{"id":58,"date":"2026-09-25T21:39:36","date_gmt":"2026-09-25T21:39:36","guid":{"rendered":"https:\/\/signatureoms.wpenginepowered.com\/?page_id=58"},"modified":"2026-09-25T21:39:36","modified_gmt":"2026-09-25T21:39:36","slug":"book-consultation","status":"publish","type":"page","link":"https:\/\/signature-oms.com\/?page_id=58","title":{"rendered":"Book a Consultation"},"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\">Request an Appointment<\/p>\n\n\n\n<h1 class=\"wp-block-heading has-primary-color has-text-color has-manrope-font-family\">Book a Consultation<\/h1>\n\n\n\n<p class=\"has-on-surface-variant-color has-text-color wp-block-paragraph\" style=\"margin-bottom:48px;font-size:20px;line-height:1.6\">Tell us a little about yourself and what brings you in. Our team reviews every request and will contact you to schedule your visit. Requests showing urgent symptoms are prioritized for same-day review.<\/p>\n\n\n<div class='fluentform ff-default fluentform_wrapper_4 ffs_default_wrap'><form data-form_id=\"4\" id=\"fluentform_4\" class=\"frm-fluent-form fluent_form_4 ff-el-form-top ff_form_instance_4_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_4_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 Book a Consultation<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='58' \/><input type=\"hidden\" id=\"_fluentform_4_fluentformnonce\" name=\"_fluentform_4_fluentformnonce\" value=\"a4d294cea7\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F58\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_1\" ><h2>1. Patient Information<\/h2><\/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_4_first_name' id='label_ff_4_first_name' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"first_name\" data-name=\"first_name\" class=\"ff-el-form-control\" id=\"ff_4_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 ff-el-is-required asterisk-right\"><label for='ff_4_last_name' id='label_ff_4_last_name' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"last_name\" data-name=\"last_name\" class=\"ff-el-form-control\" id=\"ff_4_last_name\"  aria-invalid=\"false\" aria-required=true><\/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_4_preferred_name' id='label_ff_4_preferred_name' >Preferred Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"preferred_name\" data-name=\"preferred_name\" class=\"ff-el-form-control\" id=\"ff_4_preferred_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/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_4_dob' id='label_ff_4_dob' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of Birth 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=\"dob\" placeholder=\"MM\/DD\/YYYY\" data-name=\"dob\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_4_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 ff-el-is-required asterisk-right\"><label for='ff_4_phone' id='label_ff_4_phone' aria-label=\"Phone Number\">Phone Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"phone\" placeholder=\"(555) 555-5555\" data-mask=\"(000) 000-0000\" data-name=\"phone\" class=\"ff-el-form-control\" id=\"ff_4_phone\"  aria-invalid=\"false\" aria-required=true><\/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_4_email' id='label_ff_4_email' aria-label=\"Email Address\">Email Address<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" placeholder=\"name@example.com\" data-name=\"email\" class=\"ff-el-form-control\" id=\"ff_4_email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Preferred Method of Contact\">Preferred Method of Contact<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='contact_method_ca5f79204e4c3d920389e252d054e1fe'><input  type=\"radio\" name=\"contact_method\" data-name=\"contact_method\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Phone call\"  id='contact_method_ca5f79204e4c3d920389e252d054e1fe' aria-label='Phone call' aria-invalid='false' aria-required=true> <span>Phone call<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='contact_method_ff723acfae843aa2c60a59a8b61d4341'><input  type=\"radio\" name=\"contact_method\" data-name=\"contact_method\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Text message\"  id='contact_method_ff723acfae843aa2c60a59a8b61d4341' aria-label='Text message' aria-invalid='false' aria-required=true> <span>Text message<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='contact_method_4374ab4986a1f97480e2c508d0f18255'><input  type=\"radio\" name=\"contact_method\" data-name=\"contact_method\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Email\"  id='contact_method_4374ab4986a1f97480e2c508d0f18255' aria-label='Email' aria-invalid='false' aria-required=true> <span>Email<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_guardian_name' id='label_ff_4_guardian_name' >Parent \/ Guardian Name (if patient is a minor)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"guardian_name\" data-name=\"guardian_name\" class=\"ff-el-form-control\" id=\"ff_4_guardian_name\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_2\" ><h2>2. Reason for Consultation<\/h2><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"What are you coming in for?\">What are you coming in for?