{"id":1672,"date":"2021-09-29T20:14:01","date_gmt":"2021-09-29T20:14:01","guid":{"rendered":"https:\/\/conroydentalcentre.com\/?page_id=1672"},"modified":"2023-08-24T17:56:11","modified_gmt":"2023-08-24T17:56:11","slug":"new-patient-form","status":"publish","type":"page","link":"https:\/\/conroydentalcentre.com\/new-patient-form\/","title":{"rendered":"New Patient Form"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-animated fusion-custom-z-index\" style=\"background-color: #eaeaea;background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" data-animationType=\"fadeInDown\" data-animationDuration=\"1.5\" data-animationOffset=\"top-into-view\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:calc( 100% + 0px ) !important;max-width:calc( 100% + 0px ) !important;margin-left: calc(-0px \/ 2 );margin-right: calc(-0px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 90px 0px 90px;\"><style type=\"text\/css\">@media only screen and (max-width:1024px) {.fusion-title.fusion-title-1{margin-top:0px!important; margin-right:0px!important;margin-bottom:!important;margin-left:0px!important;}}@media only screen and (max-width:640px) {.fusion-title.fusion-title-1{margin-top:0px!important; margin-right:0px!important;margin-bottom:20px!important; margin-left:0px!important;}}<\/style><div class=\"fusion-title title fusion-title-1 fusion-title-center fusion-title-text fusion-title-size-two\" style=\"margin-top:0px;margin-right:0px;margin-left:0px;\"><div class=\"title-sep-container title-sep-container-left\"><div class=\"title-sep sep-single sep-solid\" style=\"border-color:#bcbaba;\"><\/div><\/div><span class=\"awb-title-spacer\"><\/span><h2 class=\"title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:50;line-height:1.16;\">New Patient Form<\/h2><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep-single sep-solid\" style=\"border-color:#bcbaba;\"><\/div><\/div><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start\" style=\"width:calc( 100% + 0px ) !important;max-width:calc( 100% + 0px ) !important;margin-left: calc(-0px \/ 2 );margin-right: calc(-0px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-0 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 35px 35px 11px 35px;\"><div class=\"fusion-text fusion-text-1\"><p>The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly.<\/p>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-0{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-0 > .fusion-column-wrapper {padding-top : 35px !important;padding-right : 35px !important;margin-right : 0px;padding-bottom : 11px !important;padding-left : 35px !important;margin-left : 0px;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-0{width:100% !important;order : 0;}.fusion-builder-nested-column-0 > .fusion-column-wrapper {margin-right : 0px;margin-left : 0px;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-0{width:100% !important;order : 0;}.fusion-builder-nested-column-0 > .fusion-column-wrapper {margin-right : 0px;margin-left : 0px;}}<\/style><\/div><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-bottom:25px;width:100%;\"><\/div><style>.fusion-form-form-wrapper .fusion-form-1671 .fusion-form-tooltip .fusion-form-tooltip-content{color:#ffffff !important;background-color:#333333 !important;border-color:#333333 !important;}<\/style><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-1671\" data-form-id=\"1671\" data-config=\"{&quot;form_id&quot;:&quot;1671&quot;,&quot;form_post_id&quot;:&quot;1671&quot;,&quot;post_id&quot;:1672,&quot;form_type&quot;:&quot;email&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;field_labels&quot;:{&quot;date&quot;:&quot;Date&quot;,&quot;are_you_the&quot;:&quot;Are you the&quot;,&quot;salutation&quot;:&quot;Salutation&quot;,&quot;first_name&quot;:&quot;First Name&quot;,&quot;last_name&quot;:&quot;Last Name&quot;,&quot;initial&quot;:&quot;Initial&quot;,&quot;Prefers_to_be_called&quot;:&quot;Prefers to be called (if different from above)&quot;,&quot;address&quot;:&quot;Address&quot;,&quot;city&quot;:&quot;City&quot;,&quot;province&quot;:&quot;Postal Code&quot;,&quot;date_of_birth&quot;:&quot;Date of Birth&quot;,&quot;age&quot;:&quot;Age&quot;,&quot;&quot;:&quot;&quot;,&quot;home_phone&quot;:&quot;Home Phone&quot;,&quot;cell_phone&quot;:&quot;Cell Phone&quot;,&quot;family_physician&quot;:&quot;Family Physician&quot;,&quot;family_physician_phone&quot;:&quot;Family Physician Phone&quot;,&quot;medical_specialist_if_under_present_care&quot;:&quot;Medical Specialist (if under present care)&quot;,&quot;medical_specialist_phone&quot;:&quot;Medical Specialist Phone&quot;,&quot;person_responsible_for_account&quot;:&quot;Person Responsible for Account&quot;,&quot;person_responsible_name&quot;:&quot;Name&quot;,&quot;person_responsible_phone_number&quot;:&quot;Phone Number&quot;,&quot;person_responsible_address&quot;:&quot;Address&quot;,&quot;person_responsible_employer&quot;:&quot;Employer&quot;,&quot;person_responsible_work_phone&quot;:&quot;Work Phone&quot;,&quot;person_responsible_work_phone_extension&quot;:&quot;Extension&quot;,&quot;your_occupation&quot;:&quot;Your Occupation&quot;,&quot;your_employer&quot;:&quot;Your Employer&quot;,&quot;your_work_phone&quot;:&quot;Work Phone&quot;,&quot;your_work_phone_extension&quot;:&quot;Extension&quot;,&quot;spouse_employer&quot;:&quot;Spouse Employer&quot;,&quot;spouse_work_phone&quot;:&quot;Work Phone&quot;,&quot;spouse_work_phone_extension&quot;:&quot;Extension&quot;,&quot;dental_insurance&quot;:&quot;Dental Insurance&quot;,&quot;insurance_company_name&quot;:&quot;Insurance Company Name&quot;,&quot;group_policy-number&quot;:&quot;Group Policy No.&quot;,&quot;certificate-number&quot;:&quot;Secondary Insurance&quot;,&quot;secondary_group_policy-number&quot;:&quot;Group Policy No.&quot;,&quot;secondary_certificate-number&quot;:&quot;Certif. No.&quot;,&quot;basic&quot;:&quot;Basic&quot;,&quot;major&quot;:&quot;Major&quot;,&quot;preventive&quot;:&quot;Preventive&quot;,&quot;ortho&quot;:&quot;Ortho&quot;,&quot;in_case_of_emergency_please_notify&quot;:&quot;In case of emergency, please notify&quot;,&quot;Relationship&quot;:&quot;Relationship&quot;,&quot;emergency_contact_phone&quot;:&quot;Phone Number&quot;,&quot;Closest_Family_Relative&quot;:&quot;Closest Family Relative&quot;,&quot;Closest_Family_Relative_Phone_Number&quot;:&quot;Phone Number&quot;,&quot;Referral_Name&quot;:&quot;Whom may we thank for referring you?&quot;,&quot;Closest_ Family_ Relative_Phone_Number&quot;:&quot;Is a member of your family\\\/relative a patient at our office?&quot;,&quot;reason_for_todays_visit&quot;:&quot;Reason for today&#039;s visit?&quot;,&quot;Is_there_a_dental_problem_you_would_like_taken_care_as_soon_as_possible&quot;:&quot;Is there a dental problem you would like taken care as soon as possible?&quot;,&quot;have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care&quot;:&quot;Have you ever had a serious illness requiring hospitalization or extensive medical care?&quot;,&quot;if_yes_please_explain:&quot;:&quot;If yes, please explain:&quot;,&quot;Are_you_presently_under_the_care_of_a_physician&quot;:&quot;Are you presently under the care of a physician?&quot;,&quot;Have_you_been_hospitalized_in_the_last_2_years&quot;:&quot;Have you been hospitalized in the last 2 years?&quot;,&quot;Have_you_had_a_medical_examination_in_the_last_year&quot;:&quot;Have you had a medical examination in the last year?&quot;,&quot;Do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly&quot;:&quot;Do you use any prescription or non-prescription medicine including herbal remedies, regularly?&quot;,&quot;if_yes_please_specify:&quot;:&quot;If yes, please specify:&quot;,&quot;Do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies&quot;:&quot;Do you have any allergic condition: i.e. asthma, hay fever, skin rash, food allergies, metal or latex allergies?&quot;,&quot;If_yes,_please_explain&quot;:&quot;If yes, please explain:&quot;,&quot;Do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea&quot;:&quot;Do any of these allergic reactions result in headache, shortness of breath, chest constriction, nausea?&quot;,&quot;If_yes,_please_specify:&quot;:&quot;If yes, please specify:&quot;,&quot;have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following&quot;:&quot;Have you ever experienced any unusual reaction to any of the following?&quot;,&quot;or_any_other_medicine__if_yes_please_explain:&quot;:&quot;Or any other medicine? If yes, please explain:&quot;,&quot;Have_you_been_warned_against_taking_any_drug_or_medication&quot;:&quot;Have you been warned against taking any drug or medication? &quot;,&quot;do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply&quot;:&quot;Do you have or have you ever had any of the following? (please mark any\\\/all that apply)&quot;,&quot;other:&quot;:&quot;Other:&quot;,&quot;Have_you_ever_had_any_known_contact_with_the_Aids_Virus&quot;:&quot;Have you ever had any known contact with the Aids Virus?&quot;,&quot;Has_any_member_of_your_family_had_diabetes&quot;:&quot;Has any member of your family had diabetes&quot;,&quot;Do_you_bruise_easily_or_bleed_abnormally&quot;:&quot;Do you bruise easily or bleed abnormally?&quot;,&quot;Do_your_ankles_swell_during_the_day&quot;:&quot;Do your ankles swell during the day?&quot;,&quot;Have_you_had_any_weight_changes_recently&quot;:&quot;Have you had any weight changes recently?&quot;,&quot;Do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)&quot;:&quot;Do you have any blood disorders such as anaemia (thin blood)?&quot;,&quot;Have_you_ever_had_radiation_treatment_or_chemotherapy&quot;:&quot;Have you ever had radiation treatment or chemotherapy?&quot;,&quot;Have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws&quot;:&quot;Have you ever had any injury, surgery or x-ray therapy to your face or jaws?&quot;,&quot;Do_you_have_frequent_severe_headaches&quot;:&quot;Do you have frequent severe headaches?&quot;,&quot;Do_you_have_frequent_earaches,_ear\\\/throat_infections_or_any_hearing_difficulties&quot;:&quot;Do you have frequent earaches, ear\\\/throat infections or any hearing difficulties?&quot;,&quot;is_your_eyesight:&quot;:&quot;Is your eyesight:&quot;,&quot;Are_you_on_a_special_diet&quot;:&quot;Are you on a special diet?&quot;,&quot;Have_you_ever_fainted&quot;:&quot;Have you ever fainted?&quot;,&quot;Do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs&quot;:&quot;Do you ever experience shortness of breath or pain in your chest when taking a walk or climbing stairs?&quot;,&quot;Do_you_have_any_medical_or_dental_implants&quot;:&quot;Do you have any medical or dental implants?&quot;,&quot;do_you_have_any_disease_condition_or_problem_not_listed_above_that_you_think_the_doctor_should_know_about&quot;:&quot;Do you have any disease, condition or problem not listed above that you think the doctor should know about?&quot;,&quot;is_there_anything_about_yourself_that_we_should_be_made_aware_of&quot;:&quot;Is there anything about yourself that we should be made aware of?&quot;,&quot;WOMEN_ONLY_-_Are_you_pregnant?&quot;:&quot;WOMEN ONLY - Are you pregnant?&quot;,&quot;If_so_which_month_are_you_in&quot;:&quot; If so, which month are you in?&quot;,&quot;Are_you_taking_any_birth_control_pills&quot;:&quot;Are you taking any birth control pills?&quot;,&quot;how_frequently_do_you_see_your_dentist&quot;:&quot;How frequently do you see your dentist?&quot;,&quot;last_dental_visit&quot;:&quot;Last dental visit?&quot;,&quot;Last_cleaning&quot;:&quot; Last cleaning?&quot;,&quot;Last_full_mouth_series_of_x-rays&quot;:&quot;Last full mouth series of x-rays?&quot;,&quot;Have_you_been_given_oral_hygiene_instruction_in:&quot;:&quot;Have you been given oral hygiene instruction in:&quot;,&quot;Are_any_of_your_teeth_sensitive_to:&quot;:&quot;Are any of your teeth sensitive to:&quot;,&quot;Do_your_gums_bleed_when:&quot;:&quot;Do your gums bleed when:&quot;,&quot;Have_you_ever_had_any_of_the_following:&quot;:&quot;Have you ever had any of the following:&quot;,&quot;Do_you_have_any_dental_implants&quot;:&quot;Do you have any dental implants?&quot;,&quot;Do_you_suffer_from_pain_and\\\/or_swelling_of_your_gums&quot;:&quot;Do you suffer from pain and\\\/or swelling of your gums?&quot;,&quot;Are_you_aware_of_any_loose_teeth&quot;:&quot;Are you aware of any loose teeth?&quot;,&quot;if_yes_where&quot;:&quot;If yes, where?&quot;,&quot;Do_you_chew_on_only_one_side_of_your_mouth&quot;:&quot;Do you chew on only one side of your mouth?&quot;,&quot;If_so_why&quot;:&quot;If so, why?&quot;,&quot;do_you_grind_or_clench_your_teeth_during_the_day_or_night&quot;:&quot;Do you grind or clench your teeth during the day or night?&quot;,&quot;do_you_mouth_breathe_while_awake_or_asleep&quot;:&quot;Do you mouth breathe while awake or asleep?&quot;,&quot;do_you_bite_your_lips_or_cheeks_regularly&quot;:&quot;Do you bite your lips or cheeks regularly?&quot;,&quot;do_you_hold_any_foreign_objects_with_your_teeth&quot;:&quot;Do you hold any foreign objects with your teeth?&quot;,&quot;Does_any_part_of_your_mouth_hurt_when_clenched&quot;:&quot;Does any part of your mouth hurt when clenched?&quot;,&quot;Does_your_jaw_crack_or_pop_when_opened_widely&quot;:&quot;Does your jaw crack or pop when opened widely?&quot;,&quot;Do_you_have_any_difficulty_in_opening_or_closing_your_jaw&quot;:&quot;Do you have any difficulty in opening or closing your jaw?&quot;,&quot;Do_you_have_any_pain_in_your_ears&quot;:&quot;Do you have any pain in your ears?&quot;,&quot;Do_you_gag_easily&quot;:&quot;Do you gag easily?&quot;,&quot;Have_you_experienced_any_growth_or_sore_spots_in_your_mouth&quot;:&quot;Have you experienced any growth or sore spots in your mouth?&quot;,&quot;is_yes_where&quot;:&quot;Is yes, where?&quot;,&quot;Are_you_concerned_about_the_appearance_of_your_teeth&quot;:&quot;Are you concerned about the appearance of your teeth?&quot;,&quot;if_yes_what_would_you_like_to_see_changed&quot;:&quot;If yes, what would you like to see changed?&quot;,&quot;Would_you_rate_your_current_dental_health_as&quot;:&quot;Would you rate your current dental health as:&quot;,&quot;Is_your_sugar_intake&quot;:&quot;Is your sugar intake:&quot;,&quot;Brushing&quot;:&quot;Brushing: &quot;,&quot;how_often&quot;:&quot;How often?&quot;,&quot;cleaning_aids_presently_used:&quot;:&quot;Cleaning aids presently used:&quot;,&quot;Do_you_have_any_emotional_concerns_regarding_your_dental_visit&quot;:&quot;Do you have any emotional concerns regarding your dental visit?&quot;},&quot;field_logics&quot;:{&quot;date&quot;:&quot;&quot;,&quot;are_you_the&quot;:&quot;&quot;,&quot;salutation&quot;:&quot;&quot;,&quot;first_name&quot;:&quot;&quot;,&quot;last_name&quot;:&quot;&quot;,&quot;initial&quot;:&quot;&quot;,&quot;Prefers_to_be_called&quot;:&quot;&quot;,&quot;address&quot;:&quot;&quot;,&quot;city&quot;:&quot;&quot;,&quot;province&quot;:&quot;&quot;,&quot;date_of_birth&quot;:&quot;&quot;,&quot;age&quot;:&quot;&quot;,&quot;&quot;:&quot;&quot;,&quot;home_phone&quot;:&quot;&quot;,&quot;cell_phone&quot;:&quot;&quot;,&quot;family_physician&quot;:&quot;&quot;,&quot;family_physician_phone&quot;:&quot;&quot;,&quot;medical_specialist_if_under_present_care&quot;:&quot;&quot;,&quot;medical_specialist_phone&quot;:&quot;&quot;,&quot;person_responsible_for_account&quot;:&quot;&quot;,&quot;person_responsible_name&quot;:&quot;&quot;,&quot;person_responsible_phone_number&quot;:&quot;&quot;,&quot;person_responsible_address&quot;:&quot;&quot;,&quot;person_responsible_employer&quot;:&quot;&quot;,&quot;person_responsible_work_phone&quot;:&quot;&quot;,&quot;person_responsible_work_phone_extension&quot;:&quot;&quot;,&quot;your_occupation&quot;:&quot;&quot;,&quot;your_employer&quot;:&quot;&quot;,&quot;your_work_phone&quot;:&quot;&quot;,&quot;your_work_phone_extension&quot;:&quot;&quot;,&quot;spouse_employer&quot;:&quot;&quot;,&quot;spouse_work_phone&quot;:&quot;&quot;,&quot;spouse_work_phone_extension&quot;:&quot;&quot;,&quot;dental_insurance&quot;:&quot;&quot;,&quot;insurance_company_name&quot;:&quot;&quot;,&quot;group_policy-number&quot;:&quot;&quot;,&quot;certificate-number&quot;:&quot;&quot;,&quot;secondary_group_policy-number&quot;:&quot;&quot;,&quot;secondary_certificate-number&quot;:&quot;&quot;,&quot;basic&quot;:&quot;&quot;,&quot;major&quot;:&quot;&quot;,&quot;preventive&quot;:&quot;&quot;,&quot;ortho&quot;:&quot;&quot;,&quot;in_case_of_emergency_please_notify&quot;:&quot;&quot;,&quot;Relationship&quot;:&quot;&quot;,&quot;emergency_contact_phone&quot;:&quot;&quot;,&quot;Closest_Family_Relative&quot;:&quot;&quot;,&quot;Closest_Family_Relative_Phone_Number&quot;:&quot;&quot;,&quot;Referral_Name&quot;:&quot;&quot;,&quot;Closest_ Family_ Relative_Phone_Number&quot;:&quot;&quot;,&quot;reason_for_todays_visit&quot;:&quot;&quot;,&quot;Is_there_a_dental_problem_you_would_like_taken_care_as_soon_as_possible&quot;:&quot;&quot;,&quot;have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care&quot;:&quot;&quot;,&quot;if_yes_please_explain:&quot;:&quot;&quot;,&quot;Are_you_presently_under_the_care_of_a_physician&quot;:&quot;&quot;,&quot;Have_you_been_hospitalized_in_the_last_2_years&quot;:&quot;&quot;,&quot;Have_you_had_a_medical_examination_in_the_last_year&quot;:&quot;&quot;,&quot;Do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly&quot;:&quot;&quot;,&quot;if_yes_please_specify:&quot;:&quot;&quot;,&quot;Do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies&quot;:&quot;&quot;,&quot;If_yes,_please_explain&quot;:&quot;&quot;,&quot;Do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea&quot;:&quot;&quot;,&quot;If_yes,_please_specify:&quot;:&quot;&quot;,&quot;have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following&quot;:&quot;&quot;,&quot;or_any_other_medicine__if_yes_please_explain:&quot;:&quot;&quot;,&quot;Have_you_been_warned_against_taking_any_drug_or_medication&quot;:&quot;&quot;,&quot;do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply&quot;:&quot;&quot;,&quot;other:&quot;:&quot;&quot;,&quot;Have_you_ever_had_any_known_contact_with_the_Aids_Virus&quot;:&quot;&quot;,&quot;Has_any_member_of_your_family_had_diabetes&quot;:&quot;&quot;,&quot;Do_you_bruise_easily_or_bleed_abnormally&quot;:&quot;&quot;,&quot;Do_your_ankles_swell_during_the_day&quot;:&quot;&quot;,&quot;Have_you_had_any_weight_changes_recently&quot;:&quot;&quot;,&quot;Do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)&quot;:&quot;&quot;,&quot;Have_you_ever_had_radiation_treatment_or_chemotherapy&quot;:&quot;&quot;,&quot;Have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws&quot;:&quot;&quot;,&quot;Do_you_have_frequent_severe_headaches&quot;:&quot;&quot;,&quot;Do_you_have_frequent_earaches,_ear\\\/throat_infections_or_any_hearing_difficulties&quot;:&quot;&quot;,&quot;is_your_eyesight:&quot;:&quot;&quot;,&quot;Are_you_on_a_special_diet&quot;:&quot;&quot;,&quot;Have_you_ever_fainted&quot;:&quot;&quot;,&quot;Do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs&quot;:&quot;&quot;,&quot;Do_you_have_any_medical_or_dental_implants&quot;:&quot;&quot;,&quot;do_you_have_any_disease_condition_or_problem_not_listed_above_that_you_think_the_doctor_should_know_about&quot;:&quot;&quot;,&quot;is_there_anything_about_yourself_that_we_should_be_made_aware_of&quot;:&quot;&quot;,&quot;WOMEN_ONLY_-_Are_you_pregnant?&quot;:&quot;&quot;,&quot;If_so_which_month_are_you_in&quot;:&quot;&quot;,&quot;Are_you_taking_any_birth_control_pills&quot;:&quot;&quot;,&quot;how_frequently_do_you_see_your_dentist&quot;:&quot;&quot;,&quot;last_dental_visit&quot;:&quot;&quot;,&quot;Last_cleaning&quot;:&quot;&quot;,&quot;Last_full_mouth_series_of_x-rays&quot;:&quot;&quot;,&quot;Have_you_been_given_oral_hygiene_instruction_in:&quot;:&quot;&quot;,&quot;Are_any_of_your_teeth_sensitive_to:&quot;:&quot;&quot;,&quot;Do_your_gums_bleed_when:&quot;:&quot;&quot;,&quot;Have_you_ever_had_any_of_the_following:&quot;:&quot;&quot;,&quot;Do_you_have_any_dental_implants&quot;:&quot;&quot;,&quot;Do_you_suffer_from_pain_and\\\/or_swelling_of_your_gums&quot;:&quot;&quot;,&quot;Are_you_aware_of_any_loose_teeth&quot;:&quot;&quot;,&quot;if_yes_where&quot;:&quot;&quot;,&quot;Do_you_chew_on_only_one_side_of_your_mouth&quot;:&quot;&quot;,&quot;If_so_why&quot;:&quot;&quot;,&quot;do_you_grind_or_clench_your_teeth_during_the_day_or_night&quot;:&quot;&quot;,&quot;do_you_mouth_breathe_while_awake_or_asleep&quot;:&quot;&quot;,&quot;do_you_bite_your_lips_or_cheeks_regularly&quot;:&quot;&quot;,&quot;do_you_hold_any_foreign_objects_with_your_teeth&quot;:&quot;&quot;,&quot;Does_any_part_of_your_mouth_hurt_when_clenched&quot;:&quot;&quot;,&quot;Does_your_jaw_crack_or_pop_when_opened_widely&quot;:&quot;&quot;,&quot;Do_you_have_any_difficulty_in_opening_or_closing_your_jaw&quot;:&quot;&quot;,&quot;Do_you_have_any_pain_in_your_ears&quot;:&quot;&quot;,&quot;Do_you_gag_easily&quot;:&quot;&quot;,&quot;Have_you_experienced_any_growth_or_sore_spots_in_your_mouth&quot;:&quot;&quot;,&quot;is_yes_where&quot;:&quot;&quot;,&quot;Are_you_concerned_about_the_appearance_of_your_teeth&quot;:&quot;&quot;,&quot;if_yes_what_would_you_like_to_see_changed&quot;:&quot;&quot;,&quot;Would_you_rate_your_current_dental_health_as&quot;:&quot;&quot;,&quot;Is_your_sugar_intake&quot;:&quot;&quot;,&quot;Brushing&quot;:&quot;&quot;,&quot;how_often&quot;:&quot;&quot;,&quot;cleaning_aids_presently_used:&quot;:&quot;&quot;,&quot;Do_you_have_any_emotional_concerns_regarding_your_dental_visit&quot;:&quot;&quot;}}\"><form action=\"https:\/\/conroydentalcentre.com\/new-patient-form\/\" method=\"post\" class=\"fusion-form fusion-form-1671\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><style type=\"text\/css\">@media only screen and (max-width:1024px) {.fusion-title.fusion-title-2{margin-top:0px!important; margin-right:0px!important;margin-bottom:!important;margin-left:0px!important;}}@media only screen and (max-width:640px) {.fusion-title.fusion-title-2{margin-top:0px!important; margin-right:0px!important;margin-bottom:20px!important; margin-left:0px!important;}}<\/style><div class=\"fusion-title title fusion-title-2 fusion-sep-none fusion-title-text fusion-title-size-three\" style=\"margin-top:0px;margin-right:0px;margin-left:0px;\"><h3 class=\"title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:34;line-height:1.29;\">General Information<\/h3><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-1 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 15px 35px 7px 35px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"1671\"><label for=\"date\">Date <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><input autocomplete=\"no\" type=\"date\" data-format=\"\" tabindex=\"\" id=\"date\" name=\"date\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-1{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-1 > .fusion-column-wrapper {padding-top : 15px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 7px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-1{width:100% !important;order : 0;}.fusion-builder-nested-column-1 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-1{width:100% !important;order : 0;}.fusion-builder-nested-column-1 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-2 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 15px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you the <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-are_you_the-1-0\" type=\"radio\" value=\"Patient\" name=\"are_you_the\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_the-1-0\">Patient<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-are_you_the-1-1\" type=\"radio\" value=\"Parent (Guardian)\" name=\"are_you_the\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_the-1-1\">Parent (Guardian)<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-2{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-2 > .fusion-column-wrapper {padding-top : 15px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-2{width:100% !important;order : 0;}.fusion-builder-nested-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-2{width:100% !important;order : 0;}.fusion-builder-nested-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-3 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 23px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Salutation <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-salutation-2-0\" type=\"radio\" value=\"Dr.