{"id":7309,"date":"2021-10-07T13:27:39","date_gmt":"2021-10-07T19:27:39","guid":{"rendered":"https:\/\/signature28.com\/?page_id=7309"},"modified":"2021-10-07T13:27:39","modified_gmt":"2021-10-07T19:27:39","slug":"new-patient-intake-form","status":"publish","type":"page","link":"https:\/\/signature28.com\/new-patient-intake-form\/","title":{"rendered":"NEW PATIENT INTAKE FORM"},"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_safari gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_9' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">NEW PATIENT INTAKE FORM<\/h2>\n                            <p class='gform_description'>Please fill out this form prior to your appointment with Curtis or Lisa.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_9'  action='\/wp-json\/wp\/v2\/pages\/7309' data-formid='9' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LfJzVwaAAAAALYYbEmDfyEkGevIPj7cZAr66e47' data-tabindex='0'><input id=\"input_0207be8ea07b7da540f9575a8949ebc4\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_0207be8ea07b7da540f9575a8949ebc4\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_9_1\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_1\" ><label class='gfield_label gform-field-label' for='input_9_1'>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_1' id='input_9_1' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_1_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_9_1_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_1' class='gform_hidden' value='https:\/\/signature28.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_9_2\" 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_9_2\" ><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_9_2'>\n                            \n                            <span id='input_9_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_9_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_9_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_9_26\" class=\"gfield gfield--type-checkbox 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_9_26\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >GENDER<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_26'><div class='gchoice gchoice_9_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Male'  id='choice_9_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_26_1' id='label_9_26_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Female'  id='choice_9_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_26_2' id='label_9_26_2' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Prefer Not to Say'  id='choice_9_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_26_3' id='label_9_26_3' class='gform-field-label gform-field-label--type-inline'>Prefer Not to Say<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_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_9_46\" ><label class='gfield_label gform-field-label' for='input_9_46'>ALBERTA HEALTH CARE NUMBER (Seniors over 65 years old only)<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_9_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_9_3\" 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_9_3\" ><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_9_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_9_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_9_3_1' id='input_9_3_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_9_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_9_3_2' value=''     aria-required='false'   \/>\n                                        <label for='input_9_3_2' id='input_9_3_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_9_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_9_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_9_3_3' id='input_9_3_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_9_3_4_container' >\n                                        <input type='text' name='input_3.4' id='input_9_3_4' value=''      aria-required='true'    \/>\n                                        <label for='input_9_3_4' id='input_9_3_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_9_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_9_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_9_3_5' id='input_9_3_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_9_3_6_container' >\n                                        <select name='input_3.6' id='input_9_3_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_9_3_6' id='input_9_3_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_9_28\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_28\" ><label class='gfield_label gform-field-label' for='input_9_28'>Home Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_28' id='input_9_28' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_27\" 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_9_27\" ><label class='gfield_label gform-field-label' for='input_9_27'>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_27' id='input_9_27' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_29\" 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_9_29\" ><label class='gfield_label gform-field-label' for='input_9_29'>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_29' id='input_9_29' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_29_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_9_29_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_29' class='gform_hidden' value='https:\/\/signature28.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_9_31\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_31\" ><h3 class=\"gsection_title\">EMERGENCY CONTACT<\/h3><\/div><fieldset id=\"field_9_32\" 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_9_32\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of 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_9_32'>\n                            \n                            <span id='input_9_32_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_32.3' id='input_9_32_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_32_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_32_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_32.6' id='input_9_32_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_32_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_9_33\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_33\" ><label class='gfield_label gform-field-label' for='input_9_33'>Relationship to Patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_9_33' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_9_34\" 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_9_34\" ><label class='gfield_label gform-field-label' for='input_9_34'>Phone Number of Emergency Contact<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_34' id='input_9_34' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_50\" class=\"gfield gfield--type-checkbox 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_9_50\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How did you hear about Signature 28 Denture Clinic?