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='reasons_4479d4bf42f2c9e7328f80be6512225a'><input  type=\"checkbox\" name=\"reasons[]\" data-name=\"reasons\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Wisdom teeth evaluation\"  id='reasons_4479d4bf42f2c9e7328f80be6512225a' aria-label='Wisdom teeth evaluation' aria-invalid='false' aria-required=true> <span>Wisdom teeth evaluation<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='reasons_46c36a95ec103c403a80fa469fa772ee'><input  type=\"checkbox\" name=\"reasons[]\" data-name=\"reasons\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Tooth extraction\"  id='reasons_46c36a95ec103c403a80fa469fa772ee' aria-label='Tooth extraction' aria-invalid='false' aria-required=true> <span>Tooth extraction<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='reasons_9e2e8e8db31a533e81a918e799cc515f'><input  type=\"checkbox\" name=\"reasons[]\" data-name=\"reasons\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Dental implant consultation\"  id='reasons_9e2e8e8db31a533e81a918e799cc515f' aria-label='Dental implant consultation' aria-invalid='false' aria-required=true> <span>Dental implant consultation<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='reasons_6716d89cc8ea262a0283cc33e9db50e6'><input  type=\"checkbox\" name=\"reasons[]\" data-name=\"reasons\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Bone grafting\"  id='reasons_6716d89cc8ea262a0283cc33e9db50e6' aria-label='Bone grafting' aria-invalid='false' aria-required=true> <span>Bone grafting<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='reasons_e4ec87e25db83db4df3e481ac130e596'><input  type=\"checkbox\" name=\"reasons[]\" data-name=\"reasons\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Impacted tooth\"  id='reasons_e4ec87e25db83db4df3e481ac130e596' aria-label='Impacted tooth' aria-invalid='false' aria-required=true> <span>Impacted tooth<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='reasons_b5e9b7fca1c940abe66a27a4e8eaa337'><input  type=\"checkbox\" name=\"reasons[]\" data-name=\"reasons\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Jaw pain \/ TMJ\"  id='reasons_b5e9b7fca1c940abe66a27a4e8eaa337' aria-label='Jaw pain \/ TMJ' aria-invalid='false' aria-required=true> <span>Jaw pain \/ TMJ<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='reasons_ba6e6c0fb393ae285c0053dc863f1fd6'><input  type=\"checkbox\" name=\"reasons[]\" data-name=\"reasons\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Facial trauma \/ injury\"  id='reasons_ba6e6c0fb393ae285c0053dc863f1fd6' aria-label='Facial trauma \/ injury' aria-invalid='false' aria-required=true> <span>Facial trauma \/ injury<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='reasons_8a72dd436788654bfee77e6ae436ad81'><input  type=\"checkbox\" name=\"reasons[]\" data-name=\"reasons\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oral pathology \/ lesion\"  id='reasons_8a72dd436788654bfee77e6ae436ad81' aria-label='Oral pathology \/ lesion' aria-invalid='false' aria-required=true> <span>Oral pathology \/ lesion<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='reasons_934638239874dd63d779ee98eaff1546'><input  type=\"checkbox\" name=\"reasons[]\" data-name=\"reasons\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cyst or tumor evaluation\"  id='reasons_934638239874dd63d779ee98eaff1546' aria-label='Cyst or tumor evaluation' aria-invalid='false' aria-required=true> <span>Cyst or tumor evaluation<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='reasons_a547f8b86da4c6c32170c39f0e0a5f4e'><input  type=\"checkbox\" name=\"reasons[]\" data-name=\"reasons\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Frenectomy\"  id='reasons_a547f8b86da4c6c32170c39f0e0a5f4e' aria-label='Frenectomy' aria-invalid='false' aria-required=true> <span>Frenectomy<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='reasons_dc01c225a39a20da21073809bd126532'><input  type=\"checkbox\" name=\"reasons[]\" data-name=\"reasons\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Exposure and bonding\"  id='reasons_dc01c225a39a20da21073809bd126532' aria-label='Exposure and bonding' aria-invalid='false' aria-required=true> <span>Exposure and bonding<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='reasons_756c66be1fb0d705e52c0a256f3d41fa'><input  type=\"checkbox\" name=\"reasons[]\" data-name=\"reasons\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Other\"  id='reasons_756c66be1fb0d705e52c0a256f3d41fa' aria-label='Other' aria-invalid='false' aria-required=true> <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_4_reason_other' id='label_ff_4_reason_other' aria-label=\"Other \u2014 please specify\">Other \u2014 please specify<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"reason_other\" data-name=\"reason_other\" class=\"ff-el-form-control\" id=\"ff_4_reason_other\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_reason_description' id='label_ff_4_reason_description' aria-label=\"Please briefly describe what you are experiencing or what your dentist referred you for\">Please briefly describe what you are experiencing or what your dentist referred you for<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_reason_description\" name=\"reason_description\" rows=\"4\" cols=\"2\" data-name=\"reason_description\" class=\"ff-el-form-control\" id=\"ff_4_reason_description\" ><\/textarea><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Were you referred by another dentist or physician?\">Were you referred by another dentist or physician?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='referred_ad7a0ccf5db1030c4aa31eae159877a1'><input  type=\"radio\" name=\"referred\" data-name=\"referred\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='referred_ad7a0ccf5db1030c4aa31eae159877a1' 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_5e95961edbeabd37b0bc363fc4278c02'><input  type=\"radio\" name=\"referred\" data-name=\"referred\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='referred_5e95961edbeabd37b0bc363fc4278c02' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  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_4_ref_provider' id='label_ff_4_ref_provider' aria-label=\"Referring Provider Name\">Referring Provider Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"ref_provider\" data-name=\"ref_provider\" class=\"ff-el-form-control\" id=\"ff_4_ref_provider\"  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_4_ref_practice' id='label_ff_4_ref_practice' aria-label=\"Practice Name\">Practice Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"ref_practice\" data-name=\"ref_practice\" class=\"ff-el-form-control\" id=\"ff_4_ref_practice\"  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_4_ref_contact' id='label_ff_4_ref_contact' aria-label=\"Phone Number \/ Email (if known)\">Phone Number \/ Email (if known)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"ref_contact\" data-name=\"ref_contact\" class=\"ff-el-form-control\" id=\"ff_4_ref_contact\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_3\" ><div class=\"sos-urgent-head\"><h2>3. Symptoms &amp; Urgency<\/h2><p>Your answers here help our clinical team identify patients who may need to be seen the same day.