please list any medications you are currently taking<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_46\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med1_name' id='label_ff_3_med1_name' >Medication #1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med1_name\" data-name=\"med1_name\" class=\"ff-el-form-control\" id=\"ff_3_med1_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med1_dosage' id='label_ff_3_med1_dosage' aria-label=\"Dosage\">Dosage<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med1_dosage\" data-name=\"med1_dosage\" class=\"ff-el-form-control\" id=\"ff_3_med1_dosage\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med1_frequency' id='label_ff_3_med1_frequency' aria-label=\"Frequency\">Frequency<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med1_frequency\" data-name=\"med1_frequency\" class=\"ff-el-form-control\" id=\"ff_3_med1_frequency\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_47\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med2_name' id='label_ff_3_med2_name' >Medication #2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med2_name\" data-name=\"med2_name\" class=\"ff-el-form-control\" id=\"ff_3_med2_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med2_dosage' id='label_ff_3_med2_dosage' aria-label=\"Dosage\">Dosage<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med2_dosage\" data-name=\"med2_dosage\" class=\"ff-el-form-control\" id=\"ff_3_med2_dosage\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med2_frequency' id='label_ff_3_med2_frequency' aria-label=\"Frequency\">Frequency<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med2_frequency\" data-name=\"med2_frequency\" class=\"ff-el-form-control\" id=\"ff_3_med2_frequency\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_48\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med3_name' id='label_ff_3_med3_name' >Medication #3<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med3_name\" data-name=\"med3_name\" class=\"ff-el-form-control\" id=\"ff_3_med3_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med3_dosage' id='label_ff_3_med3_dosage' aria-label=\"Dosage\">Dosage<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med3_dosage\" data-name=\"med3_dosage\" class=\"ff-el-form-control\" id=\"ff_3_med3_dosage\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med3_frequency' id='label_ff_3_med3_frequency' aria-label=\"Frequency\">Frequency<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med3_frequency\" data-name=\"med3_frequency\" class=\"ff-el-form-control\" id=\"ff_3_med3_frequency\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_49\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med4_name' id='label_ff_3_med4_name' >Medication #4<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med4_name\" data-name=\"med4_name\" class=\"ff-el-form-control\" id=\"ff_3_med4_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med4_dosage' id='label_ff_3_med4_dosage' aria-label=\"Dosage\">Dosage<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med4_dosage\" data-name=\"med4_dosage\" class=\"ff-el-form-control\" id=\"ff_3_med4_dosage\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med4_frequency' id='label_ff_3_med4_frequency' aria-label=\"Frequency\">Frequency<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med4_frequency\" data-name=\"med4_frequency\" class=\"ff-el-form-control\" id=\"ff_3_med4_frequency\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_50\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med5_name' id='label_ff_3_med5_name' >Medication #5<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med5_name\" data-name=\"med5_name\" class=\"ff-el-form-control\" id=\"ff_3_med5_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med5_dosage' id='label_ff_3_med5_dosage' aria-label=\"Dosage\">Dosage<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med5_dosage\" data-name=\"med5_dosage\" class=\"ff-el-form-control\" id=\"ff_3_med5_dosage\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med5_frequency' id='label_ff_3_med5_frequency' aria-label=\"Frequency\">Frequency<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med5_frequency\" data-name=\"med5_frequency\" class=\"ff-el-form-control\" id=\"ff_3_med5_frequency\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_51\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med6_name' id='label_ff_3_med6_name' >Medication #6<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med6_name\" data-name=\"med6_name\" class=\"ff-el-form-control\" id=\"ff_3_med6_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med6_dosage' id='label_ff_3_med6_dosage' aria-label=\"Dosage\">Dosage<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med6_dosage\" data-name=\"med6_dosage\" class=\"ff-el-form-control\" id=\"ff_3_med6_dosage\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med6_frequency' id='label_ff_3_med6_frequency' aria-label=\"Frequency\">Frequency<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med6_frequency\" data-name=\"med6_frequency\" class=\"ff-el-form-control\" id=\"ff_3_med6_frequency\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_52\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med7_name' id='label_ff_3_med7_name' >Medication #7<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med7_name\" data-name=\"med7_name\" class=\"ff-el-form-control\" id=\"ff_3_med7_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med7_dosage' id='label_ff_3_med7_dosage' aria-label=\"Dosage\">Dosage<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med7_dosage\" data-name=\"med7_dosage\" class=\"ff-el-form-control\" id=\"ff_3_med7_dosage\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med7_frequency' id='label_ff_3_med7_frequency' aria-label=\"Frequency\">Frequency<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med7_frequency\" data-name=\"med7_frequency\" class=\"ff-el-form-control\" id=\"ff_3_med7_frequency\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_53\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med8_name' id='label_ff_3_med8_name' >Medication #8<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med8_name\" data-name=\"med8_name\" class=\"ff-el-form-control\" id=\"ff_3_med8_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med8_dosage' id='label_ff_3_med8_dosage' aria-label=\"Dosage\">Dosage<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med8_dosage\" data-name=\"med8_dosage\" class=\"ff-el-form-control\" id=\"ff_3_med8_dosage\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med8_frequency' id='label_ff_3_med8_frequency' aria-label=\"Frequency\">Frequency<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med8_frequency\" data-name=\"med8_frequency\" class=\"ff-el-form-control\" id=\"ff_3_med8_frequency\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_54\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med9_name' id='label_ff_3_med9_name' >Medication #9<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med9_name\" data-name=\"med9_name\" class=\"ff-el-form-control\" id=\"ff_3_med9_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med9_dosage' id='label_ff_3_med9_dosage' aria-label=\"Dosage\">Dosage<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med9_dosage\" data-name=\"med9_dosage\" class=\"ff-el-form-control\" id=\"ff_3_med9_dosage\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med9_frequency' id='label_ff_3_med9_frequency' aria-label=\"Frequency\">Frequency<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med9_frequency\" data-name=\"med9_frequency\" class=\"ff-el-form-control\" id=\"ff_3_med9_frequency\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_55\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med10_name' id='label_ff_3_med10_name' >Medication #10<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med10_name\" data-name=\"med10_name\" class=\"ff-el-form-control\" id=\"ff_3_med10_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med10_dosage' id='label_ff_3_med10_dosage' aria-label=\"Dosage\">Dosage<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med10_dosage\" data-name=\"med10_dosage\" class=\"ff-el-form-control\" id=\"ff_3_med10_dosage\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med10_frequency' id='label_ff_3_med10_frequency' aria-label=\"Frequency\">Frequency<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"med10_frequency\" data-name=\"med10_frequency\" class=\"ff-el-form-control\" id=\"ff_3_med10_frequency\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='med_more_d09129236a3bb37bef0b7a56a33ebf3d'><input  type=\"checkbox\" name=\"med_more[]\" data-name=\"med_more\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I take more than 10 medications\"  id='med_more_d09129236a3bb37bef0b7a56a33ebf3d' aria-label='I take more than 10 medications' aria-invalid='false' aria-required=false> <span>I take more than 10 medications<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_med_additional' id='label_ff_3_med_additional' aria-label=\"Additional medications (name, dosage, frequency \u2014 one per line)\">Additional medications (name, dosage, frequency \u2014 one per line)<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_med_additional\" name=\"med_additional\" rows=\"8\" cols=\"2\" data-name=\"med_additional\" class=\"ff-el-form-control\" id=\"ff_3_med_additional\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_43\" ><h3 class='ff-el-section-title'>Are you allergic to, or have you had a reaction