\" name=\"salutation\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-salutation-2-0\">Dr.<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-salutation-2-1\" type=\"radio\" value=\"Mr.\" name=\"salutation\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-salutation-2-1\">Mr.<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-salutation-2-2\" type=\"radio\" value=\"Mrs.\" name=\"salutation\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-salutation-2-2\">Mrs.<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-salutation-2-3\" type=\"radio\" value=\"Ms\" name=\"salutation\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-salutation-2-3\">Ms<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-salutation-2-4\" type=\"radio\" value=\"Miss\" name=\"salutation\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-salutation-2-4\">Miss<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-3{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-3 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 23px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-3{width:100% !important;order : 0;}.fusion-builder-nested-column-3 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-3{width:100% !important;order : 0;}.fusion-builder-nested-column-3 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-4 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"first_name\">First Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"first_name\" id=\"first_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-4{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-4 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-4{width:100% !important;order : 0;}.fusion-builder-nested-column-4 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-4{width:100% !important;order : 0;}.fusion-builder-nested-column-4 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-5 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"last_name\">Last Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"last_name\" id=\"last_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-5{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-5 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-5{width:100% !important;order : 0;}.fusion-builder-nested-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-5{width:100% !important;order : 0;}.fusion-builder-nested-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-6 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"initial\">Initial<\/label><\/div><input type=\"text\" name=\"initial\" id=\"initial\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-6{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-6 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-6{width:100% !important;order : 0;}.fusion-builder-nested-column-6 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-6{width:100% !important;order : 0;}.fusion-builder-nested-column-6 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-7 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Prefers_to_be_called\">Prefers to be called (if different from above)<\/label><\/div><input type=\"text\" name=\"Prefers_to_be_called\" id=\"Prefers_to_be_called\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-7{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-7 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-7{width:100% !important;order : 0;}.fusion-builder-nested-column-7 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-7{width:100% !important;order : 0;}.fusion-builder-nested-column-7 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-8 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"address\">Address<\/label><\/div><input type=\"text\" name=\"address\" id=\"address\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-8{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-8 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-8{width:100% !important;order : 0;}.fusion-builder-nested-column-8 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-8{width:100% !important;order : 0;}.fusion-builder-nested-column-8 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-9 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"city\">City<\/label><\/div><input type=\"text\" name=\"city\" id=\"city\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-9{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-9 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-9{width:100% !important;order : 0;}.fusion-builder-nested-column-9 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-9{width:100% !important;order : 0;}.fusion-builder-nested-column-9 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-10 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"province\">Province<\/label><\/div><input type=\"text\" name=\"province\" id=\"province\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-10{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-10 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-10{width:100% !important;order : 0;}.fusion-builder-nested-column-10 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-10{width:100% !important;order : 0;}.fusion-builder-nested-column-10 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-11 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"province\">Postal Code<\/label><\/div><input type=\"text\" name=\"province\" id=\"province\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-11{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-11 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-11{width:100% !important;order : 0;}.fusion-builder-nested-column-11 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-11{width:100% !important;order : 0;}.fusion-builder-nested-column-11 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-12 fusion_builder_column_inner_1_4 1_4 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"1671\"><label for=\"date_of_birth\">Date of Birth<\/label><input autocomplete=\"no\" type=\"date\" data-format=\"\" tabindex=\"\" id=\"date_of_birth\" name=\"date_of_birth\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-12{width:25% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-12 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 7.68%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-12{width:100% !important;order : 0;}.fusion-builder-nested-column-12 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-12{width:100% !important;order : 0;}.fusion-builder-nested-column-12 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-13 fusion_builder_column_inner_1_4 1_4 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"age\">Age <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"age\" id=\"age\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-13{width:25% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-13 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-13{width:100% !important;order : 0;}.fusion-builder-nested-column-13 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-13{width:100% !important;order : 0;}.fusion-builder-nested-column-13 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-14 fusion_builder_column_inner_1_4 1_4 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"\">Sex<\/label><\/div><input type=\"text\" name=\"\" id=\"\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-14{width:25% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-14 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-14{width:100% !important;order : 0;}.fusion-builder-nested-column-14 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-14{width:100% !important;order : 0;}.fusion-builder-nested-column-14 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-15 fusion_builder_column_inner_1_4 1_4 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"\">Marital Status<\/label><\/div><input type=\"text\" name=\"\" id=\"\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-15{width:25% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-15 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 7.68%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-15{width:100% !important;order : 0;}.fusion-builder-nested-column-15 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-15{width:100% !important;order : 0;}.fusion-builder-nested-column-15 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-16 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"home_phone\">Home Phone <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"home_phone\" id=\"home_phone\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-16{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-16 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-16{width:100% !important;order : 0;}.fusion-builder-nested-column-16 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-16{width:100% !important;order : 0;}.fusion-builder-nested-column-16 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-17 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"cell_phone\">Cell Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone_android\"><\/i><input type=\"phone-number\" name=\"cell_phone\" id=\"cell_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-17{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-17 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-17{width:100% !important;order : 0;}.fusion-builder-nested-column-17 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-17{width:100% !important;order : 0;}.fusion-builder-nested-column-17 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-18 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"family_physician\">Family Physician<\/label><\/div><input type=\"text\" name=\"family_physician\" id=\"family_physician\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-18{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-18 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-18{width:100% !important;order : 0;}.fusion-builder-nested-column-18 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-18{width:100% !important;order : 0;}.fusion-builder-nested-column-18 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-19 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"family_physician_phone\">Family Physician Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"family_physician_phone\" id=\"family_physician_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-19{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-19 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-19{width:100% !important;order : 0;}.fusion-builder-nested-column-19 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-19{width:100% !important;order : 0;}.fusion-builder-nested-column-19 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-20 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"medical_specialist_if_under_present_care\">Medical Specialist (if under present care)<\/label><\/div><input type=\"text\" name=\"medical_specialist_if_under_present_care\" id=\"medical_specialist_if_under_present_care\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-20{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-20 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-20{width:100% !important;order : 0;}.fusion-builder-nested-column-20 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-20{width:100% !important;order : 0;}.fusion-builder-nested-column-20 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-21 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"medical_specialist_phone\">Medical Specialist Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"medical_specialist_phone\" id=\"medical_specialist_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-21{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-21 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-21{width:100% !important;order : 0;}.fusion-builder-nested-column-21 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-21{width:100% !important;order : 0;}.fusion-builder-nested-column-21 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-22 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Person Responsible for Account<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-person_responsible_for_account-3-0\" type=\"radio\" value=\"Self\" name=\"person_responsible_for_account\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-person_responsible_for_account-3-0\">Self<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-person_responsible_for_account-3-1\" type=\"radio\" value=\"Spouse\" name=\"person_responsible_for_account\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-person_responsible_for_account-3-1\">Spouse<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-person_responsible_for_account-3-2\" type=\"radio\" value=\"Other\" name=\"person_responsible_for_account\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-person_responsible_for_account-3-2\">Other<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-22{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-22 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-22{width:100% !important;order : 0;}.fusion-builder-nested-column-22 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-22{width:100% !important;order : 0;}.fusion-builder-nested-column-22 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-23 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"person_responsible_name\">Name<\/label><\/div><input type=\"text\" name=\"person_responsible_name\" id=\"person_responsible_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-23{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-23 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-23{width:100% !important;order : 0;}.fusion-builder-nested-column-23 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-23{width:100% !important;order : 0;}.fusion-builder-nested-column-23 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-24 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"person_responsible_phone_number\">Phone Number<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"person_responsible_phone_number\" id=\"person_responsible_phone_number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-24{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-24 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-24{width:100% !important;order : 0;}.fusion-builder-nested-column-24 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-24{width:100% !important;order : 0;}.fusion-builder-nested-column-24 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-25 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"person_responsible_address\">Address<\/label><\/div><input type=\"text\" name=\"person_responsible_address\" id=\"person_responsible_address\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-25{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-25 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-25{width:100% !important;order : 0;}.fusion-builder-nested-column-25 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-25{width:100% !important;order : 0;}.fusion-builder-nested-column-25 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-26 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"person_responsible_employer\">Employer<\/label><\/div><input type=\"text\" name=\"person_responsible_employer\" id=\"person_responsible_employer\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-26{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-26 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-26{width:100% !important;order : 0;}.fusion-builder-nested-column-26 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-26{width:100% !important;order : 0;}.fusion-builder-nested-column-26 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-27 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"person_responsible_work_phone\">Work Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"person_responsible_work_phone\" id=\"person_responsible_work_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-27{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-27 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-27{width:100% !important;order : 0;}.fusion-builder-nested-column-27 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-27{width:100% !important;order : 0;}.fusion-builder-nested-column-27 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-28 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"person_responsible_work_phone_extension\">Extension<\/label><\/div><input type=\"number\" name=\"person_responsible_work_phone_extension\" id=\"person_responsible_work_phone_extension\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" min=\"0\" max=\"1000000\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-28{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-28 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-28{width:100% !important;order : 0;}.fusion-builder-nested-column-28 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-28{width:100% !important;order : 0;}.fusion-builder-nested-column-28 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-29 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 17px 35px 0px 35px;\"><div class=\"fusion-text fusion-text-2\"><p style=\"text-align: center;\"><b>(Above information to be completed only if person responsible for account is other than self)<\/b><\/p>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-29{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-29 > .fusion-column-wrapper {padding-top : 17px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-29{width:100% !important;order : 0;}.fusion-builder-nested-column-29 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-29{width:100% !important;order : 0;}.fusion-builder-nested-column-29 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-30 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"your_occupation\">Your Occupation<\/label><\/div><input type=\"text\" name=\"your_occupation\" id=\"your_occupation\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-30{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-30 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-30{width:100% !important;order : 0;}.fusion-builder-nested-column-30 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-30{width:100% !important;order : 0;}.fusion-builder-nested-column-30 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-31 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"your_employer\">Your Employer<\/label><\/div><input type=\"text\" name=\"your_employer\" id=\"your_employer\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-31{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-31 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-31{width:100% !important;order : 0;}.fusion-builder-nested-column-31 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-31{width:100% !important;order : 0;}.fusion-builder-nested-column-31 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-32 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"your_work_phone\">Work Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"your_work_phone\" id=\"your_work_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-32{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-32 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-32{width:100% !important;order : 0;}.fusion-builder-nested-column-32 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-32{width:100% !important;order : 0;}.fusion-builder-nested-column-32 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-33 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"your_work_phone_extension\">Extension<\/label><\/div><input type=\"number\" name=\"your_work_phone_extension\" id=\"your_work_phone_extension\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" min=\"0\" max=\"1000000\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-33{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-33 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-33{width:100% !important;order : 0;}.fusion-builder-nested-column-33 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-33{width:100% !important;order : 0;}.fusion-builder-nested-column-33 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-34 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"spouse_employer\">Spouse Employer<\/label><\/div><input type=\"text\" name=\"spouse_employer\" id=\"spouse_employer\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-34{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-34 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-34{width:100% !important;order : 0;}.fusion-builder-nested-column-34 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-34{width:100% !important;order : 0;}.fusion-builder-nested-column-34 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-35 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"spouse_work_phone\">Work Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"spouse_work_phone\" id=\"spouse_work_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-35{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-35 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-35{width:100% !important;order : 0;}.fusion-builder-nested-column-35 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-35{width:100% !important;order : 0;}.fusion-builder-nested-column-35 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-36 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"spouse_work_phone_extension\">Extension<\/label><\/div><input type=\"number\" name=\"spouse_work_phone_extension\" id=\"spouse_work_phone_extension\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" min=\"0\" max=\"1000000\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-36{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-36 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-36{width:100% !important;order : 0;}.fusion-builder-nested-column-36 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-36{width:100% !important;order : 0;}.fusion-builder-nested-column-36 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-37 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Dental Insurance<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-dental_insurance-4-0\" type=\"radio\" value=\"Yes\" name=\"dental_insurance\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-dental_insurance-4-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-dental_insurance-4-1\" type=\"radio\" value=\"No\" name=\"dental_insurance\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-dental_insurance-4-1\">No<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-37{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-37 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-37{width:100% !important;order : 0;}.fusion-builder-nested-column-37 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-37{width:100% !important;order : 0;}.fusion-builder-nested-column-37 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-38 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"insurance_company_name\">Insurance Company Name<\/label><\/div><input type=\"text\" name=\"insurance_company_name\" id=\"insurance_company_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-38{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-38 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-38{width:100% !important;order : 0;}.fusion-builder-nested-column-38 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-38{width:100% !important;order : 0;}.fusion-builder-nested-column-38 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-39 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"group_policy-number\">Group Policy No.