{"id":165,"date":"2020-08-18T10:45:32","date_gmt":"2020-08-18T15:45:32","guid":{"rendered":"https:\/\/ascentdentalcare.ca\/?page_id=165"},"modified":"2022-09-15T14:55:39","modified_gmt":"2022-09-15T19:55:39","slug":"patient-form","status":"publish","type":"page","link":"https:\/\/ascentdentalcare.ca\/your-visit\/patient-form\/","title":{"rendered":"Patient Form"},"content":{"rendered":"\n<div style=\"height:30px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n<style>#kt-layout-id_f2c924-f6 > .kt-row-column-wrap{align-content:start;}:where(#kt-layout-id_f2c924-f6 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}#kt-layout-id_f2c924-f6 > .kt-row-column-wrap{column-gap:20px;row-gap:var(--global-kb-gap-md, 2rem);padding-top:var( --global-kb-row-default-top, 25px );padding-bottom:var( --global-kb-row-default-bottom, 25px );padding-top:0px;padding-bottom:0px;padding-left:0px;padding-right:0px;grid-template-columns:minmax(0, 1fr);}#kt-layout-id_f2c924-f6 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){#kt-layout-id_f2c924-f6 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){#kt-layout-id_f2c924-f6 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style>\n<div class=\"wp-block-kadence-rowlayout alignnone\"><div id=\"kt-layout-id_f2c924-f6\" class=\"kt-row-layout-inner kt-layout-id_f2c924-f6\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-gutter-narrow kt-v-gutter-default kt-row-valign-top kt-row-layout-equal kt-tab-layout-inherit kt-m-colapse-left-to-right kt-mobile-layout-row\"><style>.kadence-column_747c9e-7c > .kt-inside-inner-col{border-top-width:0px;border-right-width:0px;border-bottom-width:0px;border-left-width:0px;}.kadence-column_747c9e-7c > .kt-inside-inner-col,.kadence-column_747c9e-7c > 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9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg version='1.1' xmlns='http:\/\/www.w3.org\/2000\/svg' width='640' height='640'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/wp-json\/wp\/v2\/pages\/165#gf_3' data-formid='3' novalidate>\n        <div id='gf_progressbar_wrapper_3' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>7<\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_14' style='width:14%;'><span>14%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_3_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_24\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_24\" ><h2 class=\"gsection_title\">Patient Information<\/h2><\/li><li id=\"field_3_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_1\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_1'>\n                            \n                            <span id='input_3_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_3_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_2\" class=\"gfield gfield--type-email float gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_2\" ><label class='gfield_label gform-field-label' for='input_3_2'>E-mail Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_3_2' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_3_3\" class=\"gfield gfield--type-phone float gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_3\" ><label class='gfield_label gform-field-label' for='input_3_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_3_3' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_14\" class=\"gfield gfield--type-radio gfield--type-choice float-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_14\" ><label class='gfield_label gform-field-label' >Preferred method of contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_14'>\n\t\t\t<li class='gchoice gchoice_3_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='Phone'  id='choice_3_14_0'    \/>\n\t\t\t\t<label for='choice_3_14_0' id='label_3_14_0' class='gform-field-label gform-field-label--type-inline'>Phone<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='Email'  id='choice_3_14_1'    \/>\n\t\t\t\t<label for='choice_3_14_1' id='label_3_14_1' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_12\" class=\"gfield gfield--type-date gfield--input-type-datefield float-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_12\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Date of Birth<\/label><div id='input_3_12' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_12_2_container'>\n                                            <input type='number' maxlength='2' name='input_12[]' id='input_3_12_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_3_12_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_12_1_container'>\n                                        <input type='number' maxlength='2' name='input_12[]' id='input_3_12_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_3_12_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_12_3_container'>\n                                        <input type='number' maxlength='4' name='input_12[]' id='input_3_12_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2025' step='1'\/>\n                                        <label for='input_3_12_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_3_13\" class=\"gfield gfield--type-radio gfield--type-choice float-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_13\" ><label class='gfield_label gform-field-label' >Gender<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_13'>\n\t\t\t<li class='gchoice gchoice_3_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Male'  id='choice_3_13_0'    \/>\n\t\t\t\t<label for='choice_3_13_0' id='label_3_13_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Female'  id='choice_3_13_1'    \/>\n\t\t\t\t<label for='choice_3_13_1' id='label_3_13_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_13_2'>\n\t\t\t\t<input name='input_13' type='radio' value='Non-binary'  id='choice_3_13_2'    \/>\n\t\t\t\t<label for='choice_3_13_2' id='label_3_13_2' class='gform-field-label gform-field-label--type-inline'>Non-binary<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_5\" class=\"gfield gfield--type-text float-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_5\" ><label class='gfield_label gform-field-label' for='input_3_5'>Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_3_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_6\" class=\"gfield gfield--type-text float-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_6\" ><label class='gfield_label gform-field-label' for='input_3_6'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_3_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_7\" class=\"gfield gfield--type-text float-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_7\" ><label class='gfield_label gform-field-label' for='input_3_7'>Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_3_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_8\" class=\"gfield gfield--type-text float-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_8\" ><label class='gfield_label gform-field-label' for='input_3_8'>Emergency Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_3_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_9\" class=\"gfield gfield--type-phone float-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_9\" ><label class='gfield_label gform-field-label' for='input_3_9'>Emergency Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_3_9' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_10\" class=\"gfield gfield--type-text float-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_10\" ><label class='gfield_label gform-field-label' for='input_3_10'>Allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_3_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_3_11' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' data-js='page-field-id-11' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_15\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_15\" ><h2 class=\"gsection_title\">Welcome to Ascent Dental Care!