to:<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_56\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Penicillin \/ Amoxicillin\">Penicillin \/ Amoxicillin<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='allergy_penicillin_79265b4f30fa12185759612a5e547f77'><input  type=\"radio\" name=\"allergy_penicillin\" data-name=\"allergy_penicillin\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='allergy_penicillin_79265b4f30fa12185759612a5e547f77' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='allergy_penicillin_2a8b40de377ad279a4f941f61f7ae3b2'><input  type=\"radio\" name=\"allergy_penicillin\" data-name=\"allergy_penicillin\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='allergy_penicillin_2a8b40de377ad279a4f941f61f7ae3b2' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Ibuprofen \/ Motrin\">Ibuprofen \/ Motrin<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='allergy_ibuprofen_86cbaef431fffea44018e9b7363883c2'><input  type=\"radio\" name=\"allergy_ibuprofen\" data-name=\"allergy_ibuprofen\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='allergy_ibuprofen_86cbaef431fffea44018e9b7363883c2' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='allergy_ibuprofen_655d0df0b089133f84c73008c0d74366'><input  type=\"radio\" name=\"allergy_ibuprofen\" data-name=\"allergy_ibuprofen\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='allergy_ibuprofen_655d0df0b089133f84c73008c0d74366' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Sulfa drugs\">Sulfa drugs<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='allergy_sulfa_4464196edab4ef0b883fced3995457bd'><input  type=\"radio\" name=\"allergy_sulfa\" data-name=\"allergy_sulfa\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='allergy_sulfa_4464196edab4ef0b883fced3995457bd' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='allergy_sulfa_24913b4341c1ffa183ccab63145b2efb'><input  type=\"radio\" name=\"allergy_sulfa\" data-name=\"allergy_sulfa\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='allergy_sulfa_24913b4341c1ffa183ccab63145b2efb' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Codeine or other narcotics\">Codeine or other narcotics<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='allergy_codeine_b0519c3eb6014626953b75c1729f2dae'><input  type=\"radio\" name=\"allergy_codeine\" data-name=\"allergy_codeine\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='allergy_codeine_b0519c3eb6014626953b75c1729f2dae' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='allergy_codeine_13d0210777f24a2118663e8cbd216afd'><input  type=\"radio\" name=\"allergy_codeine\" data-name=\"allergy_codeine\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='allergy_codeine_13d0210777f24a2118663e8cbd216afd' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Latex allergy\">Latex allergy<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='allergy_latex_62143aca224c2525a85e18c25e3fc749'><input  type=\"radio\" name=\"allergy_latex\" data-name=\"allergy_latex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='allergy_latex_62143aca224c2525a85e18c25e3fc749' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='allergy_latex_e3c50a4a3e177fe9c8241e5a43cea45d'><input  type=\"radio\" name=\"allergy_latex\" data-name=\"allergy_latex\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='allergy_latex_e3c50a4a3e177fe9c8241e5a43cea45d' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_44\" ><h3 class='ff-el-section-title'>Please list any other medication or antibiotic you are allergic to or have been advised not to take<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_57\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy1_drug' id='label_ff_3_allergy1_drug' aria-label=\"Drug #1\">Drug #1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy1_drug\" data-name=\"allergy1_drug\" class=\"ff-el-form-control\" id=\"ff_3_allergy1_drug\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy1_reaction' id='label_ff_3_allergy1_reaction' aria-label=\"Reaction\">Reaction<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy1_reaction\" data-name=\"allergy1_reaction\" class=\"ff-el-form-control\" id=\"ff_3_allergy1_reaction\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_58\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy2_drug' id='label_ff_3_allergy2_drug' aria-label=\"Drug #2\">Drug #2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy2_drug\" data-name=\"allergy2_drug\" class=\"ff-el-form-control\" id=\"ff_3_allergy2_drug\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy2_reaction' id='label_ff_3_allergy2_reaction' aria-label=\"Reaction\">Reaction<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy2_reaction\" data-name=\"allergy2_reaction\" class=\"ff-el-form-control\" id=\"ff_3_allergy2_reaction\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_59\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy3_drug' id='label_ff_3_allergy3_drug' aria-label=\"Drug #3\">Drug #3<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy3_drug\" data-name=\"allergy3_drug\" class=\"ff-el-form-control\" id=\"ff_3_allergy3_drug\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy3_reaction' id='label_ff_3_allergy3_reaction' aria-label=\"Reaction\">Reaction<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy3_reaction\" data-name=\"allergy3_reaction\" class=\"ff-el-form-control\" id=\"ff_3_allergy3_reaction\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_60\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy4_drug' id='label_ff_3_allergy4_drug' aria-label=\"Drug #4\">Drug #4<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy4_drug\" data-name=\"allergy4_drug\" class=\"ff-el-form-control\" id=\"ff_3_allergy4_drug\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy4_reaction' id='label_ff_3_allergy4_reaction' aria-label=\"Reaction\">Reaction<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy4_reaction\" data-name=\"allergy4_reaction\" class=\"ff-el-form-control\" id=\"ff_3_allergy4_reaction\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_61\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy5_drug' id='label_ff_3_allergy5_drug' aria-label=\"Drug #5\">Drug #5<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy5_drug\" data-name=\"allergy5_drug\" class=\"ff-el-form-control\" id=\"ff_3_allergy5_drug\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy5_reaction' id='label_ff_3_allergy5_reaction' aria-label=\"Reaction\">Reaction<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy5_reaction\" data-name=\"allergy5_reaction\" class=\"ff-el-form-control\" id=\"ff_3_allergy5_reaction\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_62\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy6_drug' id='label_ff_3_allergy6_drug' aria-label=\"Drug #6\">Drug #6<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy6_drug\" data-name=\"allergy6_drug\" class=\"ff-el-form-control\" id=\"ff_3_allergy6_drug\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy6_reaction' id='label_ff_3_allergy6_reaction' aria-label=\"Reaction\">Reaction<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy6_reaction\" data-name=\"allergy6_reaction\" class=\"ff-el-form-control\" id=\"ff_3_allergy6_reaction\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_63\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy7_drug' id='label_ff_3_allergy7_drug' aria-label=\"Drug #7\">Drug #7<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy7_drug\" data-name=\"allergy7_drug\" class=\"ff-el-form-control\" id=\"ff_3_allergy7_drug\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy7_reaction' id='label_ff_3_allergy7_reaction' aria-label=\"Reaction\">Reaction<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy7_reaction\" data-name=\"allergy7_reaction\" class=\"ff-el-form-control\" id=\"ff_3_allergy7_reaction\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_64\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy8_drug' id='label_ff_3_allergy8_drug' aria-label=\"Drug #8\">Drug #8<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy8_drug\" data-name=\"allergy8_drug\" class=\"ff-el-form-control\" id=\"ff_3_allergy8_drug\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy8_reaction' id='label_ff_3_allergy8_reaction' aria-label=\"Reaction\">Reaction<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy8_reaction\" data-name=\"allergy8_reaction\" class=\"ff-el-form-control\" id=\"ff_3_allergy8_reaction\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_65\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy9_drug' id='label_ff_3_allergy9_drug' aria-label=\"Drug #9\">Drug #9<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy9_drug\" data-name=\"allergy9_drug\" class=\"ff-el-form-control\" id=\"ff_3_allergy9_drug\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_allergy9_reaction' id='label_ff_3_allergy9_reaction' aria-label=\"Reaction\">Reaction<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"allergy9_reaction\" data-name=\"allergy9_reaction\" class=\"ff-el-form-control\" id=\"ff_3_allergy9_reaction\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_45\" ><h3 class='ff-el-section-title'>List any surgeries, operations, or procedures you have undergone and when<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_surgeries_list' id='label_ff_3_surgeries_list' aria-label=\"Surgeries \/ operations \/ procedures and dates\">Surgeries \/ operations \/ procedures and