<\/label><\/div><input type=\"text\" name=\"group_policy-number\" id=\"group_policy-number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-39{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-39 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-39{width:100% !important;order : 0;}.fusion-builder-nested-column-39 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-39{width:100% !important;order : 0;}.fusion-builder-nested-column-39 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-40 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"certificate-number\">Certif. No.<\/label><\/div><input type=\"text\" name=\"certificate-number\" id=\"certificate-number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-40{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-40 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-40{width:100% !important;order : 0;}.fusion-builder-nested-column-40 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-40{width:100% !important;order : 0;}.fusion-builder-nested-column-40 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-41 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"certificate-number\">Secondary Insurance<\/label><\/div><input type=\"text\" name=\"certificate-number\" id=\"certificate-number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-41{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-41 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-41{width:100% !important;order : 0;}.fusion-builder-nested-column-41 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-41{width:100% !important;order : 0;}.fusion-builder-nested-column-41 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-42 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"secondary_group_policy-number\">Group Policy No.<\/label><\/div><input type=\"text\" name=\"secondary_group_policy-number\" id=\"secondary_group_policy-number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-42{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-42 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-42{width:100% !important;order : 0;}.fusion-builder-nested-column-42 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-42{width:100% !important;order : 0;}.fusion-builder-nested-column-42 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-43 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"secondary_certificate-number\">Certif. No.<\/label><\/div><input type=\"text\" name=\"secondary_certificate-number\" id=\"secondary_certificate-number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-43{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-43 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-43{width:100% !important;order : 0;}.fusion-builder-nested-column-43 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-43{width:100% !important;order : 0;}.fusion-builder-nested-column-43 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-44 fusion_builder_column_inner_1_5 1_5 fusion-flex-column fusion-flex-align-self-center\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 57px 0px 41px 0px;\"><div class=\"fusion-text fusion-text-3\" style=\"text-align:center;\"><p>% of coverage<\/p>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-44{width:20% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-44 > .fusion-column-wrapper {padding-top : 57px !important;padding-right : 0px !important;margin-right : 0%;padding-bottom : 41px !important;padding-left : 0px !important;margin-left : 9.6%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-44{width:100% !important;order : 0;}.fusion-builder-nested-column-44 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-44{width:100% !important;order : 0;}.fusion-builder-nested-column-44 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-45 fusion_builder_column_inner_1_5 1_5 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 21px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"basic\">Basic<\/label><\/div><input type=\"text\" name=\"basic\" id=\"basic\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-45{width:20% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-45 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 21px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-45{width:100% !important;order : 0;}.fusion-builder-nested-column-45 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-45{width:100% !important;order : 0;}.fusion-builder-nested-column-45 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-46 fusion_builder_column_inner_1_5 1_5 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 21px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"major\">Major<\/label><\/div><input type=\"text\" name=\"major\" id=\"major\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-46{width:20% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-46 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 21px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-46{width:100% !important;order : 0;}.fusion-builder-nested-column-46 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-46{width:100% !important;order : 0;}.fusion-builder-nested-column-46 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-47 fusion_builder_column_inner_1_5 1_5 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 21px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"preventive\">Preventive<\/label><\/div><input type=\"text\" name=\"preventive\" id=\"preventive\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-47{width:20% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-47 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 21px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-47{width:100% !important;order : 0;}.fusion-builder-nested-column-47 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-47{width:100% !important;order : 0;}.fusion-builder-nested-column-47 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-48 fusion_builder_column_inner_1_5 1_5 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 21px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"ortho\">Ortho<\/label><\/div><input type=\"text\" name=\"ortho\" id=\"ortho\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-48{width:20% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-48 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 9.6%;padding-bottom : 21px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-48{width:100% !important;order : 0;}.fusion-builder-nested-column-48 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-48{width:100% !important;order : 0;}.fusion-builder-nested-column-48 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">@media only screen and (max-width:1024px) {.fusion-title.fusion-title-3{margin-top:40px!important; margin-right:0px!important;margin-bottom:40px!important;margin-left:0px!important;}}@media only screen and (max-width:640px) {.fusion-title.fusion-title-3{margin-top:0px!important; margin-right:0px!important;margin-bottom:20px!important; margin-left:0px!important;}}<\/style><div class=\"fusion-title title fusion-title-3 fusion-sep-none fusion-title-text fusion-title-size-three\" style=\"margin-top:40px;margin-right:0px;margin-bottom:40px;margin-left:0px;\"><h3 class=\"title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:34;line-height:1.29;\">Medical Information<\/h3><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-49 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 15px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"in_case_of_emergency_please_notify\">In case of emergency, please notify<\/label><\/div><input type=\"text\" name=\"in_case_of_emergency_please_notify\" id=\"in_case_of_emergency_please_notify\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-49{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-49 > .fusion-column-wrapper {padding-top : 15px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-49{width:100% !important;order : 0;}.fusion-builder-nested-column-49 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-49{width:100% !important;order : 0;}.fusion-builder-nested-column-49 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-50 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Relationship\">Relationship<\/label><\/div><input type=\"text\" name=\"Relationship\" id=\"Relationship\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-50{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-50 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-50{width:100% !important;order : 0;}.fusion-builder-nested-column-50 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-50{width:100% !important;order : 0;}.fusion-builder-nested-column-50 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-51 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"emergency_contact_phone\">Phone Number<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"emergency_contact_phone\" id=\"emergency_contact_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-51{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-51 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-51{width:100% !important;order : 0;}.fusion-builder-nested-column-51 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-51{width:100% !important;order : 0;}.fusion-builder-nested-column-51 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-52 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Closest_Family_Relative\">Closest Family Relative<\/label><\/div><input type=\"text\" name=\"Closest_Family_Relative\" id=\"Closest_Family_Relative\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-52{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-52 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-52{width:100% !important;order : 0;}.fusion-builder-nested-column-52 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-52{width:100% !important;order : 0;}.fusion-builder-nested-column-52 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-53 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Closest_Family_Relative_Phone_Number\">Phone Number<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"Closest_Family_Relative_Phone_Number\" id=\"Closest_Family_Relative_Phone_Number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-53{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-53 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-53{width:100% !important;order : 0;}.fusion-builder-nested-column-53 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-53{width:100% !important;order : 0;}.fusion-builder-nested-column-53 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-54 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Referral_Name\">Whom may we thank for referring you?<\/label><\/div><input type=\"text\" name=\"Referral_Name\" id=\"Referral_Name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-54{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-54 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-54{width:100% !important;order : 0;}.fusion-builder-nested-column-54 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-54{width:100% !important;order : 0;}.fusion-builder-nested-column-54 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-55 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Closest_ Family_ Relative_Phone_Number\">Is a member of your family\/relative a patient at our office?<\/label><\/div><input type=\"text\" name=\"Closest_ Family_ Relative_Phone_Number\" id=\"Closest_ Family_ Relative_Phone_Number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-55{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-55 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-55{width:100% !important;order : 0;}.fusion-builder-nested-column-55 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-55{width:100% !important;order : 0;}.fusion-builder-nested-column-55 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-56 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Reason for today&#039;s visit?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-reason_for_todays_visit-5-0\" type=\"radio\" value=\"Examination\" name=\"reason_for_todays_visit\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-reason_for_todays_visit-5-0\">Examination<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-reason_for_todays_visit-5-1\" type=\"radio\" value=\"Emergency\" name=\"reason_for_todays_visit\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-reason_for_todays_visit-5-1\">Emergency<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-reason_for_todays_visit-5-2\" type=\"radio\" value=\"Other\" name=\"reason_for_todays_visit\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-reason_for_todays_visit-5-2\">Other<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-56{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-56 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-56{width:100% !important;order : 0;}.fusion-builder-nested-column-56 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-56{width:100% !important;order : 0;}.fusion-builder-nested-column-56 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-57 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"1671\"><label for=\"Is_there_a_dental_problem_you_would_like_taken_care_as_soon_as_possible\">Is there a dental problem you would like taken care as soon as possible?<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"Is_there_a_dental_problem_you_would_like_taken_care_as_soon_as_possible\" name=\"Is_there_a_dental_problem_you_would_like_taken_care_as_soon_as_possible\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-57{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-57 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-57{width:100% !important;order : 0;}.fusion-builder-nested-column-57 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-57{width:100% !important;order : 0;}.fusion-builder-nested-column-57 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-58 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 26px 35px 0px 35px;\"><div class=\"fusion-text fusion-text-4\"><p style=\"font-size: 20px;\" data-fusion-font=\"true\"><b style=\"color: #000000;\">The following information is required by the dentist to assist in proper diagnosis and treatment.<\/b><\/p>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-58{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-58 > .fusion-column-wrapper {padding-top : 26px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-58{width:100% !important;order : 0;}.fusion-builder-nested-column-58 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-58{width:100% !important;order : 0;}.fusion-builder-nested-column-58 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-59 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever had a serious illness requiring hospitalization or extensive medical care?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care-6-0\" type=\"radio\" value=\"Yes\" name=\"have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care-6-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care-6-1\" type=\"radio\" value=\"No\" name=\"have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care-6-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_please_explain:\">If yes, please explain:<\/label><\/div><input type=\"text\" name=\"if_yes_please_explain:\" id=\"if_yes_please_explain:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-59{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-59 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-59{width:100% !important;order : 0;}.fusion-builder-nested-column-59 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-59{width:100% !important;order : 0;}.fusion-builder-nested-column-59 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-60 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you presently under the care of a physician?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_presently_under_the_care_of_a_physician-7-0\" type=\"radio\" value=\"Yes\" name=\"Are_you_presently_under_the_care_of_a_physician\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_presently_under_the_care_of_a_physician-7-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_presently_under_the_care_of_a_physician-7-1\" type=\"radio\" value=\"No\" name=\"Are_you_presently_under_the_care_of_a_physician\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_presently_under_the_care_of_a_physician-7-1\">No<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-60{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-60 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-60{width:100% !important;order : 0;}.fusion-builder-nested-column-60 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-60{width:100% !important;order : 0;}.fusion-builder-nested-column-60 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-61 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 33px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you been hospitalized in the last 2 years?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_been_hospitalized_in_the_last_2_years-8-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_been_hospitalized_in_the_last_2_years\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_been_hospitalized_in_the_last_2_years-8-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_been_hospitalized_in_the_last_2_years-8-1\" type=\"radio\" value=\"No\" name=\"Have_you_been_hospitalized_in_the_last_2_years\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_been_hospitalized_in_the_last_2_years-8-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you had a medical examination in the last year?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_had_a_medical_examination_in_the_last_year-9-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_had_a_medical_examination_in_the_last_year\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_had_a_medical_examination_in_the_last_year-9-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_had_a_medical_examination_in_the_last_year-9-1\" type=\"radio\" value=\"No\" name=\"Have_you_had_a_medical_examination_in_the_last_year\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_had_a_medical_examination_in_the_last_year-9-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you use any prescription or non-prescription medicine including herbal remedies, regularly?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly-10-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly-10-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly-10-1\" type=\"radio\" value=\"No\" name=\"Do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly-10-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_please_specify:\">If yes, please specify:<\/label><\/div><input type=\"text\" name=\"if_yes_please_specify:\" id=\"if_yes_please_specify:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any allergic condition: i.e. asthma, hay fever, skin rash, food allergies, metal or latex allergies?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies-11-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies-11-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies-11-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies-11-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"If_yes,_please_explain\">If yes, please explain:<\/label><\/div><input type=\"text\" name=\"If_yes,_please_explain\" id=\"If_yes,_please_explain\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do any of these allergic reactions result in headache, shortness of breath, chest constriction, nausea?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea-12-0\" type=\"radio\" value=\"Yes\" name=\"Do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea-12-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea-12-1\" type=\"radio\" value=\"No\" name=\"Do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea-12-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"If_yes,_please_specify:\">If yes, please specify:<\/label><\/div><input type=\"text\" name=\"If_yes,_please_specify:\" id=\"If_yes,_please_specify:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever experienced any unusual reaction to any of the following?<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-1-0\" type=\"checkbox\" value=\"local anaesthesia (freezing)\" name=\"have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-1-0\">local anaesthesia (freezing)<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-1-1\" type=\"checkbox\" value=\"aspirin\" name=\"have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-1-1\">aspirin<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-1-2\" type=\"checkbox\" value=\"penicillin\" name=\"have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-1-2\">penicillin<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-1-3\" type=\"checkbox\" value=\"iodine\" name=\"have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-1-3\">iodine<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-1-4\" type=\"checkbox\" value=\"sulfonamide (sulfa)\" name=\"have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-1-4\">sulfonamide (sulfa)<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-1-5\" type=\"checkbox\" value=\"barbiturates (sleeping pills)\" name=\"have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-1-5\">barbiturates (sleeping pills)<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"or_any_other_medicine__if_yes_please_explain:\">Or any other medicine?  