{"id":7304,"date":"2021-10-07T12:22:04","date_gmt":"2021-10-07T18:22:04","guid":{"rendered":"https:\/\/signature28.com\/?page_id=7304"},"modified":"2023-05-21T09:09:57","modified_gmt":"2023-05-21T15:09:57","slug":"new-patient-intake-form-2021","status":"publish","type":"page","link":"https:\/\/signature28.com\/new-patient-intake-form-2021\/","title":{"rendered":"Intake form 2023"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_chrome gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_10' ><div id='gf_10' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">SIGNATURE 28 DENTURE CLINIC<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_10'  action='\/wp-json\/wp\/v2\/pages\/7304#gf_10' data-formid='10' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LfJzVwaAAAAALYYbEmDfyEkGevIPj7cZAr66e47' data-tabindex='0'><input id=\"input_018af4b388ab9bbae95ab87f7e462dc7\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_018af4b388ab9bbae95ab87f7e462dc7\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_10_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_10_2\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_2\" ><h3 class=\"gsection_title\">PATIENT INFORMATION<\/h3><\/div><div id=\"field_10_3\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_3\" ><label class='gfield_label gform-field-label' for='input_10_3'>Today&#039;s Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_10_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_3_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_3' class='gform_hidden' value='https:\/\/signature28.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_4\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_4\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><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_10_4'>\n                            \n                            <span id='input_10_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.3' id='input_10_4_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_4_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_10_4_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.6' id='input_10_4_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_4_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_10_5\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_5\" ><label class='gfield_label gform-field-label' for='input_10_5'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_10_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_5' class='gform_hidden' value='https:\/\/signature28.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_6\" ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_6'>\n\t\t\t<div class='gchoice gchoice_10_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Male'  id='choice_10_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_6_0' id='label_10_6_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Female'  id='choice_10_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_6_1' id='label_10_6_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_7\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_7\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_10_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_10_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_10_7_1' value=''    aria-required='true'    \/>\n                                        <label for='input_10_7_1' id='input_10_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_10_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_10_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_10_7_2' id='input_10_7_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_10_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_10_7_3' value=''    aria-required='true'    \/>\n                                    <label for='input_10_7_3' id='input_10_7_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_10_7_4_container' >\n                                        <input type='text' name='input_7.4' id='input_10_7_4' value=''      aria-required='true'    \/>\n                                        <label for='input_10_7_4' id='input_10_7_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_10_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_10_7_5' value=''    aria-required='true'    \/>\n                                    <label for='input_10_7_5' id='input_10_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_10_7_6_container' >\n                                        <select name='input_7.6' id='input_10_7_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_10_7_6' id='input_10_7_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_10_8\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_8\" ><label class='gfield_label gform-field-label' for='input_10_8'>Home Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_10_8' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_9\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_9\" ><label class='gfield_label gform-field-label' for='input_10_9'>Cellphone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_10_9' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_14\" class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_14\" ><label class='gfield_label gform-field-label' for='input_10_14'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_14' id='input_10_14' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_10_10' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_10\").val(\"2\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_10\").val(\"2\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_2' class='gform_page' data-js='page-field-id-10' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_10_2' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_10_12\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_12\" ><h3 class=\"gsection_title\">EMERGENCY CONTACT INFORMATION<\/h3><\/div><fieldset id=\"field_10_13\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_13\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of your Emergency Contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><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_10_13'>\n                            \n                            <span id='input_10_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_10_13_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_13_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_10_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_10_13_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_13_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_10_15\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_15\" ><label class='gfield_label gform-field-label' for='input_10_15'>Phone Number of Emergency