dates<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_surgeries_list\" name=\"surgeries_list\" rows=\"8\" cols=\"2\" data-name=\"surgeries_list\" class=\"ff-el-form-control\" id=\"ff_3_surgeries_list\" ><\/textarea><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_46\" ><h2>Medical Health History Acknowledgement<\/h2><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his \/ her staff, responsible for any errors or omissions that I have made in the completion of this form.' class='ff-el-form-check-label ff_tc_label' for='ack_medical_history_d511aecc398258cde24531c40f2af239'><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"ack_medical_history\" class=\"ff-el-form-check-input ff_tc_checkbox\" data-name=\"ack_medical_history\" id=\"ack_medical_history_d511aecc398258cde24531c40f2af239\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'><strong>I certify<\/strong> that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his \/ her staff, responsible for any errors or omissions that I have made in the completion of this form.<\/div><\/label><\/div><\/div><div data-name=\"ff_cn_id_66\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_ack_sig_signature' id='label_ff_3_ack_sig_signature' aria-label=\"Signature \u2014 type your full legal name\">Signature \u2014 type your full legal name<\/label><div class=\"ff-el-tooltip\" data-content=\"Typing your name here serves as your electronic signature.\"><svg width=\"16\" height=\"16\" viewbox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"ack_sig_signature\" data-name=\"ack_sig_signature\" class=\"ff-el-form-control\" id=\"ff_3_ack_sig_signature\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_ack_sig_date' id='label_ff_3_ack_sig_date' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"ack_sig_date\" placeholder=\"MM\/DD\/YYYY\" data-name=\"ack_sig_date\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_3_ack_sig_date\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ack_sig_relationship' id='label_ff_3_ack_sig_relationship' aria-label=\"If minor, relationship to patient\">If minor, relationship to patient<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"ack_sig_relationship\" data-name=\"ack_sig_relationship\" class=\"ff-el-form-control\" id=\"ff_3_ack_sig_relationship\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_47\" ><h3 class='ff-el-section-title'>Fees &amp; Payments Policy<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_48\" ><p>We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and\/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.<\/p> <p>Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys\u2019 fees, and court costs.<\/p> <p>Signature Oral Surgery is only a part of a coordinated care team that may be required for all of my or the patient\u2019s needs. I understand that I would also be responsible for payment for services provided by the general dentist, other dental practitioners, laboratories and pathology services (e.g. review of biopsy specimens), and\/or hospitals, clinics and medical providers at other facilities, where I may need follow-up evaluation and additional treatment related to my care at Signature Oral Surgery or any complications I may encounter.<\/p> <p>The signature below is my authorization for the release of information necessary to process my claim. I hereby authorize payment to the provider named or the benefits otherwise payable to me. Also, my signature below confirms I understand and agree with the FEES &amp; PAYMENT POLICY as noted above.<\/p><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand and agree with the Fees &amp; Payments Policy above.' class='ff-el-form-check-label ff_tc_label' for='ack_fees_4985fd5696e06d9b06658874b120ae6d'><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"ack_fees\" class=\"ff-el-form-check-input ff_tc_checkbox\" data-name=\"ack_fees\" id=\"ack_fees_4985fd5696e06d9b06658874b120ae6d\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand and agree with the Fees &amp; Payments Policy above.<\/div><\/label><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_49\" ><h3 class='ff-el-section-title'>Authorization Policy<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_50\" ><p>I authorize Signature Oral Surgery, my provider and his \/ her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and\/or insurance carriers. I permit messages to be left on my phone and \/ or mobile phone concerning my appointment. My signature below confirms I understand and agree with the AUTHORIZATION POLICY for evaluation and treatment noted above.<\/p><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand and agree with the Authorization Policy above.' class='ff-el-form-check-label ff_tc_label' for='ack_authorization_a1fb90c1bec8dfad7f7a0b9e7ec93ee8'><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"ack_authorization\" class=\"ff-el-form-check-input ff_tc_checkbox\" data-name=\"ack_authorization\" id=\"ack_authorization_a1fb90c1bec8dfad7f7a0b9e7ec93ee8\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand and agree with the Authorization Policy above.