<\/h2><div class='gsection_description' id='gfield_description_3_15'>We strive to make our patient\u2019s experiences within our office as comfortable as we can. Please help us understand\nyour needs as a new patient to our office by answering the following questions.<\/div><\/li><li id=\"field_3_17\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_17\" ><label class='gfield_label gform-field-label' for='input_3_17'>How did you hear about our office?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_3_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_18\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_18\" ><label class='gfield_label gform-field-label' for='input_3_18'>When was your last dental visit?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_3_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_19\" ><label class='gfield_label gform-field-label' >Do you have a primary concern (eg. pain, bleeding gums, esthetics)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_19'>\n\t\t\t<li class='gchoice gchoice_3_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes'  id='choice_3_19_0'    \/>\n\t\t\t\t<label for='choice_3_19_0' id='label_3_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='No'  id='choice_3_19_1'    \/>\n\t\t\t\t<label for='choice_3_19_1' id='label_3_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_20\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_20\" ><label class='gfield_label gform-field-label' for='input_3_20'>Please explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_3_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_21\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_21\" ><label class='gfield_label gform-field-label' for='input_3_21'>What would be important during your visit in order for you to say you had a good experience?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_3_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_22' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"1\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"1\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_22' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"3\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"3\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_3' class='gform_page' data-js='page-field-id-22' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_23\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_23\" ><h2 class=\"gsection_title\">Insurance Information<\/h2><\/li><li id=\"field_3_26\" class=\"gfield gfield--type-name float field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_26\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name of Insured Person<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_26'>\n                            \n                            <span id='input_3_26_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_26.3' id='input_3_26_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_26_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_26_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_26.6' id='input_3_26_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_26_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_27\" class=\"gfield gfield--type-date gfield--input-type-datefield float field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_27\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Date of Birth<\/label><div id='input_3_27' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_27_2_container'>\n                                            <input type='number' maxlength='2' name='input_27[]' id='input_3_27_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_3_27_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_27_1_container'>\n                                        <input type='number' maxlength='2' name='input_27[]' id='input_3_27_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_3_27_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_27_3_container'>\n                                        <input type='number' maxlength='4' name='input_27[]' id='input_3_27_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2025' step='1'\/>\n                                        <label for='input_3_27_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_3_28\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_28\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_28' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_28_1_container' >\n                                        <input type='text' name='input_28.1' id='input_3_28_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_28_1' id='input_3_28_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_28_3_container' >\n                                    <input type='text' name='input_28.3' id='input_3_28_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_28_3' id='input_3_28_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_28_4_container' >\n                                        <select name='input_28.4' id='input_3_28_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_28_4' id='input_3_28_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_28_5_container' >\n                                    <input type='text' name='input_28.5' id='input_3_28_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_28_5' id='input_3_28_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_28.6' id='input_3_28_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_3_29\" class=\"gfield gfield--type-text float-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_29\" ><label class='gfield_label gform-field-label' for='input_3_29'>Group \/ Policy #<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_3_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_30\" class=\"gfield gfield--type-text float-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_30\" ><label class='gfield_label gform-field-label' for='input_3_30'>ID \/ Contract #<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_3_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_31\" class=\"gfield