<\/p><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Are you currently experiencing any of the following?\">Are you currently experiencing any of the following?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='symptoms_5cbeb436cc58659a5bb69885d27f393b'><input  type=\"checkbox\" name=\"symptoms[]\" data-name=\"symptoms\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pain\"  id='symptoms_5cbeb436cc58659a5bb69885d27f393b' aria-label='Pain' aria-invalid='false' aria-required=false> <span>Pain<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='symptoms_53e162e7fb19d6ae4b958fb3221fbded'><input  type=\"checkbox\" name=\"symptoms[]\" data-name=\"symptoms\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Swelling\"  id='symptoms_53e162e7fb19d6ae4b958fb3221fbded' aria-label='Swelling' aria-invalid='false' aria-required=false> <span>Swelling<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='symptoms_2a27ccfdabe2bba0b8ed90c7b280ea90'><input  type=\"checkbox\" name=\"symptoms[]\" data-name=\"symptoms\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Infection\"  id='symptoms_2a27ccfdabe2bba0b8ed90c7b280ea90' aria-label='Infection' aria-invalid='false' aria-required=false> <span>Infection<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='symptoms_0690c24f415e1ac84f7fb64e2f38fa08'><input  type=\"checkbox\" name=\"symptoms[]\" data-name=\"symptoms\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Bleeding\"  id='symptoms_0690c24f415e1ac84f7fb64e2f38fa08' aria-label='Bleeding' aria-invalid='false' aria-required=false> <span>Bleeding<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='symptoms_2cf13daf49b4183a7f47d55dcf4cde69'><input  type=\"checkbox\" name=\"symptoms[]\" data-name=\"symptoms\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Difficulty opening your mouth\"  id='symptoms_2cf13daf49b4183a7f47d55dcf4cde69' aria-label='Difficulty opening your mouth' aria-invalid='false' aria-required=false> <span>Difficulty opening your mouth<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='symptoms_a039c76511437b7b0491efc5e2a086e3'><input  type=\"checkbox\" name=\"symptoms[]\" data-name=\"symptoms\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Difficulty swallowing\"  id='symptoms_a039c76511437b7b0491efc5e2a086e3' aria-label='Difficulty swallowing' aria-invalid='false' aria-required=false> <span>Difficulty swallowing<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='symptoms_74f4f3327bbdaf915373f8283753c4f3'><input  type=\"checkbox\" name=\"symptoms[]\" data-name=\"symptoms\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Difficulty breathing\"  id='symptoms_74f4f3327bbdaf915373f8283753c4f3' aria-label='Difficulty breathing' aria-invalid='false' aria-required=false> <span>Difficulty breathing<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='symptoms_5269e5c4bd597448700eb3f32dd8e2fe'><input  type=\"checkbox\" name=\"symptoms[]\" data-name=\"symptoms\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Fever\"  id='symptoms_5269e5c4bd597448700eb3f32dd8e2fe' aria-label='Fever' aria-invalid='false' aria-required=false> <span>Fever<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='symptoms_2e3197fa7690b5f7ea7da9ec377fecc9'><input  type=\"checkbox\" name=\"symptoms[]\" data-name=\"symptoms\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Facial trauma\"  id='symptoms_2e3197fa7690b5f7ea7da9ec377fecc9' aria-label='Facial trauma' aria-invalid='false' aria-required=false> <span>Facial trauma<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='symptoms_24d760d1c70a0b04124620f82e75aba7'><input  type=\"checkbox\" name=\"symptoms[]\" data-name=\"symptoms\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"None of the above\"  id='symptoms_24d760d1c70a0b04124620f82e75aba7' aria-label='None of the above' aria-invalid='false' aria-required=false> <span>None of the above<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-4_4\" ><div class=\"sos-alert\"><strong>If you are having difficulty breathing or swallowing, rapidly spreading swelling, or bleeding that will not stop, call 911 or go to the nearest emergency room now.<\/strong> Do not wait for a consultation appointment.<\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_symptom_onset' id='label_ff_4_symptom_onset' aria-label=\"When did your symptoms begin?\">When did your symptoms begin?