<\/div><\/label><\/div><\/div><div class='ff-el-group ff_list_inline'><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='deny_sms_b9cc247de1fc052394054be9fa3b19ff'><input  type=\"checkbox\" name=\"deny_sms[]\" data-name=\"deny_sms\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I do NOT want the office to communicate with me via text message to my cell phone.\"  id='deny_sms_b9cc247de1fc052394054be9fa3b19ff' aria-label='I do NOT want the office to communicate with me via text message to my cell phone.' aria-invalid='false' aria-required=false> <span>I do NOT want the office to communicate with me via text message to my cell phone.<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_51\" ><h3 class='ff-el-section-title'>Consent for Photography \/ Radiographs<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_52\" ><p>I hereby acknowledge that during the course of my treatment, photographic records and additional radiographic imaging may be taken. These images will be retained as a part of my clinical record. My identity and images will be protected as per corporate policy towards all clinical records. I understand that these images may be used for: research purposes, relevant scientific and dental literature publications, professional website, dental and oral surgical conferences and meeting presentations and for educational purposes with other dental professionals and education of other potential patients that come to our offices. The images may be modified in ethical practices such as realigning, rotating, cropping and color correction such as exposure and contrast.<\/p><\/div><div class='ff-el-group ff_list_inline'><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='photo_optout_e41236b12b70e94610b65a5ddad01192'><input  type=\"checkbox\" name=\"photo_optout[]\" data-name=\"photo_optout\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I understand that images may be taken, however, I do NOT want any images used in publications or presentations.\"  id='photo_optout_e41236b12b70e94610b65a5ddad01192' aria-label='I understand that images may be taken, however, I do NOT want any images used in publications or presentations.' aria-invalid='false' aria-required=false> <span>I understand that images may be taken, however, I do NOT want any images used in publications or presentations.<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_53\" ><h3 class='ff-el-section-title'>Cancellation, No Show and Missed Appointments<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_54\" ><p>With the nature of an outpatient surgical office and allocation of time needed for completion of surgical services: missed appointments, \u201cno shows\u201d and last minute cancellations are disruptive to the practice and other patients. You are being advised that you (or the patient) may be dismissed from the practice and unable to make additional appointments if you (or the patient) fail to attend scheduled appointments without notifying the office at least one business day in advance.<\/p><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"I understand that failure to attend scheduled appointments without one business day notice may allow for dismissal from the practice and inability to schedule any future appointments.\">I understand that failure to attend scheduled appointments without one business day notice may allow for dismissal from the practice and inability to schedule any future appointments.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='ack_cancellation_db11563e30cd2c39e45fc5ebc03440c8'><input  type=\"radio\" name=\"ack_cancellation\" data-name=\"ack_cancellation\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='ack_cancellation_db11563e30cd2c39e45fc5ebc03440c8' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='ack_cancellation_60cf8033730e8989f7fc43ba01796bbc'><input  type=\"radio\" name=\"ack_cancellation\" data-name=\"ack_cancellation\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='ack_cancellation_60cf8033730e8989f7fc43ba01796bbc' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_55\" ><h3 class='ff-el-section-title'>Privacy and Personal Representative Authorization for Information Release Policy<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_56\" ><p>I hereby acknowledge that a copy of this office\u2019s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice. I understand that a copy of the Privacy Practices is available for me. My signature below confirms I understand and agree with the PRIVACY and PERSONAL REPRESENTATIVE AUTHORIZATION FOR INFORMATION RELEASE POLICY as noted above.