Contact<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_10_15' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_10_16' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_10\").val(\"1\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_10\").val(\"1\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_10_16' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_10\").val(\"3\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_10\").val(\"3\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_3' class='gform_page' data-js='page-field-id-16' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_10_3' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_10_17\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_17\" ><h3 class=\"gsection_title\">INSURANCE INFORMATION<\/h3><\/div><div id=\"field_10_19\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_19\" ><label class='gfield_label gform-field-label' for='input_10_19'>ALBERTA HEATH CARE NUMBER (Seniors over 65 years old only)<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_10_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_20\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_20\" ><label class='gfield_label gform-field-label' for='input_10_20'>NAME OF INSURANCE COMPANY<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_10_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_21\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_21\" ><label class='gfield_label gform-field-label' for='input_10_21'>POLICY\/ PLAN\/ GROUP #<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_10_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_22\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_22\" ><label class='gfield_label gform-field-label' for='input_10_22'>IDENTIFICATION NUMBER (ID #)<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_10_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_23\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_23\" ><label class='gfield_label gform-field-label' for='input_10_23'>DIV #<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_10_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_10_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_24\" ><legend class='gfield_label gform-field-label' >Are you the Primary Subscriber of this Insurance Policy<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_24'>\n\t\t\t<div class='gchoice gchoice_10_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_10_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_24_0' id='label_10_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_10_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_24_1' id='label_10_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_25\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_25\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If you answered &quot;No&quot; to the above, please provide the name of the Primary Subscriber<\/legend><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_10_25'>\n                            \n                            <span id='input_10_25_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.3' id='input_10_25_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_10_25_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_10_25_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.6' id='input_10_25_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_10_25_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_10_26\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_26\" ><label class='gfield_label gform-field-label' for='input_10_26'>Date of Birth of Primary Subscriber<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_26' id='input_10_26' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_26_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_26_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_26' class='gform_hidden' value='https:\/\/signature28.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_27\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_27\" ><h3 class=\"gsection_title\">MEDICAL\/ DENTAL HISTORY<\/h3><\/div><fieldset id=\"field_10_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_29\" ><legend class='gfield_label gform-field-label' >Aside from the regular routine exams, are you currently being followed by a physician or specialist?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_29'>\n\t\t\t<div class='gchoice gchoice_10_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_10_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_29_0' id='label_10_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_10_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_29_1' id='label_10_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_30\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_30\" ><label class='gfield_label gform-field-label' for='input_10_30'>If you answered &quot;Yes&quot;, what are your being followed for?<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_10_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_10_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_31\" ><legend class='gfield_label gform-field-label' >In the last two (2) years, have you had a serious illness or been hospitalized?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_31'>\n\t\t\t<div class='gchoice gchoice_10_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_10_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_31_0' id='label_10_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_10_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_31_1' id='label_10_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_32\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_32\" ><label class='gfield_label gform-field-label' for='input_10_32'>If you answered &quot;Yes&quot;, please provide us some additional details on the cause of hospitalization or illness.<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_10_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_10_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_33\" ><legend class='gfield_label gform-field-label' >Do you have any Allergies?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_33'>\n\t\t\t<div class='gchoice gchoice_10_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_10_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_33_0' id='label_10_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_10_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_33_1' id='label_10_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_34\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_34\" ><label class='gfield_label gform-field-label' for='input_10_34'>What allergies do you suffer from? (Latex, Nuts, Medications, Specific Foods, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_10_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_10_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_35\" ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_10_35'><div class='gchoice gchoice_10_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Alcohol Issues'  id='choice_10_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_1' id='label_10_35_1' class='gform-field-label gform-field-label--type-inline'>Alcohol Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='Drug Dependency'  