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"symptom_onset\" placeholder=\"Date or approximate timeframe\" data-name=\"symptom_onset\" class=\"ff-el-form-control\" id=\"ff_4_symptom_onset\"  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=\"How would you rate your pain? (0 = none, 10 = worst)\">How would you rate your pain? (0 = none, 10 = worst)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='pain_level_fa7c95fe2bc9fa91c53855c577b5ba0b'><input  type=\"radio\" name=\"pain_level\" data-name=\"pain_level\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"0\"  id='pain_level_fa7c95fe2bc9fa91c53855c577b5ba0b' aria-label='0' aria-invalid='false' aria-required=false> <span>0<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='pain_level_0a48b4fb9367b2afb95c0c1cb81cd809'><input  type=\"radio\" name=\"pain_level\" data-name=\"pain_level\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"1\"  id='pain_level_0a48b4fb9367b2afb95c0c1cb81cd809' aria-label='1' aria-invalid='false' aria-required=false> <span>1<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='pain_level_cda78b3ddc9c13d80708af050f5709cc'><input  type=\"radio\" name=\"pain_level\" data-name=\"pain_level\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"2\"  id='pain_level_cda78b3ddc9c13d80708af050f5709cc' aria-label='2' aria-invalid='false' aria-required=false> <span>2<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='pain_level_a26d6eaadd8ea34c04222a09a1fedacf'><input  type=\"radio\" name=\"pain_level\" data-name=\"pain_level\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"3\"  id='pain_level_a26d6eaadd8ea34c04222a09a1fedacf' aria-label='3' aria-invalid='false' aria-required=false> <span>3<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='pain_level_3100139dbcd8a78db48762c07fbeb353'><input  type=\"radio\" name=\"pain_level\" data-name=\"pain_level\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"4\"  id='pain_level_3100139dbcd8a78db48762c07fbeb353' aria-label='4' aria-invalid='false' aria-required=false> <span>4<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='pain_level_0c6c2f7db10ea5e32bcbd4c6e9d56f1f'><input  type=\"radio\" name=\"pain_level\" data-name=\"pain_level\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"5\"  id='pain_level_0c6c2f7db10ea5e32bcbd4c6e9d56f1f' aria-label='5' aria-invalid='false' aria-required=false> <span>5<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='pain_level_bc42f438c3c19241fad301c79e871f5a'><input  type=\"radio\" name=\"pain_level\" data-name=\"pain_level\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"6\"  id='pain_level_bc42f438c3c19241fad301c79e871f5a' aria-label='6' aria-invalid='false' aria-required=false> <span>6<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='pain_level_f068928c5bf1e6bb808d8bd6a9cc60b6'><input  type=\"radio\" name=\"pain_level\" data-name=\"pain_level\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"7\"  id='pain_level_f068928c5bf1e6bb808d8bd6a9cc60b6' aria-label='7' aria-invalid='false' aria-required=false> <span>7<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='pain_level_b227dd532d191471319a498e169cef6c'><input  type=\"radio\" name=\"pain_level\" data-name=\"pain_level\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"8\"  id='pain_level_b227dd532d191471319a498e169cef6c' aria-label='8' aria-invalid='false' aria-required=false> <span>8<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='pain_level_bb6453d779dcb29decc531ba44014e6c'><input  type=\"radio\" name=\"pain_level\" data-name=\"pain_level\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"9\"  id='pain_level_bb6453d779dcb29decc531ba44014e6c' aria-label='9' aria-invalid='false' aria-required=false> <span>9<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='pain_level_0c2109b3c62b84e7644e2eef63178364'><input  type=\"radio\" name=\"pain_level\" data-name=\"pain_level\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"10\"  id='pain_level_0c2109b3c62b84e7644e2eef63178364' aria-label='10' aria-invalid='false' aria-required=false> <span>10<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Is the condition getting:\">Is the condition getting:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='condition_trend_d66cf59dbb9d073a12d8a6bebe3741ae'><input  type=\"radio\" name=\"condition_trend\" data-name=\"condition_trend\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Better\"  id='condition_trend_d66cf59dbb9d073a12d8a6bebe3741ae' aria-label='Better' aria-invalid='false' aria-required=false> <span>Better<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='condition_trend_ac616b04e5d91bbffad45c7250207e10'><input  type=\"radio\" name=\"condition_trend\" data-name=\"condition_trend\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Worse\"  id='condition_trend_ac616b04e5d91bbffad45c7250207e10' aria-label='Worse' aria-invalid='false' aria-required=false> <span>Worse<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='condition_trend_58745a78e72d559257aaa7fdcd4ca388'><input  type=\"radio\" name=\"condition_trend\" data-name=\"condition_trend\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Staying the same\"  id='condition_trend_58745a78e72d559257aaa7fdcd4ca388' aria-label='Staying the same' aria-invalid='false' aria-required=false> <span>Staying the same<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Is this consultation related to a recent injury or emergency?\">Is this consultation related to a recent injury or emergency?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='injury_related_e218ff41fbcb24df38189b3a54cecd0e'><input  type=\"radio\" name=\"injury_related\" data-name=\"injury_related\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='injury_related_e218ff41fbcb24df38189b3a54cecd0e' 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='injury_related_39945225d781e09f2f6782bcaab333f6'><input  type=\"radio\" name=\"injury_related\" data-name=\"injury_related\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='injury_related_39945225d781e09f2f6782bcaab333f6' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_5\" ><h2>4. Medical History<\/h2><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Do you currently have, or have you ever had, any of the following?\">Do you currently have, or have you ever had, any of the following?