<\/p><\/div><div class='ff-el-group ff_list_inline'><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='decline_npp_3e89c5dada34a61b109798c925894463'><input  type=\"checkbox\" name=\"decline_npp[]\" data-name=\"decline_npp\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I decline to receive a copy of the office\u2019s Notice of Privacy Practices.\"  id='decline_npp_3e89c5dada34a61b109798c925894463' aria-label='I decline to receive a copy of the office\u2019s Notice of Privacy Practices.' aria-invalid='false' aria-required=false> <span>I decline to receive a copy of the office\u2019s Notice of Privacy Practices.<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_57\" ><h3 class='ff-el-section-title'>Personal Representative Authorization for Information Release<\/h3><div class='ff-section_break_desk'>Please list below anyone that you will allow us to discuss this account with and their relationship to you.<\/div><hr \/><\/div><div data-name=\"ff_cn_id_67\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi1_first' id='label_ff_3_phi1_first' aria-label=\"First Name\">First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi1_first\" data-name=\"phi1_first\" class=\"ff-el-form-control\" id=\"ff_3_phi1_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi1_last' id='label_ff_3_phi1_last' aria-label=\"Last Name\">Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi1_last\" data-name=\"phi1_last\" class=\"ff-el-form-control\" id=\"ff_3_phi1_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi1_relationship' id='label_ff_3_phi1_relationship' aria-label=\"Relationship\">Relationship<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi1_relationship\" data-name=\"phi1_relationship\" class=\"ff-el-form-control\" id=\"ff_3_phi1_relationship\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_68\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi2_first' id='label_ff_3_phi2_first' aria-label=\"First Name\">First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi2_first\" data-name=\"phi2_first\" class=\"ff-el-form-control\" id=\"ff_3_phi2_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi2_last' id='label_ff_3_phi2_last' aria-label=\"Last Name\">Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi2_last\" data-name=\"phi2_last\" class=\"ff-el-form-control\" id=\"ff_3_phi2_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi2_relationship' id='label_ff_3_phi2_relationship' aria-label=\"Relationship\">Relationship<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi2_relationship\" data-name=\"phi2_relationship\" class=\"ff-el-form-control\" id=\"ff_3_phi2_relationship\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_69\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi3_first' id='label_ff_3_phi3_first' aria-label=\"First Name\">First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi3_first\" data-name=\"phi3_first\" class=\"ff-el-form-control\" id=\"ff_3_phi3_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi3_last' id='label_ff_3_phi3_last' aria-label=\"Last Name\">Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi3_last\" data-name=\"phi3_last\" class=\"ff-el-form-control\" id=\"ff_3_phi3_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi3_relationship' id='label_ff_3_phi3_relationship' aria-label=\"Relationship\">Relationship<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi3_relationship\" data-name=\"phi3_relationship\" class=\"ff-el-form-control\" id=\"ff_3_phi3_relationship\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_70\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi4_first' id='label_ff_3_phi4_first' aria-label=\"First Name\">First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi4_first\" data-name=\"phi4_first\" class=\"ff-el-form-control\" id=\"ff_3_phi4_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi4_last' id='label_ff_3_phi4_last' aria-label=\"Last Name\">Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi4_last\" data-name=\"phi4_last\" class=\"ff-el-form-control\" id=\"ff_3_phi4_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi4_relationship' id='label_ff_3_phi4_relationship' aria-label=\"Relationship\">Relationship<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi4_relationship\" data-name=\"phi4_relationship\" class=\"ff-el-form-control\" id=\"ff_3_phi4_relationship\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_71\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi5_first' id='label_ff_3_phi5_first' aria-label=\"First Name\">First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi5_first\" data-name=\"phi5_first\" class=\"ff-el-form-control\" id=\"ff_3_phi5_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi5_last' id='label_ff_3_phi5_last' aria-label=\"Last