If yes, please explain:<\/label><\/div><input type=\"text\" name=\"or_any_other_medicine__if_yes_please_explain:\" id=\"or_any_other_medicine__if_yes_please_explain:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you been warned against taking any drug or medication? <\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_been_warned_against_taking_any_drug_or_medication-13-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_been_warned_against_taking_any_drug_or_medication\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_been_warned_against_taking_any_drug_or_medication-13-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_been_warned_against_taking_any_drug_or_medication-13-1\" type=\"radio\" value=\"No\" name=\"Have_you_been_warned_against_taking_any_drug_or_medication\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_been_warned_against_taking_any_drug_or_medication-13-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_please_explain:\">If yes, please explain:<\/label><\/div><input type=\"text\" name=\"if_yes_please_explain:\" id=\"if_yes_please_explain:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have or have you ever had any of the following? (please mark any\/all that apply)<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-0\" type=\"checkbox\" value=\"heart murmur or other heart condition\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-0\">heart murmur or other heart condition<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-1\" type=\"checkbox\" value=\"hepatitis A\/B\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-1\">hepatitis A\/B<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-2\" type=\"checkbox\" value=\"joint replacement (hip, knee)\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-2\">joint replacement (hip, knee)<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-3\" type=\"checkbox\" value=\"venereal disease\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-3\">venereal disease<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-4\" type=\"checkbox\" value=\"rheumatism\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-4\">rheumatism<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-5\" type=\"checkbox\" value=\"hyper (hypo) glycemia\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-5\">hyper (hypo) glycemia<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-6\" type=\"checkbox\" value=\"arthritis\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-6\">arthritis<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-7\" type=\"checkbox\" value=\"high\/low blood pressure\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-7\">high\/low blood pressure<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-8\" type=\"checkbox\" value=\"thyroid disease\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-8\">thyroid disease<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-9\" type=\"checkbox\" value=\"any lung disease\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-9\">any lung disease<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-10\" type=\"checkbox\" value=\"scarlet fever\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-10\">scarlet fever<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-11\" type=\"checkbox\" value=\"herpes\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-11\">herpes<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-12\" type=\"checkbox\" value=\"stomach\/intestinal problems\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-12\">stomach\/intestinal problems<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-13\" type=\"checkbox\" value=\"drug addiction\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-13\">drug addiction<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-14\" type=\"checkbox\" value=\"jaundice\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-14\">jaundice<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-15\" type=\"checkbox\" value=\"cancer\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-15\">cancer<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-16\" type=\"checkbox\" value=\"kidney disease\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-16\">kidney disease<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-17\" type=\"checkbox\" value=\"mental or nervous disorder\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-17\">mental or nervous disorder<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-18\" type=\"checkbox\" value=\"stroke\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-18\">stroke<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-19\" type=\"checkbox\" value=\"tuberculosis\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-19\">tuberculosis<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-20\" type=\"checkbox\" value=\"sinus trouble\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-20\">sinus trouble<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-21\" type=\"checkbox\" value=\"heart attack\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-21\">heart attack<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-22\" type=\"checkbox\" value=\"rheumatic fever\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-22\">rheumatic fever<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-23\" type=\"checkbox\" value=\"epilepsy or seizures\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-23\">epilepsy or seizures<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-24\" type=\"checkbox\" value=\"AIDS\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-24\">AIDS<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-25\" type=\"checkbox\" value=\"liver disease\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-2-25\">liver disease<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"other:\">Other:<\/label><\/div><input type=\"text\" name=\"other:\" id=\"other:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever had any known contact with the Aids Virus?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_any_known_contact_with_the_aids_virus-14-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_ever_had_any_known_contact_with_the_Aids_Virus\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_any_known_contact_with_the_aids_virus-14-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_any_known_contact_with_the_aids_virus-14-1\" type=\"radio\" value=\"No\" name=\"Have_you_ever_had_any_known_contact_with_the_Aids_Virus\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_any_known_contact_with_the_aids_virus-14-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Has any member of your family had diabetes<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-has_any_member_of_your_family_had_diabetes-15-0\" type=\"radio\" value=\"Yes\" name=\"Has_any_member_of_your_family_had_diabetes\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-has_any_member_of_your_family_had_diabetes-15-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-has_any_member_of_your_family_had_diabetes-15-1\" type=\"radio\" value=\"No\" name=\"Has_any_member_of_your_family_had_diabetes\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-has_any_member_of_your_family_had_diabetes-15-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you bruise easily or bleed abnormally?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_bruise_easily_or_bleed_abnormally-16-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_bruise_easily_or_bleed_abnormally\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_bruise_easily_or_bleed_abnormally-16-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_bruise_easily_or_bleed_abnormally-16-1\" type=\"radio\" value=\"No\" name=\"Do_you_bruise_easily_or_bleed_abnormally\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_bruise_easily_or_bleed_abnormally-16-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do your ankles swell during the day?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_your_ankles_swell_during_the_day-17-0\" type=\"radio\" value=\"Yes\" name=\"Do_your_ankles_swell_during_the_day\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_your_ankles_swell_during_the_day-17-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_your_ankles_swell_during_the_day-17-1\" type=\"radio\" value=\"No\" name=\"Do_your_ankles_swell_during_the_day\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_your_ankles_swell_during_the_day-17-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you had any weight changes recently?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_had_any_weight_changes_recently-18-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_had_any_weight_changes_recently\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_had_any_weight_changes_recently-18-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_had_any_weight_changes_recently-18-1\" type=\"radio\" value=\"No\" name=\"Have_you_had_any_weight_changes_recently\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_had_any_weight_changes_recently-18-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any blood disorders such as anaemia (thin blood)?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)-19-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)-19-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)-19-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)-19-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever had radiation treatment or chemotherapy?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_radiation_treatment_or_chemotherapy-20-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_ever_had_radiation_treatment_or_chemotherapy\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_radiation_treatment_or_chemotherapy-20-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_radiation_treatment_or_chemotherapy-20-1\" type=\"radio\" value=\"No\" name=\"Have_you_ever_had_radiation_treatment_or_chemotherapy\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_radiation_treatment_or_chemotherapy-20-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_please_explain:\">If yes, please explain:<\/label><\/div><input type=\"text\" name=\"if_yes_please_explain:\" id=\"if_yes_please_explain:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever had any injury, surgery or x-ray therapy to your face or jaws?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws-21-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws-21-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws-21-1\" type=\"radio\" value=\"No\" name=\"Have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws-21-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have frequent severe headaches?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_frequent_severe_headaches-22-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_frequent_severe_headaches\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_frequent_severe_headaches-22-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_frequent_severe_headaches-22-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_frequent_severe_headaches\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_frequent_severe_headaches-22-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have frequent earaches, ear\/throat infections or any hearing difficulties?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_frequent_earaches,_ear\/throat_infections_or_any_hearing_difficulties-23-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_frequent_earaches,_ear\/throat_infections_or_any_hearing_difficulties\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_frequent_earaches,_ear\/throat_infections_or_any_hearing_difficulties-23-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_frequent_earaches,_ear\/throat_infections_or_any_hearing_difficulties-23-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_frequent_earaches,_ear\/throat_infections_or_any_hearing_difficulties\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_frequent_earaches,_ear\/throat_infections_or_any_hearing_difficulties-23-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Is your eyesight:<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-is_your_eyesight:-24-0\" type=\"radio\" value=\"Good\" name=\"is_your_eyesight:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-is_your_eyesight:-24-0\">Good<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-is_your_eyesight:-24-1\" type=\"radio\" value=\"Adequate\" name=\"is_your_eyesight:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-is_your_eyesight:-24-1\">Adequate<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-is_your_eyesight:-24-2\" type=\"radio\" value=\"Poor\" name=\"is_your_eyesight:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-is_your_eyesight:-24-2\">Poor<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you on a special diet?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_on_a_special_diet-25-0\" type=\"radio\" value=\"Yes\" name=\"Are_you_on_a_special_diet\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_on_a_special_diet-25-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_on_a_special_diet-25-1\" type=\"radio\" value=\"No\" name=\"Are_you_on_a_special_diet\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_on_a_special_diet-25-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_please_explain:\">If yes, please explain:<\/label><\/div><input type=\"text\" name=\"if_yes_please_explain:\" id=\"if_yes_please_explain:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever fainted?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_fainted-26-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_ever_fainted\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_fainted-26-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_fainted-26-1\" type=\"radio\" value=\"No\" name=\"Have_you_ever_fainted\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_fainted-26-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you ever experience shortness of breath or pain in your chest when taking a walk or climbing stairs?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs-27-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs-27-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs-27-1\" type=\"radio\" value=\"No\" name=\"Do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs-27-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any medical or dental implants?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_medical_or_dental_implants-28-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_any_medical_or_dental_implants\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_medical_or_dental_implants-28-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_medical_or_dental_implants-28-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_any_medical_or_dental_implants\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_medical_or_dental_implants-28-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"1671\"><label for=\"do_you_have_any_disease_condition_or_problem_not_listed_above_that_you_think_the_doctor_should_know_about\">Do you have any disease, condition or problem not listed above that you think the doctor should know about?<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"do_you_have_any_disease_condition_or_problem_not_listed_above_that_you_think_the_doctor_should_know_about\" name=\"do_you_have_any_disease_condition_or_problem_not_listed_above_that_you_think_the_doctor_should_know_about\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"1671\"><label for=\"is_there_anything_about_yourself_that_we_should_be_made_aware_of\">Is there anything about yourself that we should be made aware of?<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"is_there_anything_about_yourself_that_we_should_be_made_aware_of\" name=\"is_there_anything_about_yourself_that_we_should_be_made_aware_of\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">WOMEN ONLY - Are you pregnant?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-women_only_-_are_you_pregnant?-29-0\" type=\"radio\" value=\"Yes\" name=\"WOMEN_ONLY_-_Are_you_pregnant?\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-women_only_-_are_you_pregnant?-29-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-women_only_-_are_you_pregnant?-29-1\" type=\"radio\" value=\"No\" name=\"WOMEN_ONLY_-_Are_you_pregnant?\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-women_only_-_are_you_pregnant?-29-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"If_so_which_month_are_you_in\"> If so, which month are you in?<\/label><\/div><input type=\"text\" name=\"If_so_which_month_are_you_in\" id=\"If_so_which_month_are_you_in\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you taking any birth control pills?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_taking_any_birth_control_pills-30-0\" type=\"radio\" value=\"Yes\" name=\"Are_you_taking_any_birth_control_pills\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_taking_any_birth_control_pills-30-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_taking_any_birth_control_pills-30-1\" type=\"radio\" value=\"No\" name=\"Are_you_taking_any_birth_control_pills\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_taking_any_birth_control_pills-30-1\">No<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-61{width:100% !important;margin-top : 0px;margin-bottom : 38px;}.fusion-builder-nested-column-61 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 33px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-61{width:100% !important;order : 0;}.fusion-builder-nested-column-61 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-61{width:100% !important;order : 0;}.fusion-builder-nested-column-61 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><div class=\"fusion-alert alert notice alert-warning fusion-alert-left fusion-alert-capitalize alert-shadow fusion-animated\" style=\"background-color:#fcf8e3;color:rgba(217,185,23,1);border-color:rgba(217,185,23,1);border-width:1px;\" data-animationType=\"rubberBand\" data-animationDuration=\"1.4\" data-animationOffset=\"top-into-view\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa-lg fa-cog fa\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\"><b data-fusion-font=\"true\">IN ORDER TO AVOID COMPLICATIONS AS A RESULT OF A CHANGE IN YOUR MEDICAL CONDITION, IT IS IMPORTANT THAT YOU NOTIFY OUR OFFICE OF THESE CHANGES.<\/b><\/span><\/div><\/div><style type=\"text\/css\">@media only screen and (max-width:1024px) {.fusion-title.fusion-title-4{margin-top:35px!important; margin-right:0px!important;margin-bottom:!important;margin-left:0px!important;}}@media only screen and (max-width:640px) {.fusion-title.fusion-title-4{margin-top:0px!important; margin-right:0px!important;margin-bottom:20px!important; margin-left:0px!important;}}<\/style><div class=\"fusion-title title fusion-title-4 fusion-sep-none fusion-title-text fusion-title-size-three\" style=\"margin-top:35px;margin-right:0px;margin-left:0px;\"><h3 class=\"title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:34;line-height:1.29;\">Dental History<\/h3><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-62 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 16px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">How frequently do you see your dentist?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-how_frequently_do_you_see_your_dentist-31-0\" type=\"radio\" value=\"6 Months\" name=\"how_frequently_do_you_see_your_dentist\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-how_frequently_do_you_see_your_dentist-31-0\">6 Months<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-how_frequently_do_you_see_your_dentist-31-1\" type=\"radio\" value=\"Yearly\" name=\"how_frequently_do_you_see_your_dentist\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-how_frequently_do_you_see_your_dentist-31-1\">Yearly<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-how_frequently_do_you_see_your_dentist-31-2\" type=\"radio\" value=\"Other\" name=\"how_frequently_do_you_see_your_dentist\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-how_frequently_do_you_see_your_dentist-31-2\">Other<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-62{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-62 > .fusion-column-wrapper {padding-top : 16px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-62{width:100% !important;order : 0;}.fusion-builder-nested-column-62 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-62{width:100% !important;order : 0;}.fusion-builder-nested-column-62 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-63 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"last_dental_visit\">Last dental visit?<\/label><\/div><input type=\"text\" name=\"last_dental_visit\" id=\"last_dental_visit\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-63{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-63 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-63{width:100% !important;order : 0;}.fusion-builder-nested-column-63 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-63{width:100% !important;order : 0;}.fusion-builder-nested-column-63 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-64 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Last_cleaning\"> Last cleaning?<\/label><\/div><input type=\"text\" name=\"Last_cleaning\" id=\"Last_cleaning\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-64{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-64 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-64{width:100% !important;order : 0;}.fusion-builder-nested-column-64 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-64{width:100% !important;order : 0;}.fusion-builder-nested-column-64 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-65 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Last_full_mouth_series_of_x-rays\">Last full mouth series of x-rays?