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_6344732b01258ff357869c99d8670a68'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Heart condition\"  id='medical_conditions_6344732b01258ff357869c99d8670a68' aria-label='Heart condition' aria-invalid='false' aria-required=false> <span>Heart condition<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_280f2b6443e72cd557563418c6b07f1c'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"High blood pressure\"  id='medical_conditions_280f2b6443e72cd557563418c6b07f1c' aria-label='High blood pressure' aria-invalid='false' aria-required=false> <span>High blood pressure<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_eb815823a5b2934b3235c8a4bfd57bb0'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Diabetes\"  id='medical_conditions_eb815823a5b2934b3235c8a4bfd57bb0' aria-label='Diabetes' aria-invalid='false' aria-required=false> <span>Diabetes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_92f3727980e9d8a0395b8659a60c8223'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Bleeding disorder\"  id='medical_conditions_92f3727980e9d8a0395b8659a60c8223' aria-label='Bleeding disorder' aria-invalid='false' aria-required=false> <span>Bleeding disorder<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_9e40bcdaaafe9e39e51d80a21c0f274c'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Kidney disease\"  id='medical_conditions_9e40bcdaaafe9e39e51d80a21c0f274c' aria-label='Kidney disease' aria-invalid='false' aria-required=false> <span>Kidney disease<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_d00941f7e33e92dc8498a6666ce8b32a'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Liver disease\"  id='medical_conditions_d00941f7e33e92dc8498a6666ce8b32a' aria-label='Liver disease' aria-invalid='false' aria-required=false> <span>Liver disease<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_77de493aa0527ebb157998ffa79ff4f6'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Sleep apnea\"  id='medical_conditions_77de493aa0527ebb157998ffa79ff4f6' aria-label='Sleep apnea' aria-invalid='false' aria-required=false> <span>Sleep apnea<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_fb4c2afb3efe999fd7d2dd441cb1f7b0'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Respiratory \/ lung condition\"  id='medical_conditions_fb4c2afb3efe999fd7d2dd441cb1f7b0' aria-label='Respiratory \/ lung condition' aria-invalid='false' aria-required=false> <span>Respiratory \/ lung condition<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_0a3d4cb8b533180a87d4c318acd8c500'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Immune system condition\"  id='medical_conditions_0a3d4cb8b533180a87d4c318acd8c500' aria-label='Immune system condition' aria-invalid='false' aria-required=false> <span>Immune system condition<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_ed17772386106099db33dbdea847baee'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"History of cancer\"  id='medical_conditions_ed17772386106099db33dbdea847baee' aria-label='History of cancer' aria-invalid='false' aria-required=false> <span>History of cancer<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_91fa1c68df1879dde08f3dd452af7098'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Seizures\"  id='medical_conditions_91fa1c68df1879dde08f3dd452af7098' aria-label='Seizures' aria-invalid='false' aria-required=false> <span>Seizures<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_c2367d9a7a4de170a3a2e7fc6f8f33d3'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Osteoporosis\"  id='medical_conditions_c2367d9a7a4de170a3a2e7fc6f8f33d3' 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='medical_conditions_b182298fdcd7c28b6172597aac9e88fe'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Other significant medical condition\"  id='medical_conditions_b182298fdcd7c28b6172597aac9e88fe' aria-label='Other significant medical condition' aria-invalid='false' aria-required=false> <span>Other significant medical condition<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='medical_conditions_dc11dc3fc63281b018ec42b578eeb24e'><input  type=\"checkbox\" name=\"medical_conditions[]\" data-name=\"medical_conditions\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"None\"  id='medical_conditions_dc11dc3fc63281b018ec42b578eeb24e' aria-label='None' aria-invalid='false' aria-required=false> <span>None<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Are you currently taking any medications?\">Are you currently taking any medications?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='takes_medications_113b45267af7334dcf5d182b5aba995a'><input  type=\"radio\" name=\"takes_medications\" data-name=\"takes_medications\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='takes_medications_113b45267af7334dcf5d182b5aba995a' 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='takes_medications_49a6902cddf65c8b0092ff419f51447c'><input  type=\"radio\" name=\"takes_medications\" data-name=\"takes_medications\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='takes_medications_49a6902cddf65c8b0092ff419f51447c' 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_4_medications_list' id='label_ff_4_medications_list' aria-label=\"Please list medications\">Please list medications<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_medications_list\" name=\"medications_list\" rows=\"4\" cols=\"2\" data-name=\"medications_list\" class=\"ff-el-form-control\" id=\"ff_4_medications_list\" ><\/textarea><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Do you have any medication or other allergies?\">Do you have any medication or other allergies?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='has_allergies_8f08fc45bdccf336e9774a58628b3e64'><input  type=\"radio\" name=\"has_allergies\" data-name=\"has_allergies\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='has_allergies_8f08fc45bdccf336e9774a58628b3e64' 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_allergies_9c7a34bf6f55e43408db1d081473afa8'><input  type=\"radio\" name=\"has_allergies\" data-name=\"has_allergies\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='has_allergies_9c7a34bf6f55e43408db1d081473afa8' 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_4_allergies_list' id='label_ff_4_allergies_list' aria-label=\"Please list allergies and reactions\">Please list allergies and reactions<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_allergies_list\" name=\"allergies_list\" rows=\"4\" cols=\"2\" data-name=\"allergies_list\" class=\"ff-el-form-control\" id=\"ff_4_allergies_list\" ><\/textarea><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_6\" ><h2>5. Important Surgical Considerations<\/h2><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Have you previously had surgery or anesthesia?