gfield--type-text float-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_31\" ><label class='gfield_label gform-field-label' for='input_3_31'>Employer Name<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_3_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_32\" ><label class='gfield_label gform-field-label' >Relationship of insured to patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_32'>\n\t\t\t<li class='gchoice gchoice_3_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Self'  id='choice_3_32_0'    \/>\n\t\t\t\t<label for='choice_3_32_0' id='label_3_32_0' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='Spouse'  id='choice_3_32_1'    \/>\n\t\t\t\t<label for='choice_3_32_1' id='label_3_32_1' class='gform-field-label gform-field-label--type-inline'>Spouse<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_32_2'>\n\t\t\t\t<input name='input_32' type='radio' value='Parent'  id='choice_3_32_2'    \/>\n\t\t\t\t<label for='choice_3_32_2' id='label_3_32_2' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_32_3'>\n\t\t\t\t<input name='input_32' type='radio' value='Other'  id='choice_3_32_3'    \/>\n\t\t\t\t<label for='choice_3_32_3' id='label_3_32_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_45\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_45\" ><h2 class=\"gsection_title\">Secondary Insurance Information<\/h2><\/li><li id=\"field_3_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_46\" ><label class='gfield_label gform-field-label' >Do you have secondary insurance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_46'>\n\t\t\t<li class='gchoice gchoice_3_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Yes'  id='choice_3_46_0'    \/>\n\t\t\t\t<label for='choice_3_46_0' id='label_3_46_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='No'  id='choice_3_46_1'    \/>\n\t\t\t\t<label for='choice_3_46_1' id='label_3_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_34\" class=\"gfield gfield--type-name float field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_34\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name of Insured Person<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_34'>\n                            \n                            <span id='input_3_34_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.3' id='input_3_34_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_34_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_34_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.6' id='input_3_34_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_34_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_35\" class=\"gfield gfield--type-date gfield--input-type-datefield float field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_35\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Date of Birth<\/label><div id='input_3_35' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_35_2_container'>\n                                            <input type='number' maxlength='2' name='input_35[]' id='input_3_35_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_3_35_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_35_1_container'>\n                                        <input type='number' maxlength='2' name='input_35[]' id='input_3_35_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_3_35_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_35_3_container'>\n                                        <input type='number' maxlength='4' name='input_35[]' id='input_3_35_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2025' step='1'\/>\n                                        <label for='input_3_35_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_3_36\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_36\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_36' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_36_1_container' >\n                                        <input type='text' name='input_36.1' id='input_3_36_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_36_1' id='input_3_36_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_36_3_container' >\n                                    <input type='text' name='input_36.3' id='input_3_36_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_36_3' id='input_3_36_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_36_4_container' >\n                                        <select name='input_36.4' id='input_3_36_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_36_4' id='input_3_36_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_36_5_container' >\n                                    <input type='text' name='input_36.5' id='input_3_36_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_36_5' id='input_3_36_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_36.6' id='input_3_36_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_3_37\" class=\"gfield gfield--type-text float-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_37\" ><label class='gfield_label gform-field-label' for='input_3_37'>Group \/ Policy #<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_3_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_38\" class=\"gfield gfield--type-text float-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_38\" ><label class='gfield_label gform-field-label' for='input_3_38'>ID \/ Contract #<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_3_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_39\" class=\"gfield gfield--type-text float-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_39\" ><label class='gfield_label gform-field-label' for='input_3_39'>Employer Name<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_3_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_40\" ><label class='gfield_label gform-field-label' >Relationship of insured to patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_40'>\n\t\t\t<li class='gchoice gchoice_3_40_0'>\n\t\t\t\t<input name='input_40' type='radio' value='Self'  id='choice_3_40_0'    \/>\n\t\t\t\t<label for='choice_3_40_0' id='label_3_40_0' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_40_1'>\n\t\t\t\t<input name='input_40' type='radio' value='Spouse'  id='choice_3_40_1'    \/>\n\t\t\t\t<label for='choice_3_40_1' id='label_3_40_1' class='gform-field-label gform-field-label--type-inline'>Spouse<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_40_2'>\n\t\t\t\t<input name='input_40' type='radio' value='Parent'  id='choice_3_40_2'    \/>\n\t\t\t\t<label for='choice_3_40_2' id='label_3_40_2' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_40_3'>\n\t\t\t\t<input name='input_40' type='radio' value='Other'  id='choice_3_40_3'    \/>\n\t\t\t\t<label for='choice_3_40_3' id='label_3_40_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_43' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_43' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"4\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"4\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_4' class='gform_page' data-js='page-field-id-43' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_44\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_44\" ><h2 class=\"gsection_title\">Insurance Authorization<\/h2><\/li><li id=\"field_3_47\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_47\" ><label class='gfield_label gform-field-label' for='input_3_47'>I authorize release, to my dental insurance company \/ plan administrator the information contained in claims submitted electronically from Ascent Dental Care. I also authorize the communication of information related to the coverage of services between Ascent Dental Care and my dental insurer.