<\/label><\/div><input type=\"text\" name=\"Last_full_mouth_series_of_x-rays\" id=\"Last_full_mouth_series_of_x-rays\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-65{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-65 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-65{width:100% !important;order : 0;}.fusion-builder-nested-column-65 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-65{width:100% !important;order : 0;}.fusion-builder-nested-column-65 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-66 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 33px 35px;\"><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you been given oral hygiene instruction in:<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_been_given_oral_hygiene_instruction_in:-3-0\" type=\"checkbox\" value=\"Brushing\" name=\"Have_you_been_given_oral_hygiene_instruction_in:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_been_given_oral_hygiene_instruction_in:-3-0\">Brushing<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_been_given_oral_hygiene_instruction_in:-3-1\" type=\"checkbox\" value=\"Flossing\" name=\"Have_you_been_given_oral_hygiene_instruction_in:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_been_given_oral_hygiene_instruction_in:-3-1\">Flossing<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_been_given_oral_hygiene_instruction_in:-3-2\" type=\"checkbox\" value=\"Other\" name=\"Have_you_been_given_oral_hygiene_instruction_in:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_been_given_oral_hygiene_instruction_in:-3-2\">Other<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are any of your teeth sensitive to:<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-are_any_of_your_teeth_sensitive_to:-4-0\" type=\"checkbox\" value=\"Cold\" name=\"Are_any_of_your_teeth_sensitive_to:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-are_any_of_your_teeth_sensitive_to:-4-0\">Cold<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-are_any_of_your_teeth_sensitive_to:-4-1\" type=\"checkbox\" value=\"Sweets\" name=\"Are_any_of_your_teeth_sensitive_to:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-are_any_of_your_teeth_sensitive_to:-4-1\">Sweets<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-are_any_of_your_teeth_sensitive_to:-4-2\" type=\"checkbox\" value=\"Heat\" name=\"Are_any_of_your_teeth_sensitive_to:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-are_any_of_your_teeth_sensitive_to:-4-2\">Heat<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-are_any_of_your_teeth_sensitive_to:-4-3\" type=\"checkbox\" value=\"Other\" name=\"Are_any_of_your_teeth_sensitive_to:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-are_any_of_your_teeth_sensitive_to:-4-3\">Other<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do your gums bleed when:<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_your_gums_bleed_when:-5-0\" type=\"checkbox\" value=\"Brushing\" name=\"Do_your_gums_bleed_when:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_your_gums_bleed_when:-5-0\">Brushing<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_your_gums_bleed_when:-5-1\" type=\"checkbox\" value=\"Flossing\" name=\"Do_your_gums_bleed_when:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_your_gums_bleed_when:-5-1\">Flossing<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_your_gums_bleed_when:-5-2\" type=\"checkbox\" value=\"Spontaneously\" name=\"Do_your_gums_bleed_when:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_your_gums_bleed_when:-5-2\">Spontaneously<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever had any of the following:<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_had_any_of_the_following:-6-0\" type=\"checkbox\" value=\"Oral surgery\" name=\"Have_you_ever_had_any_of_the_following:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_had_any_of_the_following:-6-0\">Oral surgery<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_had_any_of_the_following:-6-1\" type=\"checkbox\" value=\"Peridontal treatment\" name=\"Have_you_ever_had_any_of_the_following:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_had_any_of_the_following:-6-1\">Peridontal treatment<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_had_any_of_the_following:-6-2\" type=\"checkbox\" value=\"Orthodontic treatment\" name=\"Have_you_ever_had_any_of_the_following:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_had_any_of_the_following:-6-2\">Orthodontic treatment<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_had_any_of_the_following:-6-3\" type=\"checkbox\" value=\"Bite adjustment\" name=\"Have_you_ever_had_any_of_the_following:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_had_any_of_the_following:-6-3\">Bite adjustment<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_had_any_of_the_following:-6-4\" type=\"checkbox\" value=\"Bite plate or other appliance\" name=\"Have_you_ever_had_any_of_the_following:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_had_any_of_the_following:-6-4\">Bite plate or other appliance<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any dental implants?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_dental_implants-32-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_any_dental_implants\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_dental_implants-32-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_dental_implants-32-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_any_dental_implants\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_dental_implants-32-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you suffer from pain and\/or swelling of your gums?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_suffer_from_pain_and\/or_swelling_of_your_gums-33-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_suffer_from_pain_and\/or_swelling_of_your_gums\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_suffer_from_pain_and\/or_swelling_of_your_gums-33-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_suffer_from_pain_and\/or_swelling_of_your_gums-33-1\" type=\"radio\" value=\"No\" name=\"Do_you_suffer_from_pain_and\/or_swelling_of_your_gums\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_suffer_from_pain_and\/or_swelling_of_your_gums-33-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you aware of any loose teeth?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_aware_of_any_loose_teeth-34-0\" type=\"radio\" value=\"Yes\" name=\"Are_you_aware_of_any_loose_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_aware_of_any_loose_teeth-34-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_aware_of_any_loose_teeth-34-1\" type=\"radio\" value=\"No\" name=\"Are_you_aware_of_any_loose_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_aware_of_any_loose_teeth-34-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_where\">If yes, where?<\/label><\/div><input type=\"text\" name=\"if_yes_where\" id=\"if_yes_where\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you chew on only one side of your mouth?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_chew_on_only_one_side_of_your_mouth-35-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_chew_on_only_one_side_of_your_mouth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_chew_on_only_one_side_of_your_mouth-35-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_chew_on_only_one_side_of_your_mouth-35-1\" type=\"radio\" value=\"No\" name=\"Do_you_chew_on_only_one_side_of_your_mouth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_chew_on_only_one_side_of_your_mouth-35-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"If_so_why\">If so, why?<\/label><\/div><input type=\"text\" name=\"If_so_why\" id=\"If_so_why\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you grind or clench your teeth during the day or night?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_grind_or_clench_your_teeth_during_the_day_or_night-36-0\" type=\"radio\" value=\"Yes\" name=\"do_you_grind_or_clench_your_teeth_during_the_day_or_night\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_grind_or_clench_your_teeth_during_the_day_or_night-36-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_grind_or_clench_your_teeth_during_the_day_or_night-36-1\" type=\"radio\" value=\"No\" name=\"do_you_grind_or_clench_your_teeth_during_the_day_or_night\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_grind_or_clench_your_teeth_during_the_day_or_night-36-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you mouth breathe while awake or asleep?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_mouth_breathe_while_awake_or_asleep-37-0\" type=\"radio\" value=\"Yes\" name=\"do_you_mouth_breathe_while_awake_or_asleep\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_mouth_breathe_while_awake_or_asleep-37-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_mouth_breathe_while_awake_or_asleep-37-1\" type=\"radio\" value=\"No\" name=\"do_you_mouth_breathe_while_awake_or_asleep\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_mouth_breathe_while_awake_or_asleep-37-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you bite your lips or cheeks regularly?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_bite_your_lips_or_cheeks_regularly-38-0\" type=\"radio\" value=\"Yes\" name=\"do_you_bite_your_lips_or_cheeks_regularly\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_bite_your_lips_or_cheeks_regularly-38-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_bite_your_lips_or_cheeks_regularly-38-1\" type=\"radio\" value=\"No\" name=\"do_you_bite_your_lips_or_cheeks_regularly\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_bite_your_lips_or_cheeks_regularly-38-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you hold any foreign objects with your teeth?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_hold_any_foreign_objects_with_your_teeth-39-0\" type=\"radio\" value=\"Yes\" name=\"do_you_hold_any_foreign_objects_with_your_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_hold_any_foreign_objects_with_your_teeth-39-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_hold_any_foreign_objects_with_your_teeth-39-1\" type=\"radio\" value=\"No\" name=\"do_you_hold_any_foreign_objects_with_your_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_hold_any_foreign_objects_with_your_teeth-39-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Does any part of your mouth hurt when clenched?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-does_any_part_of_your_mouth_hurt_when_clenched-40-0\" type=\"radio\" value=\"Yes\" name=\"Does_any_part_of_your_mouth_hurt_when_clenched\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-does_any_part_of_your_mouth_hurt_when_clenched-40-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-does_any_part_of_your_mouth_hurt_when_clenched-40-1\" type=\"radio\" value=\"No\" name=\"Does_any_part_of_your_mouth_hurt_when_clenched\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-does_any_part_of_your_mouth_hurt_when_clenched-40-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Does your jaw crack or pop when opened widely?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-does_your_jaw_crack_or_pop_when_opened_widely-41-0\" type=\"radio\" value=\"Yes\" name=\"Does_your_jaw_crack_or_pop_when_opened_widely\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-does_your_jaw_crack_or_pop_when_opened_widely-41-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-does_your_jaw_crack_or_pop_when_opened_widely-41-1\" type=\"radio\" value=\"No\" name=\"Does_your_jaw_crack_or_pop_when_opened_widely\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-does_your_jaw_crack_or_pop_when_opened_widely-41-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any difficulty in opening or closing your jaw?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_difficulty_in_opening_or_closing_your_jaw-42-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_any_difficulty_in_opening_or_closing_your_jaw\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_difficulty_in_opening_or_closing_your_jaw-42-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_difficulty_in_opening_or_closing_your_jaw-42-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_any_difficulty_in_opening_or_closing_your_jaw\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_difficulty_in_opening_or_closing_your_jaw-42-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any pain in your ears?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_pain_in_your_ears-43-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_any_pain_in_your_ears\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_pain_in_your_ears-43-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_pain_in_your_ears-43-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_any_pain_in_your_ears\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_pain_in_your_ears-43-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you gag easily?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_gag_easily-44-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_gag_easily\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_gag_easily-44-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_gag_easily-44-1\" type=\"radio\" value=\"No\" name=\"Do_you_gag_easily\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_gag_easily-44-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you experienced any growth or sore spots in your mouth?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_experienced_any_growth_or_sore_spots_in_your_mouth-45-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_experienced_any_growth_or_sore_spots_in_your_mouth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_experienced_any_growth_or_sore_spots_in_your_mouth-45-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_experienced_any_growth_or_sore_spots_in_your_mouth-45-1\" type=\"radio\" value=\"No\" name=\"Have_you_experienced_any_growth_or_sore_spots_in_your_mouth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_experienced_any_growth_or_sore_spots_in_your_mouth-45-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"is_yes_where\">Is yes, where?<\/label><\/div><input type=\"text\" name=\"is_yes_where\" id=\"is_yes_where\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you concerned about the appearance of your teeth?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_concerned_about_the_appearance_of_your_teeth-46-0\" type=\"radio\" value=\"Yes\" name=\"Are_you_concerned_about_the_appearance_of_your_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_concerned_about_the_appearance_of_your_teeth-46-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_concerned_about_the_appearance_of_your_teeth-46-1\" type=\"radio\" value=\"No\" name=\"Are_you_concerned_about_the_appearance_of_your_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_concerned_about_the_appearance_of_your_teeth-46-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_what_would_you_like_to_see_changed\">If yes, what would you like to see changed?<\/label><\/div><input type=\"text\" name=\"if_yes_what_would_you_like_to_see_changed\" id=\"if_yes_what_would_you_like_to_see_changed\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Would you rate your current dental health as:<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-would_you_rate_your_current_dental_health_as-47-0\" type=\"radio\" value=\"Excellent\" name=\"Would_you_rate_your_current_dental_health_as\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-would_you_rate_your_current_dental_health_as-47-0\">Excellent<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-would_you_rate_your_current_dental_health_as-47-1\" type=\"radio\" value=\"Good\" name=\"Would_you_rate_your_current_dental_health_as\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-would_you_rate_your_current_dental_health_as-47-1\">Good<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-would_you_rate_your_current_dental_health_as-47-2\" type=\"radio\" value=\"Fair\" name=\"Would_you_rate_your_current_dental_health_as\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-would_you_rate_your_current_dental_health_as-47-2\">Fair<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-would_you_rate_your_current_dental_health_as-47-3\" type=\"radio\" value=\"Poor\" name=\"Would_you_rate_your_current_dental_health_as\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-would_you_rate_your_current_dental_health_as-47-3\">Poor<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Is your sugar intake:<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-is_your_sugar_intake-48-0\" type=\"radio\" value=\"High\" name=\"Is_your_sugar_intake\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-is_your_sugar_intake-48-0\">High<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-is_your_sugar_intake-48-1\" type=\"radio\" value=\"Medium\" name=\"Is_your_sugar_intake\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-is_your_sugar_intake-48-1\">Medium<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-is_your_sugar_intake-48-2\" type=\"radio\" value=\"Low\" name=\"Is_your_sugar_intake\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-is_your_sugar_intake-48-2\">Low<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Brushing: <\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-brushing-49-0\" type=\"radio\" value=\"Vigorous\" name=\"Brushing\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-brushing-49-0\">Vigorous<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-brushing-49-1\" type=\"radio\" value=\"Light\" name=\"Brushing\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-brushing-49-1\">Light<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"how_often\">How often?<\/label><\/div><input type=\"text\" name=\"how_often\" id=\"how_often\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Cleaning aids presently used:<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-cleaning_aids_presently_used:-7-0\" type=\"checkbox\" value=\"Floss\" name=\"cleaning_aids_presently_used:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-cleaning_aids_presently_used:-7-0\">Floss<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-cleaning_aids_presently_used:-7-1\" type=\"checkbox\" value=\"Toothpick\" name=\"cleaning_aids_presently_used:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-cleaning_aids_presently_used:-7-1\">Toothpick<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-cleaning_aids_presently_used:-7-2\" type=\"checkbox\" value=\"Other\" name=\"cleaning_aids_presently_used:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-cleaning_aids_presently_used:-7-2\">Other<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any emotional concerns regarding your dental visit?<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-8-0\" type=\"checkbox\" value=\"Fear\" name=\"Do_you_have_any_emotional_concerns_regarding_your_dental_visit[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-8-0\">Fear<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-8-1\" type=\"checkbox\" value=\"Pain\" name=\"Do_you_have_any_emotional_concerns_regarding_your_dental_visit[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-8-1\">Pain<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-8-2\" type=\"checkbox\" value=\"Money\" name=\"Do_you_have_any_emotional_concerns_regarding_your_dental_visit[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-8-2\">Money<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-8-3\" type=\"checkbox\" value=\"Embarrassment\" name=\"Do_you_have_any_emotional_concerns_regarding_your_dental_visit[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-8-3\">Embarrassment<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-8-4\" type=\"checkbox\" value=\"Other\" name=\"Do_you_have_any_emotional_concerns_regarding_your_dental_visit[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-8-4\">Other<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-66{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-66 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 33px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-66{width:100% !important;order : 0;}.fusion-builder-nested-column-66 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-66{width:100% !important;order : 0;}.fusion-builder-nested-column-66 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">@media only screen and (max-width:1024px) {.fusion-title.fusion-title-5{margin-top:35px!important; margin-right:0px!important;margin-bottom:!important;margin-left:0px!important;}}@media only screen and (max-width:640px) {.fusion-title.fusion-title-5{margin-top:0px!important; margin-right:0px!important;margin-bottom:20px!important; margin-left:0px!important;}}<\/style><div class=\"fusion-title title fusion-title-5 fusion-sep-none fusion-title-text fusion-title-size-three\" style=\"margin-top:35px;margin-right:0px;margin-left:0px;\"><h3 class=\"title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:34;line-height:1.29;\">General Release<\/h3><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-67 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 35px 35px 26px 35px;\"><div class=\"fusion-text fusion-text-5\"><p>I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. <b>Should there be any change in either my health status or any other information I have provided, I will advise this dental office.<\/b> I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.<\/p>\n<p><b>By clicking submit you agree to certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician being contacted if necessary, as this information may be required for my dental care.<\/b><\/p>\n<\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><fieldset><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox--9-0\" type=\"checkbox\" value=\"I confirm that all of the medical and dental information provided above is true to the best of my knowledge.\" name=\"[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox--9-0\">I confirm that all of the medical and dental information provided above is true to the best of my knowledge.<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-67{width:100% !important;margin-top : 0px;margin-bottom : 40px;}.fusion-builder-nested-column-67 > .fusion-column-wrapper {padding-top : 35px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 26px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-67{width:100% !important;order : 0;}.fusion-builder-nested-column-67 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-67{width:100% !important;order : 0;}.fusion-builder-nested-column-67 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><div class=\"fusion-form-field fusion-form-submit-field fusion-form-label-above\" data-form-id=\"1671\"><div ><style>.fusion-button.button-1{border-color:#ffffff;border-radius:0px 0px 0px 0px;background:#3d434c;}.fusion-button.button-1 .fusion-button-text,.fusion-button.button-1 i,.fusion-button.button-1:hover .fusion-button-text,.fusion-button.button-1:hover i,.fusion-button.button-1:focus .fusion-button-text,.fusion-button.button-1:focus i,.fusion-button.button-1:active .fusion-button-text,.fusion-button.button-1:active i{color:#ffffff;}.fusion-button.button-1:hover,.fusion-button.button-1:active,.fusion-button.button-1:focus{border-color:#ffffff;background:#dbb55f;}<\/style><button type=\"submit\" class=\"fusion-button button-flat button-xlarge button-custom button-1 fusion-button-span-yes  form-form-submit button-default\" data-form-number=\"1671\" style=\"margin-top:16px;margin-bottom:30px;\" tabindex=\"\"><span class=\"fusion-button-text\">Submit New Patient Form<\/span><\/button><\/div><\/div><div class=\"form-submission-notices\" id=\"fusion-notices-1\"><div class=\"fusion-alert alert success alert-success fusion-alert-center fusion-form-response fusion-form-response-success fusion-alert-capitalize alert-dismissable\" style=\"background-color:#dff0d8;color:rgba(92,163,64,1);border-color:rgba(92,163,64,1);border-width:1px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa fa-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Thank you for submitting your information - it has been sent to us for review.<\/span><\/div><\/div><div class=\"fusion-alert alert error alert-danger fusion-alert-center fusion-form-response fusion-form-response-error fusion-alert-capitalize alert-dismissable\" style=\"background-color:#f2dede;color:rgba(166,66,66,1);border-color:rgba(166,66,66,1);border-width:1px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa fa-exclamation-triangle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">There was an error trying to send your message. Please try again later.