id='choice_10_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_2' id='label_10_35_2' class='gform-field-label gform-field-label--type-inline'>Drug Dependency<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.3' type='checkbox'  value='Hepatitis A'  id='choice_10_35_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_3' id='label_10_35_3' class='gform-field-label gform-field-label--type-inline'>Hepatitis A<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.4' type='checkbox'  value='Hepatitis B'  id='choice_10_35_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_4' id='label_10_35_4' class='gform-field-label gform-field-label--type-inline'>Hepatitis B<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.5' type='checkbox'  value='Hepatitis C'  id='choice_10_35_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_5' id='label_10_35_5' class='gform-field-label gform-field-label--type-inline'>Hepatitis C<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.6' type='checkbox'  value='Other Liver Disease'  id='choice_10_35_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_6' id='label_10_35_6' class='gform-field-label gform-field-label--type-inline'>Other Liver Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.7' type='checkbox'  value='Arthritis'  id='choice_10_35_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_7' id='label_10_35_7' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.8' type='checkbox'  value='Artificial Joint Replacement'  id='choice_10_35_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_8' id='label_10_35_8' class='gform-field-label gform-field-label--type-inline'>Artificial Joint Replacement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.9' type='checkbox'  value='Diabetes'  id='choice_10_35_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_9' id='label_10_35_9' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.11' type='checkbox'  value='Eating Disorder'  id='choice_10_35_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_11' id='label_10_35_11' class='gform-field-label gform-field-label--type-inline'>Eating Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.12' type='checkbox'  value='Epilepsy\/ Seizure Disorder'  id='choice_10_35_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_12' id='label_10_35_12' class='gform-field-label gform-field-label--type-inline'>Epilepsy\/ Seizure Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.13' type='checkbox'  value='HIV\/ AIDS'  id='choice_10_35_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_13' id='label_10_35_13' class='gform-field-label gform-field-label--type-inline'>HIV\/ AIDS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.14' type='checkbox'  value='Immune Deficiency'  id='choice_10_35_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_14' id='label_10_35_14' class='gform-field-label gform-field-label--type-inline'>Immune Deficiency<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.15' type='checkbox'  value='Cold Sores'  id='choice_10_35_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_15' id='label_10_35_15' class='gform-field-label gform-field-label--type-inline'>Cold Sores<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.16' type='checkbox'  value='High Cholesterol'  id='choice_10_35_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_16' id='label_10_35_16' class='gform-field-label gform-field-label--type-inline'>High Cholesterol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.17' type='checkbox'  value='High Blood Pressure\/  Low Blood Pressure'  id='choice_10_35_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_17' id='label_10_35_17' class='gform-field-label gform-field-label--type-inline'>High Blood Pressure\/  Low Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.18' type='checkbox'  value='Bleeding disorder\/ Hemophilia'  id='choice_10_35_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_18' id='label_10_35_18' class='gform-field-label gform-field-label--type-inline'>Bleeding disorder\/ Hemophilia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.19' type='checkbox'  value='Nervousness\/ Psychiatric Condition'  id='choice_10_35_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_19' id='label_10_35_19' class='gform-field-label gform-field-label--type-inline'>Nervousness\/ Psychiatric Condition<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_35_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.21' type='checkbox'  value='Organ transplant'  id='choice_10_35_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_35_21' id='label_10_35_21' class='gform-field-label gform-field-label--type-inline'>Organ transplant<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_36\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_36\" ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_10_36'><div class='gchoice gchoice_10_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Tuberculosis'  id='choice_10_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_1' id='label_10_36_1' class='gform-field-label gform-field-label--type-inline'>Tuberculosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='Asthma'  id='choice_10_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_2' id='label_10_36_2' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.3' type='checkbox'  value='Difficulty Breathing'  id='choice_10_36_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_3' id='label_10_36_3' class='gform-field-label gform-field-label--type-inline'>Difficulty Breathing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.4' type='checkbox'  value='Emphysema'  id='choice_10_36_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_4' id='label_10_36_4' class='gform-field-label gform-field-label--type-inline'>Emphysema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.5' type='checkbox'  value='Chronic Obstructive Pulmonary Disease'  id='choice_10_36_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_5' id='label_10_36_5' class='gform-field-label gform-field-label--type-inline'>Chronic Obstructive Pulmonary Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.6' type='checkbox'  value='Cancer'  id='choice_10_36_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_6' id='label_10_36_6' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.7' type='checkbox'  value='Chemotherapy'  id='choice_10_36_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_7' id='label_10_36_7' class='gform-field-label gform-field-label--type-inline'>Chemotherapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.8' type='checkbox'  value='Radiation Therapy'  id='choice_10_36_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_8' id='label_10_36_8' class='gform-field-label gform-field-label--type-inline'>Radiation Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.9' type='checkbox'  value='Dizziness\/ Fainting'  id='choice_10_36_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_9' id='label_10_36_9' class='gform-field-label gform-field-label--type-inline'>Dizziness\/ Fainting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.11' type='checkbox'  value='Kidney stones'  id='choice_10_36_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_11' id='label_10_36_11' class='gform-field-label gform-field-label--type-inline'>Kidney stones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.12' type='checkbox'  value='Kidney disease'  id='choice_10_36_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_12' id='label_10_36_12' class='gform-field-label gform-field-label--type-inline'>Kidney disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.13' type='checkbox'  value='Heart Attack\/  Heart Disease'  id='choice_10_36_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_13' id='label_10_36_13' class='gform-field-label gform-field-label--type-inline'>Heart Attack\/  Heart Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.14' type='checkbox'  value='Heart Murmur'  id='choice_10_36_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_14' id='label_10_36_14' class='gform-field-label gform-field-label--type-inline'>Heart Murmur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.15' type='checkbox'  value='Heart Surgery'  id='choice_10_36_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_15' id='label_10_36_15' class='gform-field-label gform-field-label--type-inline'>Heart Surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.16' type='checkbox'  value='Artificial Heart Valve'  id='choice_10_36_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_16' id='label_10_36_16' class='gform-field-label gform-field-label--type-inline'>Artificial Heart Valve<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.17' type='checkbox'  value='Pacemaker'  id='choice_10_36_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_17' id='label_10_36_17' class='gform-field-label gform-field-label--type-inline'>Pacemaker<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.18' type='checkbox'  value='Angina Pectoris'  id='choice_10_36_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_18' id='label_10_36_18' class='gform-field-label gform-field-label--type-inline'>Angina Pectoris<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.19' type='checkbox'  value='Rheumatic Fever'  id='choice_10_36_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_19' id='label_10_36_19' class='gform-field-label gform-field-label--type-inline'>Rheumatic Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.21' type='checkbox'  value='Surgery'  id='choice_10_36_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_21' id='label_10_36_21' class='gform-field-label gform-field-label--type-inline'>Surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_36_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.22' type='checkbox'  value='NONE OF THESE APPLY TO ME'  id='choice_10_36_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_36_22' id='label_10_36_22' class='gform-field-label gform-field-label--type-inline'>NONE OF THESE APPLY TO ME<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_43\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_43\" ><label class='gfield_label gform-field-label' for='input_10_43'>Are there any other health issues, not listed above, that you wish to tell us about? If so, please provide additional details.<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_10_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_10_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_39\" ><legend class='gfield_label gform-field-label' >Are you currently taking any medications, prescriptions, or herbal remedies?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_39'>\n\t\t\t<div class='gchoice gchoice_10_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Yes'  id='choice_10_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_39_0' id='label_10_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_10_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_39_1' id='label_10_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_37\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_37\" ><label class='gfield_label gform-field-label' for='input_10_37'>If you answered &#039;Yes&quot;, please provide the names of your medications\/ herbal supplements<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_10_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_10_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_38\" ><legend class='gfield_label gform-field-label' >Have you recently gained or lost weight?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_38'>\n\t\t\t<div class='gchoice gchoice_10_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_10_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_38_0' id='label_10_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_10_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_38_1' id='label_10_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_40\" ><legend class='gfield_label gform-field-label' >Do you frequently have indigestion?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_40'>\n\t\t\t<div class='gchoice gchoice_10_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_10_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_40_0' id='label_10_40_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_10_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_40_1' id='label_10_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_41\" ><legend class='gfield_label gform-field-label' >WOMEN: Are you currently pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_41'>\n\t\t\t<div class='gchoice gchoice_10_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Yes'  id='choice_10_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_41_0' id='label_10_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='No'  id='choice_10_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_41_1' id='label_10_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_41_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Not Applicable'  id='choice_10_41_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_41_2' id='label_10_41_2' class='gform-field-label gform-field-label--type-inline'>Not Applicable<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_10_44' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_10\").val(\"2\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_10\").val(\"2\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_10_44' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_10\").val(\"4\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_10\").val(\"4\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_4' class='gform_page' data-js='page-field-id-44' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_10_4' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_10_45\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_45\" ><h3 class=\"gsection_title\">DENTURE INFORMATION<\/h3><\/div><div id=\"field_10_46\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_46\" ><label class='gfield_label gform-field-label' for='input_10_46'>How long have you had your CURRENT dentures?