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_3_47' type='text' value='' class='large'    placeholder='Full name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_48' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"3\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"3\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_48' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"5\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"5\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_5' class='gform_page' data-js='page-field-id-48' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_49\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_49\" ><h2 class=\"gsection_title\">Overall Health Information<\/h2><\/li><li id=\"field_3_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_50\" ><label class='gfield_label gform-field-label' >Would you consider yourself to be in good health?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_50'>\n\t\t\t<li class='gchoice gchoice_3_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_3_50_0'    \/>\n\t\t\t\t<label for='choice_3_50_0' id='label_3_50_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_3_50_1'    \/>\n\t\t\t\t<label for='choice_3_50_1' id='label_3_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_51\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_51\" ><label class='gfield_label gform-field-label' for='input_3_51'>Please explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_3_51' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_53\" ><label class='gfield_label gform-field-label' >Within the last year have there been any changes to your general health?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_53'>\n\t\t\t<li class='gchoice gchoice_3_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='Yes'  id='choice_3_53_0'    \/>\n\t\t\t\t<label for='choice_3_53_0' id='label_3_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='No'  id='choice_3_53_1'    \/>\n\t\t\t\t<label for='choice_3_53_1' id='label_3_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_52\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_52\" ><label class='gfield_label gform-field-label' for='input_3_52'>If yes, please explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_3_52' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_54\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_54\" ><label class='gfield_label gform-field-label' for='input_3_54'>What is your primary care physician&#039;s name?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_3_54' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_55\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_55\" ><label class='gfield_label gform-field-label' for='input_3_55'>What is your primary care physician&#039;s contact information?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_3_55' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_56\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_56\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Please indicate if you have been diagnosed with or experience any of the following<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_56'><li class='gchoice gchoice_3_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='Alzheimer&#039;s Disease'  id='choice_3_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_1' id='label_3_56_1' class='gform-field-label gform-field-label--type-inline'>Alzheimer&#8217;s Disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.2' type='checkbox'  value='Anemia'  id='choice_3_56_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_2' id='label_3_56_2' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.3' type='checkbox'  value='Anxiety'  id='choice_3_56_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_3' id='label_3_56_3' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.4' type='checkbox'  value='Arthritis'  id='choice_3_56_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_4' id='label_3_56_4' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.5' type='checkbox'  value='Artificial Joints'  id='choice_3_56_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_5' id='label_3_56_5' class='gform-field-label gform-field-label--type-inline'>Artificial Joints<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.6' type='checkbox'  value='Asthma'  id='choice_3_56_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_6' id='label_3_56_6' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.7' type='checkbox'  value='Autoimmune disease'  id='choice_3_56_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_7' id='label_3_56_7' class='gform-field-label gform-field-label--type-inline'>Autoimmune disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.8' type='checkbox'  value='Blindness'  id='choice_3_56_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_8' id='label_3_56_8' class='gform-field-label gform-field-label--type-inline'>Blindness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.9' type='checkbox'  value='Cancer'  id='choice_3_56_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_9' id='label_3_56_9' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.11' type='checkbox'  value='Chronic Lymphocytic Leukemia'  id='choice_3_56_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_11' id='label_3_56_11' class='gform-field-label gform-field-label--type-inline'>Chronic Lymphocytic Leukemia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.12' type='checkbox'  value='COPD'  id='choice_3_56_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_12' id='label_3_56_12' class='gform-field-label gform-field-label--type-inline'>COPD<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.13' type='checkbox'  value='Diabetes'  id='choice_3_56_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_13' id='label_3_56_13' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.14' type='checkbox'  value='Dialysis'  id='choice_3_56_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_14' id='label_3_56_14' class='gform-field-label gform-field-label--type-inline'>Dialysis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.15' type='checkbox'  value='Epilepsy'  