<\/span><\/div><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-1{width:100% !important;margin-top : 0px;margin-bottom : 40px;}.fusion-builder-column-1 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-1{width:100% !important;order : 0;}.fusion-builder-column-1 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-1{width:100% !important;order : 0;}.fusion-builder-column-1 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-1{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><input type=\"hidden\" name=\"fusion_privacy_store_ip_ua\" value=\"false\"><input type=\"hidden\" name=\"fusion_privacy_expiration_interval\" value=\"48\"><input type=\"hidden\" name=\"privacy_expiration_action\" value=\"anonymize\"><\/form><\/div><style>.fusion-form-form-wrapper .fusion-form-1671 .fusion-form-tooltip .fusion-form-tooltip-content{color:#ffffff !important;background-color:#333333 !important;border-color:#333333 !important;}<\/style><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-1671\" data-form-id=\"1671\" data-config=\"{&quot;form_id&quot;:&quot;1671&quot;,&quot;form_post_id&quot;:&quot;1671&quot;,&quot;post_id&quot;:1672,&quot;form_type&quot;:&quot;email&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;field_labels&quot;:{&quot;date&quot;:&quot;Date&quot;,&quot;are_you_the&quot;:&quot;Are you the&quot;,&quot;salutation&quot;:&quot;Salutation&quot;,&quot;first_name&quot;:&quot;First Name&quot;,&quot;last_name&quot;:&quot;Last Name&quot;,&quot;initial&quot;:&quot;Initial&quot;,&quot;Prefers_to_be_called&quot;:&quot;Prefers to be called (if different from above)&quot;,&quot;address&quot;:&quot;Address&quot;,&quot;city&quot;:&quot;City&quot;,&quot;province&quot;:&quot;Postal Code&quot;,&quot;date_of_birth&quot;:&quot;Date of Birth&quot;,&quot;age&quot;:&quot;Age&quot;,&quot;&quot;:&quot;&quot;,&quot;home_phone&quot;:&quot;Home Phone&quot;,&quot;cell_phone&quot;:&quot;Cell Phone&quot;,&quot;family_physician&quot;:&quot;Family Physician&quot;,&quot;family_physician_phone&quot;:&quot;Family Physician Phone&quot;,&quot;medical_specialist_if_under_present_care&quot;:&quot;Medical Specialist (if under present care)&quot;,&quot;medical_specialist_phone&quot;:&quot;Medical Specialist Phone&quot;,&quot;person_responsible_for_account&quot;:&quot;Person Responsible for Account&quot;,&quot;person_responsible_name&quot;:&quot;Name&quot;,&quot;person_responsible_phone_number&quot;:&quot;Phone Number&quot;,&quot;person_responsible_address&quot;:&quot;Address&quot;,&quot;person_responsible_employer&quot;:&quot;Employer&quot;,&quot;person_responsible_work_phone&quot;:&quot;Work Phone&quot;,&quot;person_responsible_work_phone_extension&quot;:&quot;Extension&quot;,&quot;your_occupation&quot;:&quot;Your Occupation&quot;,&quot;your_employer&quot;:&quot;Your Employer&quot;,&quot;your_work_phone&quot;:&quot;Work Phone&quot;,&quot;your_work_phone_extension&quot;:&quot;Extension&quot;,&quot;spouse_employer&quot;:&quot;Spouse Employer&quot;,&quot;spouse_work_phone&quot;:&quot;Work Phone&quot;,&quot;spouse_work_phone_extension&quot;:&quot;Extension&quot;,&quot;dental_insurance&quot;:&quot;Dental Insurance&quot;,&quot;insurance_company_name&quot;:&quot;Insurance Company Name&quot;,&quot;group_policy-number&quot;:&quot;Group Policy No.&quot;,&quot;certificate-number&quot;:&quot;Secondary Insurance&quot;,&quot;secondary_group_policy-number&quot;:&quot;Group Policy No.&quot;,&quot;secondary_certificate-number&quot;:&quot;Certif. No.&quot;,&quot;basic&quot;:&quot;Basic&quot;,&quot;major&quot;:&quot;Major&quot;,&quot;preventive&quot;:&quot;Preventive&quot;,&quot;ortho&quot;:&quot;Ortho&quot;,&quot;in_case_of_emergency_please_notify&quot;:&quot;In case of emergency, please notify&quot;,&quot;Relationship&quot;:&quot;Relationship&quot;,&quot;emergency_contact_phone&quot;:&quot;Phone Number&quot;,&quot;Closest_Family_Relative&quot;:&quot;Closest Family Relative&quot;,&quot;Closest_Family_Relative_Phone_Number&quot;:&quot;Phone Number&quot;,&quot;Referral_Name&quot;:&quot;Whom may we thank for referring you?&quot;,&quot;Closest_ Family_ Relative_Phone_Number&quot;:&quot;Is a member of your family\\\/relative a patient at our office?&quot;,&quot;reason_for_todays_visit&quot;:&quot;Reason for today&#039;s visit?&quot;,&quot;Is_there_a_dental_problem_you_would_like_taken_care_as_soon_as_possible&quot;:&quot;Is there a dental problem you would like taken care as soon as possible?&quot;,&quot;have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care&quot;:&quot;Have you ever had a serious illness requiring hospitalization or extensive medical care?&quot;,&quot;if_yes_please_explain:&quot;:&quot;If yes, please explain:&quot;,&quot;Are_you_presently_under_the_care_of_a_physician&quot;:&quot;Are you presently under the care of a physician?&quot;,&quot;Have_you_been_hospitalized_in_the_last_2_years&quot;:&quot;Have you been hospitalized in the last 2 years?&quot;,&quot;Have_you_had_a_medical_examination_in_the_last_year&quot;:&quot;Have you had a medical examination in the last year?&quot;,&quot;Do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly&quot;:&quot;Do you use any prescription or non-prescription medicine including herbal remedies, regularly?&quot;,&quot;if_yes_please_specify:&quot;:&quot;If yes, please specify:&quot;,&quot;Do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies&quot;:&quot;Do you have any allergic condition: i.e. asthma, hay fever, skin rash, food allergies, metal or latex allergies?&quot;,&quot;If_yes,_please_explain&quot;:&quot;If yes, please explain:&quot;,&quot;Do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea&quot;:&quot;Do any of these allergic reactions result in headache, shortness of breath, chest constriction, nausea?&quot;,&quot;If_yes,_please_specify:&quot;:&quot;If yes, please specify:&quot;,&quot;have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following&quot;:&quot;Have you ever experienced any unusual reaction to any of the following?&quot;,&quot;or_any_other_medicine__if_yes_please_explain:&quot;:&quot;Or any other medicine? If yes, please explain:&quot;,&quot;Have_you_been_warned_against_taking_any_drug_or_medication&quot;:&quot;Have you been warned against taking any drug or medication? &quot;,&quot;do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply&quot;:&quot;Do you have or have you ever had any of the following? (please mark any\\\/all that apply)&quot;,&quot;other:&quot;:&quot;Other:&quot;,&quot;Have_you_ever_had_any_known_contact_with_the_Aids_Virus&quot;:&quot;Have you ever had any known contact with the Aids Virus?&quot;,&quot;Has_any_member_of_your_family_had_diabetes&quot;:&quot;Has any member of your family had diabetes&quot;,&quot;Do_you_bruise_easily_or_bleed_abnormally&quot;:&quot;Do you bruise easily or bleed abnormally?&quot;,&quot;Do_your_ankles_swell_during_the_day&quot;:&quot;Do your ankles swell during the day?&quot;,&quot;Have_you_had_any_weight_changes_recently&quot;:&quot;Have you had any weight changes recently?&quot;,&quot;Do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)&quot;:&quot;Do you have any blood disorders such as anaemia (thin blood)?&quot;,&quot;Have_you_ever_had_radiation_treatment_or_chemotherapy&quot;:&quot;Have you ever had radiation treatment or chemotherapy?&quot;,&quot;Have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws&quot;:&quot;Have you ever had any injury, surgery or x-ray therapy to your face or jaws?&quot;,&quot;Do_you_have_frequent_severe_headaches&quot;:&quot;Do you have frequent severe headaches?&quot;,&quot;Do_you_have_frequent_earaches,_ear\\\/throat_infections_or_any_hearing_difficulties&quot;:&quot;Do you have frequent earaches, ear\\\/throat infections or any hearing difficulties?&quot;,&quot;is_your_eyesight:&quot;:&quot;Is your eyesight:&quot;,&quot;Are_you_on_a_special_diet&quot;:&quot;Are you on a special diet?&quot;,&quot;Have_you_ever_fainted&quot;:&quot;Have you ever fainted?&quot;,&quot;Do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs&quot;:&quot;Do you ever experience shortness of breath or pain in your chest when taking a walk or climbing stairs?&quot;,&quot;Do_you_have_any_medical_or_dental_implants&quot;:&quot;Do you have any medical or dental implants?&quot;,&quot;do_you_have_any_disease_condition_or_problem_not_listed_above_that_you_think_the_doctor_should_know_about&quot;:&quot;Do you have any disease, condition or problem not listed above that you think the doctor should know about?&quot;,&quot;is_there_anything_about_yourself_that_we_should_be_made_aware_of&quot;:&quot;Is there anything about yourself that we should be made aware of?&quot;,&quot;WOMEN_ONLY_-_Are_you_pregnant?&quot;:&quot;WOMEN ONLY - Are you pregnant?&quot;,&quot;If_so_which_month_are_you_in&quot;:&quot; If so, which month are you in?&quot;,&quot;Are_you_taking_any_birth_control_pills&quot;:&quot;Are you taking any birth control pills?&quot;,&quot;how_frequently_do_you_see_your_dentist&quot;:&quot;How frequently do you see your dentist?&quot;,&quot;last_dental_visit&quot;:&quot;Last dental visit?&quot;,&quot;Last_cleaning&quot;:&quot; Last cleaning?&quot;,&quot;Last_full_mouth_series_of_x-rays&quot;:&quot;Last full mouth series of x-rays?&quot;,&quot;Have_you_been_given_oral_hygiene_instruction_in:&quot;:&quot;Have you been given oral hygiene instruction in:&quot;,&quot;Are_any_of_your_teeth_sensitive_to:&quot;:&quot;Are any of your teeth sensitive to:&quot;,&quot;Do_your_gums_bleed_when:&quot;:&quot;Do your gums bleed when:&quot;,&quot;Have_you_ever_had_any_of_the_following:&quot;:&quot;Have you ever had any of the following:&quot;,&quot;Do_you_have_any_dental_implants&quot;:&quot;Do you have any dental implants?&quot;,&quot;Do_you_suffer_from_pain_and\\\/or_swelling_of_your_gums&quot;:&quot;Do you suffer from pain and\\\/or swelling of your gums?&quot;,&quot;Are_you_aware_of_any_loose_teeth&quot;:&quot;Are you aware of any loose teeth?&quot;,&quot;if_yes_where&quot;:&quot;If yes, where?&quot;,&quot;Do_you_chew_on_only_one_side_of_your_mouth&quot;:&quot;Do you chew on only one side of your mouth?&quot;,&quot;If_so_why&quot;:&quot;If so, why?&quot;,&quot;do_you_grind_or_clench_your_teeth_during_the_day_or_night&quot;:&quot;Do you grind or clench your teeth during the day or night?&quot;,&quot;do_you_mouth_breathe_while_awake_or_asleep&quot;:&quot;Do you mouth breathe while awake or asleep?&quot;,&quot;do_you_bite_your_lips_or_cheeks_regularly&quot;:&quot;Do you bite your lips or cheeks regularly?&quot;,&quot;do_you_hold_any_foreign_objects_with_your_teeth&quot;:&quot;Do you hold any foreign objects with your teeth?&quot;,&quot;Does_any_part_of_your_mouth_hurt_when_clenched&quot;:&quot;Does any part of your mouth hurt when clenched?&quot;,&quot;Does_your_jaw_crack_or_pop_when_opened_widely&quot;:&quot;Does your jaw crack or pop when opened widely?&quot;,&quot;Do_you_have_any_difficulty_in_opening_or_closing_your_jaw&quot;:&quot;Do you have any difficulty in opening or closing your jaw?&quot;,&quot;Do_you_have_any_pain_in_your_ears&quot;:&quot;Do you have any pain in your ears?&quot;,&quot;Do_you_gag_easily&quot;:&quot;Do you gag easily?&quot;,&quot;Have_you_experienced_any_growth_or_sore_spots_in_your_mouth&quot;:&quot;Have you experienced any growth or sore spots in your mouth?&quot;,&quot;is_yes_where&quot;:&quot;Is yes, where?&quot;,&quot;Are_you_concerned_about_the_appearance_of_your_teeth&quot;:&quot;Are you concerned about the appearance of your teeth?&quot;,&quot;if_yes_what_would_you_like_to_see_changed&quot;:&quot;If yes, what would you like to see changed?&quot;,&quot;Would_you_rate_your_current_dental_health_as&quot;:&quot;Would you rate your current dental health as:&quot;,&quot;Is_your_sugar_intake&quot;:&quot;Is your sugar intake:&quot;,&quot;Brushing&quot;:&quot;Brushing: &quot;,&quot;how_often&quot;:&quot;How often?&quot;,&quot;cleaning_aids_presently_used:&quot;:&quot;Cleaning aids presently used:&quot;,&quot;Do_you_have_any_emotional_concerns_regarding_your_dental_visit&quot;:&quot;Do you have any emotional concerns regarding your dental visit?&quot;},&quot;field_logics&quot;:{&quot;date&quot;:&quot;&quot;,&quot;are_you_the&quot;:&quot;&quot;,&quot;salutation&quot;:&quot;&quot;,&quot;first_name&quot;:&quot;&quot;,&quot;last_name&quot;:&quot;&quot;,&quot;initial&quot;:&quot;&quot;,&quot;Prefers_to_be_called&quot;:&quot;&quot;,&quot;address&quot;:&quot;&quot;,&quot;city&quot;:&quot;&quot;,&quot;province&quot;:&quot;&quot;,&quot;date_of_birth&quot;:&quot;&quot;,&quot;age&quot;:&quot;&quot;,&quot;&quot;:&quot;&quot;,&quot;home_phone&quot;:&quot;&quot;,&quot;cell_phone&quot;:&quot;&quot;,&quot;family_physician&quot;:&quot;&quot;,&quot;family_physician_phone&quot;:&quot;&quot;,&quot;medical_specialist_if_under_present_care&quot;:&quot;&quot;,&quot;medical_specialist_phone&quot;:&quot;&quot;,&quot;person_responsible_for_account&quot;:&quot;&quot;,&quot;person_responsible_name&quot;:&quot;&quot;,&quot;person_responsible_phone_number&quot;:&quot;&quot;,&quot;person_responsible_address&quot;:&quot;&quot;,&quot;person_responsible_employer&quot;:&quot;&quot;,&quot;person_responsible_work_phone&quot;:&quot;&quot;,&quot;person_responsible_work_phone_extension&quot;:&quot;&quot;,&quot;your_occupation&quot;:&quot;&quot;,&quot;your_employer&quot;:&quot;&quot;,&quot;your_work_phone&quot;:&quot;&quot;,&quot;your_work_phone_extension&quot;:&quot;&quot;,&quot;spouse_employer&quot;:&quot;&quot;,&quot;spouse_work_phone&quot;:&quot;&quot;,&quot;spouse_work_phone_extension&quot;:&quot;&quot;,&quot;dental_insurance&quot;:&quot;&quot;,&quot;insurance_company_name&quot;:&quot;&quot;,&quot;group_policy-number&quot;:&quot;&quot;,&quot;certificate-number&quot;:&quot;&quot;,&quot;secondary_group_policy-number&quot;:&quot;&quot;,&quot;secondary_certificate-number&quot;:&quot;&quot;,&quot;basic&quot;:&quot;&quot;,&quot;major&quot;:&quot;&quot;,&quot;preventive&quot;:&quot;&quot;,&quot;ortho&quot;:&quot;&quot;,&quot;in_case_of_emergency_please_notify&quot;:&quot;&quot;,&quot;Relationship&quot;:&quot;&quot;,&quot;emergency_contact_phone&quot;:&quot;&quot;,&quot;Closest_Family_Relative&quot;:&quot;&quot;,&quot;Closest_Family_Relative_Phone_Number&quot;:&quot;&quot;,&quot;Referral_Name&quot;:&quot;&quot;,&quot;Closest_ Family_ Relative_Phone_Number&quot;:&quot;&quot;,&quot;reason_for_todays_visit&quot;:&quot;&quot;,&quot;Is_there_a_dental_problem_you_would_like_taken_care_as_soon_as_possible&quot;:&quot;&quot;,&quot;have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care&quot;:&quot;&quot;,&quot;if_yes_please_explain:&quot;:&quot;&quot;,&quot;Are_you_presently_under_the_care_of_a_physician&quot;:&quot;&quot;,&quot;Have_you_been_hospitalized_in_the_last_2_years&quot;:&quot;&quot;,&quot;Have_you_had_a_medical_examination_in_the_last_year&quot;:&quot;&quot;,&quot;Do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly&quot;:&quot;&quot;,&quot;if_yes_please_specify:&quot;:&quot;&quot;,&quot;Do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies&quot;:&quot;&quot;,&quot;If_yes,_please_explain&quot;:&quot;&quot;,&quot;Do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea&quot;:&quot;&quot;,&quot;If_yes,_please_specify:&quot;:&quot;&quot;,&quot;have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following&quot;:&quot;&quot;,&quot;or_any_other_medicine__if_yes_please_explain:&quot;:&quot;&quot;,&quot;Have_you_been_warned_against_taking_any_drug_or_medication&quot;:&quot;&quot;,&quot;do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply&quot;:&quot;&quot;,&quot;other:&quot;:&quot;&quot;,&quot;Have_you_ever_had_any_known_contact_with_the_Aids_Virus&quot;:&quot;&quot;,&quot;Has_any_member_of_your_family_had_diabetes&quot;:&quot;&quot;,&quot;Do_you_bruise_easily_or_bleed_abnormally&quot;:&quot;&quot;,&quot;Do_your_ankles_swell_during_the_day&quot;:&quot;&quot;,&quot;Have_you_had_any_weight_changes_recently&quot;:&quot;&quot;,&quot;Do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)&quot;:&quot;&quot;,&quot;Have_you_ever_had_radiation_treatment_or_chemotherapy&quot;:&quot;&quot;,&quot;Have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws&quot;:&quot;&quot;,&quot;Do_you_have_frequent_severe_headaches&quot;:&quot;&quot;,&quot;Do_you_have_frequent_earaches,_ear\\\/throat_infections_or_any_hearing_difficulties&quot;:&quot;&quot;,&quot;is_your_eyesight:&quot;:&quot;&quot;,&quot;Are_you_on_a_special_diet&quot;:&quot;&quot;,&quot;Have_you_ever_fainted&quot;:&quot;&quot;,&quot;Do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs&quot;:&quot;&quot;,&quot;Do_you_have_any_medical_or_dental_implants&quot;:&quot;&quot;,&quot;do_you_have_any_disease_condition_or_problem_not_listed_above_that_you_think_the_doctor_should_know_about&quot;:&quot;&quot;,&quot;is_there_anything_about_yourself_that_we_should_be_made_aware_of&quot;:&quot;&quot;,&quot;WOMEN_ONLY_-_Are_you_pregnant?&quot;:&quot;&quot;,&quot;If_so_which_month_are_you_in&quot;:&quot;&quot;,&quot;Are_you_taking_any_birth_control_pills&quot;:&quot;&quot;,&quot;how_frequently_do_you_see_your_dentist&quot;:&quot;&quot;,&quot;last_dental_visit&quot;:&quot;&quot;,&quot;Last_cleaning&quot;:&quot;&quot;,&quot;Last_full_mouth_series_of_x-rays&quot;:&quot;&quot;,&quot;Have_you_been_given_oral_hygiene_instruction_in:&quot;:&quot;&quot;,&quot;Are_any_of_your_teeth_sensitive_to:&quot;:&quot;&quot;,&quot;Do_your_gums_bleed_when:&quot;:&quot;&quot;,&quot;Have_you_ever_had_any_of_the_following:&quot;:&quot;&quot;,&quot;Do_you_have_any_dental_implants&quot;:&quot;&quot;,&quot;Do_you_suffer_from_pain_and\\\/or_swelling_of_your_gums&quot;:&quot;&quot;,&quot;Are_you_aware_of_any_loose_teeth&quot;:&quot;&quot;,&quot;if_yes_where&quot;:&quot;&quot;,&quot;Do_you_chew_on_only_one_side_of_your_mouth&quot;:&quot;&quot;,&quot;If_so_why&quot;:&quot;&quot;,&quot;do_you_grind_or_clench_your_teeth_during_the_day_or_night&quot;:&quot;&quot;,&quot;do_you_mouth_breathe_while_awake_or_asleep&quot;:&quot;&quot;,&quot;do_you_bite_your_lips_or_cheeks_regularly&quot;:&quot;&quot;,&quot;do_you_hold_any_foreign_objects_with_your_teeth&quot;:&quot;&quot;,&quot;Does_any_part_of_your_mouth_hurt_when_clenched&quot;:&quot;&quot;,&quot;Does_your_jaw_crack_or_pop_when_opened_widely&quot;:&quot;&quot;,&quot;Do_you_have_any_difficulty_in_opening_or_closing_your_jaw&quot;:&quot;&quot;,&quot;Do_you_have_any_pain_in_your_ears&quot;:&quot;&quot;,&quot;Do_you_gag_easily&quot;:&quot;&quot;,&quot;Have_you_experienced_any_growth_or_sore_spots_in_your_mouth&quot;:&quot;&quot;,&quot;is_yes_where&quot;:&quot;&quot;,&quot;Are_you_concerned_about_the_appearance_of_your_teeth&quot;:&quot;&quot;,&quot;if_yes_what_would_you_like_to_see_changed&quot;:&quot;&quot;,&quot;Would_you_rate_your_current_dental_health_as&quot;:&quot;&quot;,&quot;Is_your_sugar_intake&quot;:&quot;&quot;,&quot;Brushing&quot;:&quot;&quot;,&quot;how_often&quot;:&quot;&quot;,&quot;cleaning_aids_presently_used:&quot;:&quot;&quot;,&quot;Do_you_have_any_emotional_concerns_regarding_your_dental_visit&quot;:&quot;&quot;}}\"><form action=\"https:\/\/conroydentalcentre.com\/new-patient-form\/\" method=\"post\" class=\"fusion-form fusion-form-1671\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><style type=\"text\/css\">@media only screen and (max-width:1024px) {.fusion-title.fusion-title-6{margin-top:0px!important; margin-right:0px!important;margin-bottom:!important;margin-left:0px!important;}}@media only screen and (max-width:640px) {.fusion-title.fusion-title-6{margin-top:0px!important; margin-right:0px!important;margin-bottom:20px!important; margin-left:0px!important;}}<\/style><div class=\"fusion-title title fusion-title-6 fusion-sep-none fusion-title-text fusion-title-size-three\" style=\"margin-top:0px;margin-right:0px;margin-left:0px;\"><h3 class=\"title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:34;line-height:1.29;\">General Information<\/h3><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-68 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 15px 35px 7px 35px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"1671\"><label for=\"date\">Date <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><input autocomplete=\"no\" type=\"date\" data-format=\"\" tabindex=\"\" id=\"date\" name=\"date\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-68{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-68 > .fusion-column-wrapper {padding-top : 15px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 7px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-68{width:100% !important;order : 0;}.fusion-builder-nested-column-68 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-68{width:100% !important;order : 0;}.fusion-builder-nested-column-68 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-69 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 15px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you the <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-are_you_the-50-0\" type=\"radio\" value=\"Patient\" name=\"are_you_the\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_the-50-0\">Patient<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-are_you_the-50-1\" type=\"radio\" value=\"Parent (Guardian)\" name=\"are_you_the\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_the-50-1\">Parent (Guardian)<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-69{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-69 > .fusion-column-wrapper {padding-top : 15px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-69{width:100% !important;order : 0;}.fusion-builder-nested-column-69 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-69{width:100% !important;order : 0;}.fusion-builder-nested-column-69 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-70 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 23px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Salutation <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-salutation-51-0\" type=\"radio\" value=\"Dr.\" name=\"salutation\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-salutation-51-0\">Dr.<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-salutation-51-1\" type=\"radio\" value=\"Mr.\" name=\"salutation\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-salutation-51-1\">Mr.<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-salutation-51-2\" type=\"radio\" value=\"Mrs.\" name=\"salutation\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-salutation-51-2\">Mrs.