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_50'><div class='gchoice gchoice_9_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Google Search'  id='choice_9_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_50_1' id='label_9_50_1' class='gform-field-label gform-field-label--type-inline'>Google Search<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='Radio Advertisement'  id='choice_9_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_50_2' id='label_9_50_2' class='gform-field-label gform-field-label--type-inline'>Radio Advertisement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_50_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.3' type='checkbox'  value='Flyer'  id='choice_9_50_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_50_3' id='label_9_50_3' class='gform-field-label gform-field-label--type-inline'>Flyer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_50_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.4' type='checkbox'  value='Friend\/ Family Referral'  id='choice_9_50_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_50_4' id='label_9_50_4' class='gform-field-label gform-field-label--type-inline'>Friend\/ Family Referral<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_50_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.5' type='checkbox'  value='OTHER'  id='choice_9_50_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_50_5' id='label_9_50_5' class='gform-field-label gform-field-label--type-inline'>OTHER<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_35\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_35\" ><h3 class=\"gsection_title\">INSURANCE COVERAGE<\/h3><\/div><div id=\"field_9_37\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_37\" ><label class='gfield_label gform-field-label' for='input_9_37'>Name of Insurance Company<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_9_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_9_38\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_38\" ><label class='gfield_label gform-field-label' for='input_9_38'>POLICY\/ PLAN\/ GROUP #<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_9_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_9_39\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_39\" ><label class='gfield_label gform-field-label' for='input_9_39'>IDENTIFICATION (ID) #<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_9_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_9_40\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_40\" ><label class='gfield_label gform-field-label' for='input_9_40'>DIV #<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_9_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_9_41\" 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_9_41\" ><legend class='gfield_label gform-field-label' >Are you the primary subscriber?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_41'>\n\t\t\t<div class='gchoice gchoice_9_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='YES'  id='choice_9_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_41_0' id='label_9_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_9_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='NO'  id='choice_9_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_41_1' id='label_9_41_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_44\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_44\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If you answered NO, 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_9_44'>\n                            \n                            <span id='input_9_44_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_44.3' id='input_9_44_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_44_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_44_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_44.6' id='input_9_44_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_44_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_9_45\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_45\" ><label class='gfield_label gform-field-label' for='input_9_45'>Date of Birth of PRIMARY SUBSCRIBER<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_45' id='input_9_45' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_45_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_9_45_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_45' class='gform_hidden' value='https:\/\/signature28.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_9_47\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_47\" ><h3 class=\"gsection_title\">FINANCIAL<\/h3><div class='gsection_description' id='gfield_description_9_47'>Please note that a 50% Deposit is collected on the day treatment is started. The balance is due upon delivery. Delinquent accounts are subject to interest charges of 2% per month (26.8% per annum) and third party collection fees.<\/div><\/div><div id=\"field_9_48\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_48\" ><h3 class=\"gsection_title\">INFORMATION ABOUT YOUR DENTURES<\/h3><\/div><div id=\"field_9_51\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_51\" ><label class='gfield_label gform-field-label' for='input_9_51'>How old are your current dentures?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_9_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_9_53\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_53\" ><label class='gfield_label gform-field-label' for='input_9_53'>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_53' id='input_9_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_9_52\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_52\" ><label class='gfield_label gform-field-label' for='input_9_52'>Are you currently pleased with the comfort, fit and the functional state of your dentures? If no, please explain.<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_9_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_9_55\" 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_9_55\" ><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_9_55'>\n\t\t\t<div class='gchoice gchoice_9_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='YES'  id='choice_9_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_55_0' id='label_9_55_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_9_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='NO'  id='choice_9_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_55_1' id='label_9_55_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_9_55_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='NO, but I am interested in discussing the possibility of dental implants.'  id='choice_9_55_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_55_2' id='label_9_55_2' class='gform-field-label gform-field-label--type-inline'>NO, but I am interested in discussing the possibility of dental implants.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_56\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_56\" ><label class='gfield_label gform-field-label' for='input_9_56'>TYPE FULL LEGAL NAME<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_9_56' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_9' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_9\"]){return false;}  if( !jQuery(\"#gform_9\")[0].checkValidity || jQuery(\"#gform_9\")[0].checkValidity()){window[\"gf_submitting_9\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_9\"]){return false;} if( !jQuery(\"#gform_9\")[0].checkValidity || jQuery(\"#gform_9\")[0].checkValidity()){window[\"gf_submitting_9\"]=true;}  jQuery(\"#gform_9\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_9' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='9' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_9' value='WyJ7XCI0MVwiOltcImJkNWQzZTc5OTZlOWI1NjQ1M2UyYjk0ZjIwZDdlMmNlXCIsXCJjZTA4NGJjYTY0NjAxYjVmZGQ3MGNiZGJjMWE4ZjI5N1wiXSxcIjU1XCI6W1wiYmQ1ZDNlNzk5NmU5YjU2NDUzZTJiOTRmMjBkN2UyY2VcIixcImNlMDg0YmNhNjQ2MDFiNWZkZDcwY2JkYmMxYThmMjk3XCIsXCJkOTFkMTU1YTVmMzEyNWM1Y2U3ZWRhZmM1NDE2ODlmM1wiXX0iLCJkZTE0YjI5MWQ3NzQ1MmY0YmZhNTRiNmY4ZDQ1NmIzNSJd' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_9' id='gform_target_page_number_9' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_9' id='gform_source_page_number_9' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 9, 'https:\/\/signature28.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_9').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_9');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_9').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! 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