id='choice_3_56_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_15' id='label_3_56_15' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.16' type='checkbox'  value='Excessive Bleeding'  id='choice_3_56_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_16' id='label_3_56_16' class='gform-field-label gform-field-label--type-inline'>Excessive Bleeding<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.17' type='checkbox'  value='Fainting'  id='choice_3_56_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_17' id='label_3_56_17' class='gform-field-label gform-field-label--type-inline'>Fainting<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.18' type='checkbox'  value='Gastro-intestinal issues'  id='choice_3_56_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_18' id='label_3_56_18' class='gform-field-label gform-field-label--type-inline'>Gastro-intestinal issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.19' type='checkbox'  value='Glaucoma'  id='choice_3_56_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_19' id='label_3_56_19' class='gform-field-label gform-field-label--type-inline'>Glaucoma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.21' type='checkbox'  value='Heart Disease'  id='choice_3_56_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_21' id='label_3_56_21' class='gform-field-label gform-field-label--type-inline'>Heart Disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.22' type='checkbox'  value='Heart Attack'  id='choice_3_56_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_22' id='label_3_56_22' class='gform-field-label gform-field-label--type-inline'>Heart Attack<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.23' type='checkbox'  value='Heart Murmur'  id='choice_3_56_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_23' id='label_3_56_23' class='gform-field-label gform-field-label--type-inline'>Heart Murmur<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.24' type='checkbox'  value='Heart Valve Replacement'  id='choice_3_56_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_24' id='label_3_56_24' class='gform-field-label gform-field-label--type-inline'>Heart Valve Replacement<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.25' type='checkbox'  value='Hepatitis'  id='choice_3_56_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_25' id='label_3_56_25' class='gform-field-label gform-field-label--type-inline'>Hepatitis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.26' type='checkbox'  value='HIV+'  id='choice_3_56_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_26' id='label_3_56_26' class='gform-field-label gform-field-label--type-inline'>HIV+<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.27' type='checkbox'  value='Hypertension'  id='choice_3_56_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_27' id='label_3_56_27' class='gform-field-label gform-field-label--type-inline'>Hypertension<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.28' type='checkbox'  value='Hyperthyroidism'  id='choice_3_56_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_28' id='label_3_56_28' class='gform-field-label gform-field-label--type-inline'>Hyperthyroidism<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.29' type='checkbox'  value='Hypothyroidism'  id='choice_3_56_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_29' id='label_3_56_29' class='gform-field-label gform-field-label--type-inline'>Hypothyroidism<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.31' type='checkbox'  value='Immune Deficiency'  id='choice_3_56_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_31' id='label_3_56_31' class='gform-field-label gform-field-label--type-inline'>Immune Deficiency<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.32' type='checkbox'  value='Joint replacement'  id='choice_3_56_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_32' id='label_3_56_32' class='gform-field-label gform-field-label--type-inline'>Joint replacement<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.33' type='checkbox'  value='Kidney Disease'  id='choice_3_56_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_33' id='label_3_56_33' class='gform-field-label gform-field-label--type-inline'>Kidney Disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.34' type='checkbox'  value='Knee Replacement'  id='choice_3_56_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_34' id='label_3_56_34' class='gform-field-label gform-field-label--type-inline'>Knee Replacement<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.35' type='checkbox'  value='Leukemia'  id='choice_3_56_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_35' id='label_3_56_35' class='gform-field-label gform-field-label--type-inline'>Leukemia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.36' type='checkbox'  value='Liver Disease'  id='choice_3_56_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_36' id='label_3_56_36' class='gform-field-label gform-field-label--type-inline'>Liver Disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_37'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.37' type='checkbox'  value='Low Blood Pressure'  id='choice_3_56_37'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_37' id='label_3_56_37' class='gform-field-label gform-field-label--type-inline'>Low Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_38'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.38' type='checkbox'  value='Mental health issues'  id='choice_3_56_38'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_38' id='label_3_56_38' class='gform-field-label gform-field-label--type-inline'>Mental health issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_39'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.39' type='checkbox'  value='Multiple sclerosis'  id='choice_3_56_39'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_39' id='label_3_56_39' class='gform-field-label gform-field-label--type-inline'>Multiple sclerosis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_41'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.41' type='checkbox'  value='Nerve dysfunction \/ damage'  id='choice_3_56_41'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_41' id='label_3_56_41' class='gform-field-label gform-field-label--type-inline'>Nerve dysfunction \/ damage<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_42'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.42' type='checkbox'  value='Pacemaker'  id='choice_3_56_42'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_42' id='label_3_56_42' class='gform-field-label gform-field-label--type-inline'>Pacemaker<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_43'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.43' type='checkbox'  value='Parkinson&#039;s Disease'  id='choice_3_56_43'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_43' id='label_3_56_43' class='gform-field-label gform-field-label--type-inline'>Parkinson&#8217;s Disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_44'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.44' type='checkbox'  value='Pre-medication'  id='choice_3_56_44'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_44' id='label_3_56_44' class='gform-field-label gform-field-label--type-inline'>Pre-medication<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_45'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.45' type='checkbox'  value='Respiratory Distress'  id='choice_3_56_45'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_45' id='label_3_56_45' class='gform-field-label gform-field-label--type-inline'>Respiratory Distress<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_46'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.46' type='checkbox'  value='Rheumatic Fever'  id='choice_3_56_46'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_46' id='label_3_56_46' class='gform-field-label gform-field-label--type-inline'>Rheumatic Fever<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_47'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.47' type='checkbox'  value='Rheumatism'  id='choice_3_56_47'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_47' id='label_3_56_47' class='gform-field-label gform-field-label--type-inline'>Rheumatism<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_48'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.48' type='checkbox'  value='Sinus inlammation'  id='choice_3_56_48'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_48' id='label_3_56_48' class='gform-field-label gform-field-label--type-inline'>Sinus inlammation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_49'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.49' type='checkbox'  value='Spinal stenosis'  id='choice_3_56_49'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_49' id='label_3_56_49' class='gform-field-label gform-field-label--type-inline'>Spinal stenosis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_51'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.51' type='checkbox'  value='Stroke'  id='choice_3_56_51'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_51' id='label_3_56_51' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_52'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.52' type='checkbox'  value='Thyroid Disease'  id='choice_3_56_52'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_52' id='label_3_56_52' class='gform-field-label gform-field-label--type-inline'>Thyroid Disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_53'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.53' type='checkbox'  value='TMJ issues'  id='choice_3_56_53'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_53' id='label_3_56_53' class='gform-field-label gform-field-label--type-inline'>TMJ issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_54'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.54' type='checkbox'  value='Tuberculosis'  id='choice_3_56_54'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_54' id='label_3_56_54' class='gform-field-label gform-field-label--type-inline'>Tuberculosis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_55'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.55' type='checkbox'  value='Tumors'  id='choice_3_56_55'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_55' id='label_3_56_55' class='gform-field-label gform-field-label--type-inline'>Tumors<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_56'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.56' type='checkbox'  value='Ulcers'  id='choice_3_56_56'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_56' id='label_3_56_56' class='gform-field-label gform-field-label--type-inline'>Ulcers<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_56_57'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.57' type='checkbox'  value='Women only: Pregnant'  id='choice_3_56_57'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_57' id='label_3_56_57' class='gform-field-label gform-field-label--type-inline'>Women only: Pregnant<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_57\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_57\" ><label class='gfield_label gform-field-label' for='input_3_57'>Due Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_3_57' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_58\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_58\" ><label class='gfield_label gform-field-label' for='input_3_58'>For any checks above, please indicate date of diagnosis, area of body involved, and severity<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_58' id='input_3_58' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_59\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_59\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Please indicate any known allergies<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_59'><li class='gchoice gchoice_3_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Amoxicillin'  id='choice_3_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_1' id='label_3_59_1' class='gform-field-label gform-field-label--type-inline'>Amoxicillin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='Aspirin'  id='choice_3_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_2' id='label_3_59_2' class='gform-field-label gform-field-label--type-inline'>Aspirin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.3' type='checkbox'  value='Barbiturates'  id='choice_3_59_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_3' id='label_3_59_3' class='gform-field-label gform-field-label--type-inline'>Barbiturates<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.4' type='checkbox'  value='Ciprofloxacin'  id='choice_3_59_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_4' id='label_3_59_4' class='gform-field-label gform-field-label--type-inline'>Ciprofloxacin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.5' type='checkbox'  value='Clindamycin Codeine'  id='choice_3_59_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_5' id='label_3_59_5' class='gform-field-label gform-field-label--type-inline'>Clindamycin Codeine<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.6' type='checkbox'  value='Erthromycin'  id='choice_3_59_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_6' id='label_3_59_6' class='gform-field-label gform-field-label--type-inline'>Erthromycin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.7' type='checkbox'  value='Ibuprofen'  id='choice_3_59_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_7' id='label_3_59_7' class='gform-field-label gform-field-label--type-inline'>Ibuprofen<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.8' type='checkbox'  value='Latex'  id='choice_3_59_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_8' id='label_3_59_8' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.9' type='checkbox'  value='Local anesthesia'  