Name\">Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi5_last\" data-name=\"phi5_last\" class=\"ff-el-form-control\" id=\"ff_3_phi5_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi5_relationship' id='label_ff_3_phi5_relationship' aria-label=\"Relationship\">Relationship<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi5_relationship\" data-name=\"phi5_relationship\" class=\"ff-el-form-control\" id=\"ff_3_phi5_relationship\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_72\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi6_first' id='label_ff_3_phi6_first' aria-label=\"First Name\">First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi6_first\" data-name=\"phi6_first\" class=\"ff-el-form-control\" id=\"ff_3_phi6_first\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi6_last' id='label_ff_3_phi6_last' aria-label=\"Last Name\">Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi6_last\" data-name=\"phi6_last\" class=\"ff-el-form-control\" id=\"ff_3_phi6_last\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_phi6_relationship' id='label_ff_3_phi6_relationship' aria-label=\"Relationship\">Relationship<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phi6_relationship\" data-name=\"phi6_relationship\" class=\"ff-el-form-control\" id=\"ff_3_phi6_relationship\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break sos-section ff_left\" data-name=\"section_break-3_58\" ><h3 class='ff-el-section-title'>Signature of Patient (Parent or Guardian if Minor)<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand and agree with the Privacy and Personal Representative Authorization policy above.' class='ff-el-form-check-label ff_tc_label' for='ack_privacy_9d28acddae0d35f23c491dfd4444404b'><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"ack_privacy\" class=\"ff-el-form-check-input ff_tc_checkbox\" data-name=\"ack_privacy\" id=\"ack_privacy_9d28acddae0d35f23c491dfd4444404b\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I understand and agree with the Privacy and Personal Representative Authorization policy above.<\/div><\/label><\/div><\/div><div data-name=\"ff_cn_id_73\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_privacy_sig_signature' id='label_ff_3_privacy_sig_signature' aria-label=\"Signature \u2014 type your full legal name\">Signature \u2014 type your full legal name<\/label><div class=\"ff-el-tooltip\" data-content=\"Typing your name here serves as your electronic signature.\"><svg width=\"16\" height=\"16\" viewbox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"privacy_sig_signature\" data-name=\"privacy_sig_signature\" class=\"ff-el-form-control\" id=\"ff_3_privacy_sig_signature\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_privacy_sig_date' id='label_ff_3_privacy_sig_date' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"privacy_sig_date\" placeholder=\"MM\/DD\/YYYY\" data-name=\"privacy_sig_date\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_3_privacy_sig_date\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_privacy_sig_relationship' id='label_ff_3_privacy_sig_relationship' aria-label=\"Relationship to patient (if signing for a minor or as guardian)\">Relationship to patient (if signing for a minor or as guardian)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"privacy_sig_relationship\" data-name=\"privacy_sig_relationship\" class=\"ff-el-form-control\" id=\"ff_3_privacy_sig_relationship\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-lg ff_btn_style\"  aria-label=\"Submit Intake Form\">Submit Intake Form<\/button><\/div><\/fieldset><\/form><div id='fluentform_3_errors' class='ff-errors-in-stack ff_form_instance_3_1 ff-form-loading_errors ff_form_instance_3_1_errors'><\/div><\/div>            <script type=\"text\/javascript\">\n                window.fluent_form_ff_form_instance_3_1 = {\"id\":\"3\",\"ajaxUrl\":\"https:\\\/\\\/signature-oms.com\\\/wp-admin\\\/admin-ajax.php\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"asteriskPlacement\":\"asterisk-right\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_3_1\",\"form_id_selector\":\"fluentform_3\",\"rules\":{\"patient_prefix\":[],\"patient_first_name\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"patient_middle_initial\":[],\"patient_last_name\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"patient_maiden_name\":[],\"patient_dob\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"patient_age\":[],\"patient_ssn\":[],\"patient_sex\":[],\"patient_street\":[],\"patient_apt\":[],\"patient_city\":[],\"patient_state\":[],\"patient_zip\":[],\"patient_dl_number\":[],\"patient_dl_state\":[],\"patient_email\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"email\":{\"value\":true,\"message\":\"Please enter a valid email 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