<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-salutation-51-3\" type=\"radio\" value=\"Ms\" name=\"salutation\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-salutation-51-3\">Ms<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-salutation-51-4\" type=\"radio\" value=\"Miss\" name=\"salutation\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-salutation-51-4\">Miss<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-70{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-70 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 23px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-70{width:100% !important;order : 0;}.fusion-builder-nested-column-70 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-70{width:100% !important;order : 0;}.fusion-builder-nested-column-70 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-71 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"first_name\">First Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"first_name\" id=\"first_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-71{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-71 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-71{width:100% !important;order : 0;}.fusion-builder-nested-column-71 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-71{width:100% !important;order : 0;}.fusion-builder-nested-column-71 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-72 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"last_name\">Last Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"last_name\" id=\"last_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-72{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-72 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-72{width:100% !important;order : 0;}.fusion-builder-nested-column-72 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-72{width:100% !important;order : 0;}.fusion-builder-nested-column-72 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-73 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"initial\">Initial<\/label><\/div><input type=\"text\" name=\"initial\" id=\"initial\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-73{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-73 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-73{width:100% !important;order : 0;}.fusion-builder-nested-column-73 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-73{width:100% !important;order : 0;}.fusion-builder-nested-column-73 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-74 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Prefers_to_be_called\">Prefers to be called (if different from above)<\/label><\/div><input type=\"text\" name=\"Prefers_to_be_called\" id=\"Prefers_to_be_called\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-74{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-74 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-74{width:100% !important;order : 0;}.fusion-builder-nested-column-74 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-74{width:100% !important;order : 0;}.fusion-builder-nested-column-74 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-75 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"address\">Address<\/label><\/div><input type=\"text\" name=\"address\" id=\"address\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-75{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-75 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-75{width:100% !important;order : 0;}.fusion-builder-nested-column-75 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-75{width:100% !important;order : 0;}.fusion-builder-nested-column-75 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-76 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"city\">City<\/label><\/div><input type=\"text\" name=\"city\" id=\"city\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-76{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-76 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-76{width:100% !important;order : 0;}.fusion-builder-nested-column-76 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-76{width:100% !important;order : 0;}.fusion-builder-nested-column-76 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-77 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"province\">Province<\/label><\/div><input type=\"text\" name=\"province\" id=\"province\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-77{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-77 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-77{width:100% !important;order : 0;}.fusion-builder-nested-column-77 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-77{width:100% !important;order : 0;}.fusion-builder-nested-column-77 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-78 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"province\">Postal Code<\/label><\/div><input type=\"text\" name=\"province\" id=\"province\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-78{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-78 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-78{width:100% !important;order : 0;}.fusion-builder-nested-column-78 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-78{width:100% !important;order : 0;}.fusion-builder-nested-column-78 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-79 fusion_builder_column_inner_1_4 1_4 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"1671\"><label for=\"date_of_birth\">Date of Birth<\/label><input autocomplete=\"no\" type=\"date\" data-format=\"\" tabindex=\"\" id=\"date_of_birth\" name=\"date_of_birth\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-79{width:25% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-79 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 7.68%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-79{width:100% !important;order : 0;}.fusion-builder-nested-column-79 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-79{width:100% !important;order : 0;}.fusion-builder-nested-column-79 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-80 fusion_builder_column_inner_1_4 1_4 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"age\">Age <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"age\" id=\"age\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-80{width:25% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-80 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-80{width:100% !important;order : 0;}.fusion-builder-nested-column-80 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-80{width:100% !important;order : 0;}.fusion-builder-nested-column-80 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-81 fusion_builder_column_inner_1_4 1_4 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"\">Sex<\/label><\/div><input type=\"text\" name=\"\" id=\"\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-81{width:25% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-81 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-81{width:100% !important;order : 0;}.fusion-builder-nested-column-81 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-81{width:100% !important;order : 0;}.fusion-builder-nested-column-81 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-82 fusion_builder_column_inner_1_4 1_4 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"\">Marital Status<\/label><\/div><input type=\"text\" name=\"\" id=\"\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-82{width:25% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-82 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 7.68%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-82{width:100% !important;order : 0;}.fusion-builder-nested-column-82 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-82{width:100% !important;order : 0;}.fusion-builder-nested-column-82 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-83 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"home_phone\">Home Phone <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"home_phone\" id=\"home_phone\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-83{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-83 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-83{width:100% !important;order : 0;}.fusion-builder-nested-column-83 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-83{width:100% !important;order : 0;}.fusion-builder-nested-column-83 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-84 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"cell_phone\">Cell Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone_android\"><\/i><input type=\"phone-number\" name=\"cell_phone\" id=\"cell_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-84{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-84 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-84{width:100% !important;order : 0;}.fusion-builder-nested-column-84 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-84{width:100% !important;order : 0;}.fusion-builder-nested-column-84 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-85 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"family_physician\">Family Physician<\/label><\/div><input type=\"text\" name=\"family_physician\" id=\"family_physician\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-85{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-85 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-85{width:100% !important;order : 0;}.fusion-builder-nested-column-85 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-85{width:100% !important;order : 0;}.fusion-builder-nested-column-85 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-86 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"family_physician_phone\">Family Physician Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"family_physician_phone\" id=\"family_physician_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-86{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-86 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-86{width:100% !important;order : 0;}.fusion-builder-nested-column-86 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-86{width:100% !important;order : 0;}.fusion-builder-nested-column-86 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-87 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"medical_specialist_if_under_present_care\">Medical Specialist (if under present care)<\/label><\/div><input type=\"text\" name=\"medical_specialist_if_under_present_care\" id=\"medical_specialist_if_under_present_care\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-87{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-87 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-87{width:100% !important;order : 0;}.fusion-builder-nested-column-87 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-87{width:100% !important;order : 0;}.fusion-builder-nested-column-87 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-88 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"medical_specialist_phone\">Medical Specialist Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"medical_specialist_phone\" id=\"medical_specialist_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-88{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-88 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-88{width:100% !important;order : 0;}.fusion-builder-nested-column-88 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-88{width:100% !important;order : 0;}.fusion-builder-nested-column-88 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-89 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Person Responsible for Account<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-person_responsible_for_account-52-0\" type=\"radio\" value=\"Self\" name=\"person_responsible_for_account\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-person_responsible_for_account-52-0\">Self<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-person_responsible_for_account-52-1\" type=\"radio\" value=\"Spouse\" name=\"person_responsible_for_account\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-person_responsible_for_account-52-1\">Spouse<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-person_responsible_for_account-52-2\" type=\"radio\" value=\"Other\" name=\"person_responsible_for_account\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-person_responsible_for_account-52-2\">Other<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-89{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-89 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-89{width:100% !important;order : 0;}.fusion-builder-nested-column-89 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-89{width:100% !important;order : 0;}.fusion-builder-nested-column-89 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-90 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"person_responsible_name\">Name<\/label><\/div><input type=\"text\" name=\"person_responsible_name\" id=\"person_responsible_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-90{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-90 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-90{width:100% !important;order : 0;}.fusion-builder-nested-column-90 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-90{width:100% !important;order : 0;}.fusion-builder-nested-column-90 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-91 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"person_responsible_phone_number\">Phone Number<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"person_responsible_phone_number\" id=\"person_responsible_phone_number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-91{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-91 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-91{width:100% !important;order : 0;}.fusion-builder-nested-column-91 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-91{width:100% !important;order : 0;}.fusion-builder-nested-column-91 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-92 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"person_responsible_address\">Address<\/label><\/div><input type=\"text\" name=\"person_responsible_address\" id=\"person_responsible_address\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-92{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-92 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-92{width:100% !important;order : 0;}.fusion-builder-nested-column-92 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-92{width:100% !important;order : 0;}.fusion-builder-nested-column-92 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-93 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"person_responsible_employer\">Employer<\/label><\/div><input type=\"text\" name=\"person_responsible_employer\" id=\"person_responsible_employer\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-93{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-93 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-93{width:100% !important;order : 0;}.fusion-builder-nested-column-93 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-93{width:100% !important;order : 0;}.fusion-builder-nested-column-93 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-94 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"person_responsible_work_phone\">Work Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"person_responsible_work_phone\" id=\"person_responsible_work_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-94{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-94 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-94{width:100% !important;order : 0;}.fusion-builder-nested-column-94 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-94{width:100% !important;order : 0;}.fusion-builder-nested-column-94 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-95 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"person_responsible_work_phone_extension\">Extension<\/label><\/div><input type=\"number\" name=\"person_responsible_work_phone_extension\" id=\"person_responsible_work_phone_extension\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" min=\"0\" max=\"1000000\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-95{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-95 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-95{width:100% !important;order : 0;}.fusion-builder-nested-column-95 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-95{width:100% !important;order : 0;}.fusion-builder-nested-column-95 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-96 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 17px 35px 0px 35px;\"><div class=\"fusion-text fusion-text-6\"><p style=\"text-align: center;\"><b>(Above information to be completed only if person responsible for account is other than self)<\/b><\/p>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-96{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-96 > .fusion-column-wrapper {padding-top : 17px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-96{width:100% !important;order : 0;}.fusion-builder-nested-column-96 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-96{width:100% !important;order : 0;}.fusion-builder-nested-column-96 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-97 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"your_occupation\">Your Occupation<\/label><\/div><input type=\"text\" name=\"your_occupation\" id=\"your_occupation\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-97{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-97 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-97{width:100% !important;order : 0;}.fusion-builder-nested-column-97 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-97{width:100% !important;order : 0;}.fusion-builder-nested-column-97 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-98 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"your_employer\">Your Employer<\/label><\/div><input type=\"text\" name=\"your_employer\" id=\"your_employer\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-98{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-98 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-98{width:100% !important;order : 0;}.fusion-builder-nested-column-98 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-98{width:100% !important;order : 0;}.fusion-builder-nested-column-98 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-99 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"your_work_phone\">Work Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"your_work_phone\" id=\"your_work_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-99{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-99 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-99{width:100% !important;order : 0;}.fusion-builder-nested-column-99 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-99{width:100% !important;order : 0;}.fusion-builder-nested-column-99 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-100 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"your_work_phone_extension\">Extension<\/label><\/div><input type=\"number\" name=\"your_work_phone_extension\" id=\"your_work_phone_extension\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" min=\"0\" max=\"1000000\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-100{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-100 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-100{width:100% !important;order : 0;}.fusion-builder-nested-column-100 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-100{width:100% !important;order : 0;}.fusion-builder-nested-column-100 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-101 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"spouse_employer\">Spouse Employer<\/label><\/div><input type=\"text\" name=\"spouse_employer\" id=\"spouse_employer\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-101{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-101 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-101{width:100% !important;order : 0;}.fusion-builder-nested-column-101 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-101{width:100% !important;order : 0;}.fusion-builder-nested-column-101 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-102 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"spouse_work_phone\">Work Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"spouse_work_phone\" id=\"spouse_work_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-102{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-102 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-102{width:100% !important;order : 0;}.fusion-builder-nested-column-102 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-102{width:100% !important;order : 0;}.fusion-builder-nested-column-102 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-103 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"spouse_work_phone_extension\">Extension<\/label><\/div><input type=\"number\" name=\"spouse_work_phone_extension\" id=\"spouse_work_phone_extension\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" min=\"0\" max=\"1000000\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-103{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-103 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-103{width:100% !important;order : 0;}.fusion-builder-nested-column-103 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-103{width:100% !important;order : 0;}.fusion-builder-nested-column-103 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-104 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Dental Insurance<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-dental_insurance-53-0\" type=\"radio\" value=\"Yes\" name=\"dental_insurance\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-dental_insurance-53-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-dental_insurance-53-1\" type=\"radio\" value=\"No\" name=\"dental_insurance\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-dental_insurance-53-1\">No<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-104{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-104 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-104{width:100% !important;order : 0;}.fusion-builder-nested-column-104 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-104{width:100% !important;order : 0;}.fusion-builder-nested-column-104 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-105 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"insurance_company_name\">Insurance Company Name<\/label><\/div><input type=\"text\" name=\"insurance_company_name\" id=\"insurance_company_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-105{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-105 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-105{width:100% !important;order : 0;}.fusion-builder-nested-column-105 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-105{width:100% !important;order : 0;}.fusion-builder-nested-column-105 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-106 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"group_policy-number\">Group Policy No.<\/label><\/div><input type=\"text\" name=\"group_policy-number\" id=\"group_policy-number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-106{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-106 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-106{width:100% !important;order : 0;}.fusion-builder-nested-column-106 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-106{width:100% !important;order : 0;}.fusion-builder-nested-column-106 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-107 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"certificate-number\">Certif. No.<\/label><\/div><input type=\"text\" name=\"certificate-number\" id=\"certificate-number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-107{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-107 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-107{width:100% !important;order : 0;}.fusion-builder-nested-column-107 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-107{width:100% !important;order : 0;}.fusion-builder-nested-column-107 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-108 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"certificate-number\">Secondary Insurance<\/label><\/div><input type=\"text\" name=\"certificate-number\" id=\"certificate-number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-108{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-108 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-108{width:100% !important;order : 0;}.fusion-builder-nested-column-108 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-108{width:100% !important;order : 0;}.fusion-builder-nested-column-108 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-109 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"secondary_group_policy-number\">Group Policy No.