id='choice_3_59_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_9' id='label_3_59_9' class='gform-field-label gform-field-label--type-inline'>Local anesthesia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.11' type='checkbox'  value='Metal'  id='choice_3_59_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_11' id='label_3_59_11' class='gform-field-label gform-field-label--type-inline'>Metal<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.12' type='checkbox'  value='Morphine'  id='choice_3_59_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_12' id='label_3_59_12' class='gform-field-label gform-field-label--type-inline'>Morphine<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.13' type='checkbox'  value='Nuts'  id='choice_3_59_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_13' id='label_3_59_13' class='gform-field-label gform-field-label--type-inline'>Nuts<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.14' type='checkbox'  value='Penicillin'  id='choice_3_59_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_14' id='label_3_59_14' class='gform-field-label gform-field-label--type-inline'>Penicillin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.15' type='checkbox'  value='Sulfa drugs'  id='choice_3_59_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_15' id='label_3_59_15' class='gform-field-label gform-field-label--type-inline'>Sulfa drugs<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.16' type='checkbox'  value='Tetracycline'  id='choice_3_59_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_16' id='label_3_59_16' class='gform-field-label gform-field-label--type-inline'>Tetracycline<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_59_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.17' type='checkbox'  value='Tylenol #3'  id='choice_3_59_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_17' id='label_3_59_17' class='gform-field-label gform-field-label--type-inline'>Tylenol #3<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_60\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_60\" ><label class='gfield_label gform-field-label' for='input_3_60'>Local anesthesia &#8211; specify<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_3_60' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_61\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_61\" ><label class='gfield_label gform-field-label' for='input_3_61'>Metal &#8211; specify<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_3_61' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_62\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_62\" ><label class='gfield_label gform-field-label' for='input_3_62'>Do you have any other health concerns or allergies? If so, please indicate below<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_3_62' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_63\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_63\" ><label class='gfield_label gform-field-label' for='input_3_63'>Please indicate the name of any medications you are currently taking<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_63' id='input_3_63' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_64\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_64\" ><label class='gfield_label gform-field-label' for='input_3_64'>If you do not know the names of all of your medications, we can request the list from your pharmacy. Please provide the name and phone number of your pharmacy<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_3_64' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_65' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"4\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"4\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_65' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"6\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"6\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_6' class='gform_page' data-js='page-field-id-65' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_66\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_66\" ><h2 class=\"gsection_title\">Dental Health Information<\/h2><\/li><li id=\"field_3_67\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_67\" ><label class='gfield_label gform-field-label' for='input_3_67'>What is the reason for your dental visit today?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_3_67' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_68\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_68\" ><label class='gfield_label gform-field-label' >Is there anything you would like to change about your mouth, teeth, or smile?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_68'>\n\t\t\t<li class='gchoice gchoice_3_68_0'>\n\t\t\t\t<input name='input_68' type='radio' value='Yes'  id='choice_3_68_0'    \/>\n\t\t\t\t<label for='choice_3_68_0' id='label_3_68_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_68_1'>\n\t\t\t\t<input name='input_68' type='radio' value='No'  id='choice_3_68_1'    \/>\n\t\t\t\t<label for='choice_3_68_1' id='label_3_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_69\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_69\" ><label class='gfield_label gform-field-label' for='input_3_69'>Please elaborate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_3_69' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_70\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_70\" ><label class='gfield_label gform-field-label' for='input_3_70'>When was your last visit to the dentist?<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_3_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_71\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_71\" ><label class='gfield_label gform-field-label' for='input_3_71'>What was done at your last dental visit?<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_3_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_72\" ><label class='gfield_label gform-field-label' >Are you nervous \/ anxious about having dental work done?