\">Have you previously had surgery or anesthesia?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='prior_surgery_ef82ba81d1110df92f2779cd228cbd9d'><input  type=\"radio\" name=\"prior_surgery\" data-name=\"prior_surgery\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='prior_surgery_ef82ba81d1110df92f2779cd228cbd9d' 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='prior_surgery_3dd92852bfdfb3e2a8e46d393891c813'><input  type=\"radio\" name=\"prior_surgery\" data-name=\"prior_surgery\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='prior_surgery_3dd92852bfdfb3e2a8e46d393891c813' 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=\"Have you ever had a problem with anesthesia or sedation?\">Have you ever had a problem with anesthesia or sedation?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='anesthesia_problem_0a29116cac29f0bbcdbea88405954df9'><input  type=\"radio\" name=\"anesthesia_problem\" data-name=\"anesthesia_problem\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='anesthesia_problem_0a29116cac29f0bbcdbea88405954df9' 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='anesthesia_problem_6fbf3933a5092391a0f2a005b056f088'><input  type=\"radio\" name=\"anesthesia_problem\" data-name=\"anesthesia_problem\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='anesthesia_problem_6fbf3933a5092391a0f2a005b056f088' 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=\"Do you take blood thinners or medications that affect bleeding?\">Do you take blood thinners or medications that affect bleeding?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='blood_thinners_76acb36402e4e694e853fd01be610de8'><input  type=\"radio\" name=\"blood_thinners\" data-name=\"blood_thinners\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='blood_thinners_76acb36402e4e694e853fd01be610de8' 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='blood_thinners_2f6877608a19cd0be41721c207c7c0b0'><input  type=\"radio\" name=\"blood_thinners\" data-name=\"blood_thinners\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='blood_thinners_2f6877608a19cd0be41721c207c7c0b0' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='blood_thinners_7c17724c80eabfda06c64804ecaa318b'><input  type=\"radio\" name=\"blood_thinners\" data-name=\"blood_thinners\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not sure\"  id='blood_thinners_7c17724c80eabfda06c64804ecaa318b' aria-label='Not sure' aria-invalid='false' aria-required=false> <span>Not sure<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Are you currently pregnant or could you be pregnant?\">Are you currently pregnant 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='pregnant_2cfc213db8d9e123877c695f95941ccd'><input  type=\"radio\" name=\"pregnant\" data-name=\"pregnant\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='pregnant_2cfc213db8d9e123877c695f95941ccd' 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='pregnant_c888341e9f14526a45ad85d2ec6ab194'><input  type=\"radio\" name=\"pregnant\" data-name=\"pregnant\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='pregnant_c888341e9f14526a45ad85d2ec6ab194' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='pregnant_38a10b41039a0834cbefdf703fba1257'><input  type=\"radio\" name=\"pregnant\" data-name=\"pregnant\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not applicable\"  id='pregnant_38a10b41039a0834cbefdf703fba1257' aria-label='Not applicable' aria-invalid='false' aria-required=false> <span>Not applicable<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_7\" ><h2>6. Dental Information<\/h2><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_last_dental_visit' id='label_ff_4_last_dental_visit' aria-label=\"When was your last dental visit?\">When was your last dental visit?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"last_dental_visit\" placeholder=\"Date or approximate date\" data-name=\"last_dental_visit\" class=\"ff-el-form-control\" id=\"ff_4_last_dental_visit\"  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 had recent dental X-rays or a CBCT scan?\">Have you had recent dental X-rays or a CBCT scan?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='recent_xrays_f8df2fba93eb44c83d9a8e47e98dba69'><input  type=\"radio\" name=\"recent_xrays\" data-name=\"recent_xrays\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='recent_xrays_f8df2fba93eb44c83d9a8e47e98dba69' 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='recent_xrays_2bf361badcd36b8e704d2950368f54bb'><input  type=\"radio\" name=\"recent_xrays\" data-name=\"recent_xrays\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='recent_xrays_2bf361badcd36b8e704d2950368f54bb' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='recent_xrays_7c0460fee28a5132bf9f19607e73d8ed'><input  type=\"radio\" name=\"recent_xrays\" data-name=\"recent_xrays\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not sure\"  id='recent_xrays_7c0460fee28a5132bf9f19607e73d8ed' aria-label='Not sure' aria-invalid='false' aria-required=false> <span>Not sure<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If available, can your referring dentist send your X-rays \/ records before your consultation?\">If available, can your referring dentist send your X-rays \/ records before your consultation?