<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_10_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_47\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_47\" ><label class='gfield_label gform-field-label' for='input_10_47'>Are you currently pleased with the appearance of your dentures? If no, please explain.<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_10_47' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_48\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_48\" ><label class='gfield_label gform-field-label' for='input_10_48'>Are you pleased with the fit, comfort, and functional state of your dentures? If no, please explain.<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_10_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_10_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_49\" ><legend class='gfield_label gform-field-label' >Do you currently have dental implants?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_49'>\n\t\t\t<div class='gchoice gchoice_10_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Yes'  id='choice_10_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_49_0' id='label_10_49_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='No'  id='choice_10_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_49_1' id='label_10_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_49_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='No, but I would like to discuss the possibility of dental implants'  id='choice_10_49_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_49_2' id='label_10_49_2' class='gform-field-label gform-field-label--type-inline'>No, but I would like to discuss the possibility of dental implants<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_10_50' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_10\").val(\"3\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_10\").val(\"3\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_10_50' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_10\").val(\"5\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_10\").val(\"5\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_5' class='gform_page' data-js='page-field-id-50' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_10_5' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_10_51\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_51\" ><h3 class=\"gsection_title\">FINANCIAL<\/h3><div class='gsection_description' id='gfield_description_10_51'>Please note that a 50% deposit is collected on the day treatment is initiated. The remaining balance is due upon delivery of your denture(s). Delinquent accounts are subject to interest charges of 2% per month (26.8% per annum) and third party collection fees. Thank you for your understanding.<\/div><\/div><fieldset id=\"field_10_54\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_54\" ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_54.1' id='input_10_54_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_10_54_1' >I have read and understand the financial policies of Signature 28 Denture Clinic<\/label><input type='hidden' name='input_54.2' value='I have read and understand the financial policies of Signature 28 Denture Clinic' class='gform_hidden' \/><input type='hidden' name='input_54.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_10_55' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_10\").val(\"4\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_10\").val(\"4\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_10_55' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_10\").val(\"6\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_10\").val(\"6\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_6' class='gform_page' data-js='page-field-id-55' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_10_6' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_10_56\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_56\" ><h3 class=\"gsection_title\">CONSENT<\/h3><\/div><fieldset id=\"field_10_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_60\" ><legend class='gfield_label gform-field-label' >How did you hear about Signature 28 Denture Clinic?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_60'>\n\t\t\t<div class='gchoice gchoice_10_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Google Search'  id='choice_10_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_60_0' id='label_10_60_0' class='gform-field-label gform-field-label--type-inline'>Google Search<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Radio Advertisement'  id='choice_10_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_60_1' id='label_10_60_1' class='gform-field-label gform-field-label--type-inline'>Radio Advertisement<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_60_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Promotional flyer'  id='choice_10_60_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_60_2' id='label_10_60_2' class='gform-field-label gform-field-label--type-inline'>Promotional flyer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_60_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Friend\/ Family Referral'  id='choice_10_60_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_60_3' id='label_10_60_3' class='gform-field-label gform-field-label--type-inline'>Friend\/ Family Referral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_60_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='OTHER'  id='choice_10_60_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_60_4' id='label_10_60_4' class='gform-field-label gform-field-label--type-inline'>OTHER<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_61\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_61\" ><label class='gfield_label gform-field-label' for='input_10_61'>If this is a friend\/ family referral, please share their name so we can personally thank them.<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_10_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_57\" class=\"gfield gfield--type-signature gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_57\" ><label class='gfield_label gform-field-label' for='input_10_57'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_10_57_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_10_57_valid' id='input_10_57_valid' \/><canvas id='input_10_57' width='300' height='180'><\/canvas><\/div><\/div><\/div><fieldset id=\"field_10_58\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_58\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_58.1' id='input_10_58_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_10_58_1' >I confirm the information I have provided is truthful and accurate. I willingly consent to receive dental treatment at Signature 28 Denture Clinic.<\/label><input type='hidden' name='input_58.2' value='I confirm the information I have provided is truthful and accurate. 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