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_72'>\n\t\t\t<li class='gchoice gchoice_3_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='Yes'  id='choice_3_72_0'    \/>\n\t\t\t\t<label for='choice_3_72_0' id='label_3_72_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='No'  id='choice_3_72_1'    \/>\n\t\t\t\t<label for='choice_3_72_1' id='label_3_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_73\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_73\" ><label class='gfield_label gform-field-label' for='input_3_73'>Please elaborate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_3_73' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_75\" ><label class='gfield_label gform-field-label' >How frequently do you brush your teeth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_75'>\n\t\t\t<li class='gchoice gchoice_3_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='At least 2x\/day'  id='choice_3_75_0'    \/>\n\t\t\t\t<label for='choice_3_75_0' id='label_3_75_0' class='gform-field-label gform-field-label--type-inline'>At least 2x\/day<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='Once a day'  id='choice_3_75_1'    \/>\n\t\t\t\t<label for='choice_3_75_1' id='label_3_75_1' class='gform-field-label gform-field-label--type-inline'>Once a day<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_75_2'>\n\t\t\t\t<input name='input_75' type='radio' value='A few times a week'  id='choice_3_75_2'    \/>\n\t\t\t\t<label for='choice_3_75_2' id='label_3_75_2' class='gform-field-label gform-field-label--type-inline'>A few times a week<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_75_3'>\n\t\t\t\t<input name='input_75' type='radio' value='Seldom'  id='choice_3_75_3'    \/>\n\t\t\t\t<label for='choice_3_75_3' id='label_3_75_3' class='gform-field-label gform-field-label--type-inline'>Seldom<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_76\" ><label class='gfield_label gform-field-label' >How frequently do you floss your teeth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_76'>\n\t\t\t<li class='gchoice gchoice_3_76_0'>\n\t\t\t\t<input name='input_76' type='radio' value='Daily'  id='choice_3_76_0'    \/>\n\t\t\t\t<label for='choice_3_76_0' id='label_3_76_0' class='gform-field-label gform-field-label--type-inline'>Daily<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_76_1'>\n\t\t\t\t<input name='input_76' type='radio' value='A few times a week'  id='choice_3_76_1'    \/>\n\t\t\t\t<label for='choice_3_76_1' id='label_3_76_1' class='gform-field-label gform-field-label--type-inline'>A few times a week<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_76_2'>\n\t\t\t\t<input name='input_76' type='radio' value='Seldom'  id='choice_3_76_2'    \/>\n\t\t\t\t<label for='choice_3_76_2' id='label_3_76_2' class='gform-field-label gform-field-label--type-inline'>Seldom<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_76_3'>\n\t\t\t\t<input name='input_76' type='radio' value='Never'  id='choice_3_76_3'    \/>\n\t\t\t\t<label for='choice_3_76_3' id='label_3_76_3' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_77\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_77\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Please check any of the following that apply to you<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_77'><li class='gchoice gchoice_3_77_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.1' type='checkbox'  value='Do your gums bleed when you brush or floss?'  id='choice_3_77_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_77_1' id='label_3_77_1' class='gform-field-label gform-field-label--type-inline'>Do your gums bleed when you brush or floss?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_77_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.2' type='checkbox'  value='Are your teeth sensitive to hot or cold?'  id='choice_3_77_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_77_2' id='label_3_77_2' class='gform-field-label gform-field-label--type-inline'>Are your teeth sensitive to hot or cold?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_77_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.3' type='checkbox'  value='Are any of your teeth currently causing you pain?'  id='choice_3_77_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_77_3' id='label_3_77_3' class='gform-field-label gform-field-label--type-inline'>Are any of your teeth currently causing you pain?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_77_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.4' type='checkbox'  value='Do you grind your teeth (either consciously or during your sleep)?'  id='choice_3_77_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_77_4' id='label_3_77_4' class='gform-field-label gform-field-label--type-inline'>Do you grind your teeth (either consciously or during your sleep)?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_77_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.5' type='checkbox'  value='Is your goal to keep your teeth for as long as possible?'  id='choice_3_77_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_77_5' id='label_3_77_5' class='gform-field-label gform-field-label--type-inline'>Is your goal to keep your teeth for as long as possible?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_77_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.6' type='checkbox'  value='Do you have any dental implants, dentures, or partial dentures?'  id='choice_3_77_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_77_6' id='label_3_77_6' class='gform-field-label gform-field-label--type-inline'>Do you have any dental implants, dentures, or partial dentures?<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_78\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_78\" ><label class='gfield_label gform-field-label' for='input_3_78'>If you checked any of the above, please elaborate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_78' id='input_3_78' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_79\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_79\" ><label class='gfield_label gform-field-label' for='input_3_79'>Please indicate if there is anything else you would like us to know before your appointment<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_79' id='input_3_79' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_80' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"5\");  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acknowledge that I have read and understand the <a href=\"https:\/\/wordpress-364990-1429934.cloudwaysapps.com\/privacy-policy\/\" target=\"_blank\">privacy policy<\/a><\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_82\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_82\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consent for Dental Services<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_82'><li class='gchoice gchoice_3_82_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.1' type='checkbox'  value='I acknowledge that I have read and understand the &lt;a href=&quot;https:\/\/wordpress-364990-1429934.cloudwaysapps.com\/consent-for-dental-services\/&quot; target=&quot;_blank&quot;&gt;consent for dental services policy&lt;\/a&gt;'  id='choice_3_82_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_82_1' id='label_3_82_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read and understand the <a href=\"https:\/\/wordpress-364990-1429934.cloudwaysapps.com\/consent-for-dental-services\/\" target=\"_blank\">consent for dental services policy<\/a><\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_83\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_83\" ><label class='gfield_label gform-field-label' for='input_3_83'>Phone<\/label><div class='ginput_container'><input name='input_83' id='input_3_83' type='text' value='' 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