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='records_sendable_995b3df32bf356e82a1336cc190f6338'><input  type=\"radio\" name=\"records_sendable\" data-name=\"records_sendable\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='records_sendable_995b3df32bf356e82a1336cc190f6338' 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='records_sendable_1f0395b8779f4295d6e3b1f4ce614e59'><input  type=\"radio\" name=\"records_sendable\" data-name=\"records_sendable\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='records_sendable_1f0395b8779f4295d6e3b1f4ce614e59' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='records_sendable_cfd6b2c6afbeb136ef70d6dd9c2b4075'><input  type=\"radio\" name=\"records_sendable\" data-name=\"records_sendable\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not sure\"  id='records_sendable_cfd6b2c6afbeb136ef70d6dd9c2b4075' aria-label='Not sure' aria-invalid='false' aria-required=false> <span>Not sure<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_8\" ><h2>7. Insurance &amp; Payment<\/h2><\/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_4_ins_company' id='label_ff_4_ins_company' aria-label=\"Insurance Company\">Insurance Company<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"ins_company\" data-name=\"ins_company\" class=\"ff-el-form-control\" id=\"ff_4_ins_company\"  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_4_ins_member_id' id='label_ff_4_ins_member_id' aria-label=\"Member ID\">Member ID<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"ins_member_id\" data-name=\"ins_member_id\" class=\"ff-el-form-control\" id=\"ff_4_ins_member_id\"  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_4_ins_group' id='label_ff_4_ins_group' aria-label=\"Group Number\">Group Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"ins_group\" data-name=\"ins_group\" class=\"ff-el-form-control\" id=\"ff_4_ins_group\"  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_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_4_ins_subscriber' id='label_ff_4_ins_subscriber' aria-label=\"Subscriber Name\">Subscriber Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"ins_subscriber\" data-name=\"ins_subscriber\" class=\"ff-el-form-control\" id=\"ff_4_ins_subscriber\"  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_4_ins_subscriber_dob' id='label_ff_4_ins_subscriber_dob' aria-label=\"Subscriber Date of Birth\">Subscriber Date of Birth<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Subscriber Date of Birth 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=\"ins_subscriber_dob\" placeholder=\"MM\/DD\/YYYY\" data-name=\"ins_subscriber_dob\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_4_ins_subscriber_dob\"  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_4_ins_relationship' id='label_ff_4_ins_relationship' aria-label=\"Relationship to Subscriber\">Relationship to Subscriber<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"ins_relationship\" data-name=\"ins_relationship\" class=\"ff-el-form-control\" id=\"ff_4_ins_relationship\"  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=\"Do you have secondary dental \/ medical insurance?\">Do you have secondary dental \/ medical insurance?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='secondary_insurance_bca4b8748f9c8ffa869d0ea58e34b399'><input  type=\"radio\" name=\"secondary_insurance\" data-name=\"secondary_insurance\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='secondary_insurance_bca4b8748f9c8ffa869d0ea58e34b399' 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='secondary_insurance_0f1ab20e602755ee426f08a68790eb24'><input  type=\"radio\" name=\"secondary_insurance\" data-name=\"secondary_insurance\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='secondary_insurance_0f1ab20e602755ee426f08a68790eb24' 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=\"Would you like our office to verify your benefits before your appointment?\">Would you like our office to verify your benefits before your appointment?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='verify_benefits_2b620562d01e9825e98f06e929626367'><input  type=\"radio\" name=\"verify_benefits\" data-name=\"verify_benefits\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='verify_benefits_2b620562d01e9825e98f06e929626367' 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='verify_benefits_3cddaf550cec8aeed2d5dc5b1a6a6632'><input  type=\"radio\" name=\"verify_benefits\" data-name=\"verify_benefits\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='verify_benefits_3cddaf550cec8aeed2d5dc5b1a6a6632' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_9\" ><h2>8. Appointment Preferences<\/h2><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Preferred appointment timeframe\">Preferred appointment timeframe<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='timeframe_3dffd4ecdc8f80b48f34b19e7a7dd401'><input  type=\"radio\" name=\"timeframe\" data-name=\"timeframe\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"As soon as possible\"  id='timeframe_3dffd4ecdc8f80b48f34b19e7a7dd401' aria-label='As soon as possible' aria-invalid='false' aria-required=false> <span>As soon as possible<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='timeframe_15bf03a4da4d1449a3d044c8bde67faa'><input  type=\"radio\" name=\"timeframe\" data-name=\"timeframe\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Within 1\u20132 weeks\"  id='timeframe_15bf03a4da4d1449a3d044c8bde67faa' aria-label='Within 1\u20132 weeks' aria-invalid='false' aria-required=false> <span>Within 1\u20132 weeks<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='timeframe_9fd438b3050ff35bb5555e86dfefe13d'><input  type=\"radio\" name=\"timeframe\" data-name=\"timeframe\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Within 1 month\"  id='timeframe_9fd438b3050ff35bb5555e86dfefe13d' aria-label='Within 1 month' aria-invalid='false' aria-required=false> <span>Within 1 month<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='timeframe_00ae6a93dc3e316f059572e14c87a296'><input  type=\"radio\" name=\"timeframe\" data-name=\"timeframe\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Flexible\"  id='timeframe_00ae6a93dc3e316f059572e14c87a296' aria-label='Flexible' aria-invalid='false' aria-required=false> <span>Flexible<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Preferred days\">Preferred days<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='preferred_days_d0a62d6337eea14e045b7f1bb2f378b1'><input  type=\"checkbox\" name=\"preferred_days[]\" data-name=\"preferred_days\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Monday\"  id='preferred_days_d0a62d6337eea14e045b7f1bb2f378b1' aria-label='Monday' aria-invalid='false' aria-required=false> <span>Monday<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='preferred_days_476721e7f273d90568c19a963f90fe1c'><input  type=\"checkbox\" name=\"preferred_days[]\" data-name=\"preferred_days\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Tuesday\"  id='preferred_days_476721e7f273d90568c19a963f90fe1c' aria-label='Tuesday' aria-invalid='false' aria-required=false> <span>Tuesday<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='preferred_days_2262529db5399efdd0f877630cc16944'><input  type=\"checkbox\" name=\"preferred_days[]\" data-name=\"preferred_days\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Wednesday\"  id='preferred_days_2262529db5399efdd0f877630cc16944' aria-label='Wednesday' aria-invalid='false' aria-required=false> <span>Wednesday<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='preferred_days_5b1898ad992ab62d47e0b7f272acf346'><input  type=\"checkbox\" name=\"preferred_days[]\" data-name=\"preferred_days\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Thursday\"  id='preferred_days_5b1898ad992ab62d47e0b7f272acf346' aria-label='Thursday' aria-invalid='false' aria-required=false> <span>Thursday<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='preferred_days_5eb87a776dd78a045392c867ff329de0'><input  type=\"checkbox\" name=\"preferred_days[]\" data-name=\"preferred_days\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Friday\"  id='preferred_days_5eb87a776dd78a045392c867ff329de0' aria-label='Friday' aria-invalid='false' aria-required=false> <span>Friday<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Preferred time\">Preferred time<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='preferred_time_4963f0c0917f3e713dbf850a4db22def'><input  type=\"radio\" name=\"preferred_time\" data-name=\"preferred_time\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Morning\"  id='preferred_time_4963f0c0917f3e713dbf850a4db22def' aria-label='Morning' aria-invalid='false' aria-required=false> <span>Morning<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='preferred_time_217f5279e4b0f315c3d2528e734dda61'><input  type=\"radio\" name=\"preferred_time\" data-name=\"preferred_time\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Afternoon\"  id='preferred_time_217f5279e4b0f315c3d2528e734dda61' aria-label='Afternoon' aria-invalid='false' aria-required=false> <span>Afternoon<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='preferred_time_0039724f7778bcf0e5937fc3d12c47b4'><input  type=\"radio\" name=\"preferred_time\" data-name=\"preferred_time\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No preference\"  id='preferred_time_0039724f7778bcf0e5937fc3d12c47b4' aria-label='No preference' aria-invalid='false' aria-required=false> <span>No preference<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_10\" ><h2>9. Records &amp; Communication Authorization<\/h2><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I authorize the office to contact me regarding my consultation and to obtain or coordinate the transfer of relevant dental\/medical records from my referring provider.' class='ff-el-form-check-label ff_tc_label' for='auth_records_845b7c6a8b23732d4ee5a63a70f17c75'><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"auth_records\" class=\"ff-el-form-check-input ff_tc_checkbox\" data-name=\"auth_records\" id=\"auth_records_845b7c6a8b23732d4ee5a63a70f17c75\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I authorize the office to contact me regarding my consultation and to obtain or coordinate the transfer of relevant dental\/medical records from my referring provider.<\/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='sms_consent_b15e7fd0b08b0f3e56d0f7ba6f5bef33'><input  type=\"checkbox\" name=\"sms_consent[]\" data-name=\"sms_consent\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I consent to receive appointment reminders and other communications by text message.\"  id='sms_consent_b15e7fd0b08b0f3e56d0f7ba6f5bef33' aria-label='I consent to receive appointment reminders and other communications by text message.' aria-invalid='false' aria-required=false> <span>I consent to receive appointment reminders and other communications by text message.<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_11\" ><h2>10. Final Question<\/h2><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_anything_else' id='label_ff_4_anything_else' aria-label=\"Is there anything else you would like our oral surgery team to know before your consultation?\">Is there anything else you would like our oral surgery team to know before your consultation?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_anything_else\" name=\"anything_else\" rows=\"6\" cols=\"2\" data-name=\"anything_else\" class=\"ff-el-form-control\" id=\"ff_4_anything_else\" ><\/textarea><\/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=\"Request Consultation\">Request Consultation<\/button><\/div><\/fieldset><\/form><div id='fluentform_4_errors' class='ff-errors-in-stack ff_form_instance_4_1 ff-form-loading_errors 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