<\/label><\/div><input type=\"text\" name=\"secondary_group_policy-number\" id=\"secondary_group_policy-number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-109{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-109 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-109{width:100% !important;order : 0;}.fusion-builder-nested-column-109 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-109{width:100% !important;order : 0;}.fusion-builder-nested-column-109 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-110 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"secondary_certificate-number\">Certif. No.<\/label><\/div><input type=\"text\" name=\"secondary_certificate-number\" id=\"secondary_certificate-number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-110{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-110 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-110{width:100% !important;order : 0;}.fusion-builder-nested-column-110 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-110{width:100% !important;order : 0;}.fusion-builder-nested-column-110 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-111 fusion_builder_column_inner_1_5 1_5 fusion-flex-column fusion-flex-align-self-center\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 57px 0px 41px 0px;\"><div class=\"fusion-text fusion-text-7\" style=\"text-align:center;\"><p>% of coverage<\/p>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-111{width:20% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-111 > .fusion-column-wrapper {padding-top : 57px !important;padding-right : 0px !important;margin-right : 0%;padding-bottom : 41px !important;padding-left : 0px !important;margin-left : 9.6%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-111{width:100% !important;order : 0;}.fusion-builder-nested-column-111 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-111{width:100% !important;order : 0;}.fusion-builder-nested-column-111 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-112 fusion_builder_column_inner_1_5 1_5 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 21px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"basic\">Basic<\/label><\/div><input type=\"text\" name=\"basic\" id=\"basic\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-112{width:20% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-112 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 21px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-112{width:100% !important;order : 0;}.fusion-builder-nested-column-112 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-112{width:100% !important;order : 0;}.fusion-builder-nested-column-112 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-113 fusion_builder_column_inner_1_5 1_5 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 21px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"major\">Major<\/label><\/div><input type=\"text\" name=\"major\" id=\"major\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-113{width:20% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-113 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 21px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-113{width:100% !important;order : 0;}.fusion-builder-nested-column-113 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-113{width:100% !important;order : 0;}.fusion-builder-nested-column-113 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-114 fusion_builder_column_inner_1_5 1_5 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 21px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"preventive\">Preventive<\/label><\/div><input type=\"text\" name=\"preventive\" id=\"preventive\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-114{width:20% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-114 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 21px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-114{width:100% !important;order : 0;}.fusion-builder-nested-column-114 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-114{width:100% !important;order : 0;}.fusion-builder-nested-column-114 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-115 fusion_builder_column_inner_1_5 1_5 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 21px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"ortho\">Ortho<\/label><\/div><input type=\"text\" name=\"ortho\" id=\"ortho\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-115{width:20% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-115 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 9.6%;padding-bottom : 21px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-115{width:100% !important;order : 0;}.fusion-builder-nested-column-115 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-115{width:100% !important;order : 0;}.fusion-builder-nested-column-115 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">@media only screen and (max-width:1024px) {.fusion-title.fusion-title-7{margin-top:40px!important; margin-right:0px!important;margin-bottom:40px!important;margin-left:0px!important;}}@media only screen and (max-width:640px) {.fusion-title.fusion-title-7{margin-top:0px!important; margin-right:0px!important;margin-bottom:20px!important; margin-left:0px!important;}}<\/style><div class=\"fusion-title title fusion-title-7 fusion-sep-none fusion-title-text fusion-title-size-three\" style=\"margin-top:40px;margin-right:0px;margin-bottom:40px;margin-left:0px;\"><h3 class=\"title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:34;line-height:1.29;\">Medical Information<\/h3><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-116 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 15px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"in_case_of_emergency_please_notify\">In case of emergency, please notify<\/label><\/div><input type=\"text\" name=\"in_case_of_emergency_please_notify\" id=\"in_case_of_emergency_please_notify\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-116{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-116 > .fusion-column-wrapper {padding-top : 15px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-116{width:100% !important;order : 0;}.fusion-builder-nested-column-116 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-116{width:100% !important;order : 0;}.fusion-builder-nested-column-116 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-117 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Relationship\">Relationship<\/label><\/div><input type=\"text\" name=\"Relationship\" id=\"Relationship\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-117{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-117 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-117{width:100% !important;order : 0;}.fusion-builder-nested-column-117 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-117{width:100% !important;order : 0;}.fusion-builder-nested-column-117 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-118 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"emergency_contact_phone\">Phone Number<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"emergency_contact_phone\" id=\"emergency_contact_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-118{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-118 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-118{width:100% !important;order : 0;}.fusion-builder-nested-column-118 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-118{width:100% !important;order : 0;}.fusion-builder-nested-column-118 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-119 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Closest_Family_Relative\">Closest Family Relative<\/label><\/div><input type=\"text\" name=\"Closest_Family_Relative\" id=\"Closest_Family_Relative\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-119{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-119 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-119{width:100% !important;order : 0;}.fusion-builder-nested-column-119 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-119{width:100% !important;order : 0;}.fusion-builder-nested-column-119 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-120 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Closest_Family_Relative_Phone_Number\">Phone Number<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"icon-materialphone\"><\/i><input type=\"phone-number\" name=\"Closest_Family_Relative_Phone_Number\" id=\"Closest_Family_Relative_Phone_Number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-120{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-120 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-120{width:100% !important;order : 0;}.fusion-builder-nested-column-120 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-120{width:100% !important;order : 0;}.fusion-builder-nested-column-120 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-121 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Referral_Name\">Whom may we thank for referring you?<\/label><\/div><input type=\"text\" name=\"Referral_Name\" id=\"Referral_Name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-121{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-121 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-121{width:100% !important;order : 0;}.fusion-builder-nested-column-121 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-121{width:100% !important;order : 0;}.fusion-builder-nested-column-121 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-122 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Closest_ Family_ Relative_Phone_Number\">Is a member of your family\/relative a patient at our office?<\/label><\/div><input type=\"text\" name=\"Closest_ Family_ Relative_Phone_Number\" id=\"Closest_ Family_ Relative_Phone_Number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-122{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-122 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-122{width:100% !important;order : 0;}.fusion-builder-nested-column-122 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-122{width:100% !important;order : 0;}.fusion-builder-nested-column-122 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-123 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Reason for today&#039;s visit?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-reason_for_todays_visit-54-0\" type=\"radio\" value=\"Examination\" name=\"reason_for_todays_visit\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-reason_for_todays_visit-54-0\">Examination<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-reason_for_todays_visit-54-1\" type=\"radio\" value=\"Emergency\" name=\"reason_for_todays_visit\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-reason_for_todays_visit-54-1\">Emergency<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-reason_for_todays_visit-54-2\" type=\"radio\" value=\"Other\" name=\"reason_for_todays_visit\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-reason_for_todays_visit-54-2\">Other<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-123{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-123 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-123{width:100% !important;order : 0;}.fusion-builder-nested-column-123 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-123{width:100% !important;order : 0;}.fusion-builder-nested-column-123 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-124 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"1671\"><label for=\"Is_there_a_dental_problem_you_would_like_taken_care_as_soon_as_possible\">Is there a dental problem you would like taken care as soon as possible?<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"Is_there_a_dental_problem_you_would_like_taken_care_as_soon_as_possible\" name=\"Is_there_a_dental_problem_you_would_like_taken_care_as_soon_as_possible\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-124{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-124 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-124{width:100% !important;order : 0;}.fusion-builder-nested-column-124 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-124{width:100% !important;order : 0;}.fusion-builder-nested-column-124 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-125 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 26px 35px 0px 35px;\"><div class=\"fusion-text fusion-text-8\"><p style=\"font-size: 20px;\" data-fusion-font=\"true\"><b style=\"color: #000000;\">The following information is required by the dentist to assist in proper diagnosis and treatment.<\/b><\/p>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-125{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-125 > .fusion-column-wrapper {padding-top : 26px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-125{width:100% !important;order : 0;}.fusion-builder-nested-column-125 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-125{width:100% !important;order : 0;}.fusion-builder-nested-column-125 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-126 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever had a serious illness requiring hospitalization or extensive medical care?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care-55-0\" type=\"radio\" value=\"Yes\" name=\"have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care-55-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care-55-1\" type=\"radio\" value=\"No\" name=\"have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_a_serious_illness_requiring_hospitalization_or_extensive_medical_care-55-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_please_explain:\">If yes, please explain:<\/label><\/div><input type=\"text\" name=\"if_yes_please_explain:\" id=\"if_yes_please_explain:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-126{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-126 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-126{width:100% !important;order : 0;}.fusion-builder-nested-column-126 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-126{width:100% !important;order : 0;}.fusion-builder-nested-column-126 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-127 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you presently under the care of a physician?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_presently_under_the_care_of_a_physician-56-0\" type=\"radio\" value=\"Yes\" name=\"Are_you_presently_under_the_care_of_a_physician\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_presently_under_the_care_of_a_physician-56-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_presently_under_the_care_of_a_physician-56-1\" type=\"radio\" value=\"No\" name=\"Are_you_presently_under_the_care_of_a_physician\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_presently_under_the_care_of_a_physician-56-1\">No<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-127{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-127 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-127{width:100% !important;order : 0;}.fusion-builder-nested-column-127 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-127{width:100% !important;order : 0;}.fusion-builder-nested-column-127 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-128 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 33px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you been hospitalized in the last 2 years?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_been_hospitalized_in_the_last_2_years-57-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_been_hospitalized_in_the_last_2_years\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_been_hospitalized_in_the_last_2_years-57-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_been_hospitalized_in_the_last_2_years-57-1\" type=\"radio\" value=\"No\" name=\"Have_you_been_hospitalized_in_the_last_2_years\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_been_hospitalized_in_the_last_2_years-57-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you had a medical examination in the last year?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_had_a_medical_examination_in_the_last_year-58-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_had_a_medical_examination_in_the_last_year\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_had_a_medical_examination_in_the_last_year-58-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_had_a_medical_examination_in_the_last_year-58-1\" type=\"radio\" value=\"No\" name=\"Have_you_had_a_medical_examination_in_the_last_year\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_had_a_medical_examination_in_the_last_year-58-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you use any prescription or non-prescription medicine including herbal remedies, regularly?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly-59-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly-59-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly-59-1\" type=\"radio\" value=\"No\" name=\"Do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_use_any_prescription_or_non-prescription_medicine_including_herbal_remedies_regularly-59-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_please_specify:\">If yes, please specify:<\/label><\/div><input type=\"text\" name=\"if_yes_please_specify:\" id=\"if_yes_please_specify:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any allergic condition: i.e. asthma, hay fever, skin rash, food allergies, metal or latex allergies?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies-60-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies-60-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies-60-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_allergic_condition:_i.e._asthma,_hay_fever_skin_rash,_food_allergies_metal_or_latex_allergies-60-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"If_yes,_please_explain\">If yes, please explain:<\/label><\/div><input type=\"text\" name=\"If_yes,_please_explain\" id=\"If_yes,_please_explain\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do any of these allergic reactions result in headache, shortness of breath, chest constriction, nausea?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea-61-0\" type=\"radio\" value=\"Yes\" name=\"Do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea-61-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea-61-1\" type=\"radio\" value=\"No\" name=\"Do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_any_of_these_allergic_reactions_result_in_headache,_shortness_of_breath,_chest_constriction,_nausea-61-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"If_yes,_please_specify:\">If yes, please specify:<\/label><\/div><input type=\"text\" name=\"If_yes,_please_specify:\" id=\"If_yes,_please_specify:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever experienced any unusual reaction to any of the following?<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-10-0\" type=\"checkbox\" value=\"local anaesthesia (freezing)\" name=\"have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-10-0\">local anaesthesia (freezing)<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-10-1\" type=\"checkbox\" value=\"aspirin\" name=\"have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-10-1\">aspirin<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-10-2\" type=\"checkbox\" value=\"penicillin\" name=\"have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-10-2\">penicillin<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-10-3\" type=\"checkbox\" value=\"iodine\" name=\"have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-10-3\">iodine<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-10-4\" type=\"checkbox\" value=\"sulfonamide (sulfa)\" name=\"have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-10-4\">sulfonamide (sulfa)<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-10-5\" type=\"checkbox\" value=\"barbiturates (sleeping pills)\" name=\"have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_experienced_any_unusual_reaction_to_any_of_the_following-10-5\">barbiturates (sleeping pills)<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"or_any_other_medicine__if_yes_please_explain:\">Or any other medicine?  If yes, please explain:<\/label><\/div><input type=\"text\" name=\"or_any_other_medicine__if_yes_please_explain:\" id=\"or_any_other_medicine__if_yes_please_explain:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you been warned against taking any drug or medication? <\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_been_warned_against_taking_any_drug_or_medication-62-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_been_warned_against_taking_any_drug_or_medication\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_been_warned_against_taking_any_drug_or_medication-62-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_been_warned_against_taking_any_drug_or_medication-62-1\" type=\"radio\" value=\"No\" name=\"Have_you_been_warned_against_taking_any_drug_or_medication\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_been_warned_against_taking_any_drug_or_medication-62-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_please_explain:\">If yes, please explain:<\/label><\/div><input type=\"text\" name=\"if_yes_please_explain:\" id=\"if_yes_please_explain:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have or have you ever had any of the following? (please mark any\/all that apply)<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-0\" type=\"checkbox\" value=\"heart murmur or other heart condition\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-0\">heart murmur or other heart condition<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-1\" type=\"checkbox\" value=\"hepatitis A\/B\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-1\">hepatitis A\/B<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-2\" type=\"checkbox\" value=\"joint replacement (hip, knee)\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-2\">joint replacement (hip, knee)<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-3\" type=\"checkbox\" value=\"venereal disease\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-3\">venereal disease<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-4\" type=\"checkbox\" value=\"rheumatism\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-4\">rheumatism<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-5\" type=\"checkbox\" value=\"hyper (hypo) glycemia\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-5\">hyper (hypo) glycemia<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-6\" type=\"checkbox\" value=\"arthritis\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-6\">arthritis<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-7\" type=\"checkbox\" value=\"high\/low blood pressure\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-7\">high\/low blood pressure<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-8\" type=\"checkbox\" value=\"thyroid disease\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-8\">thyroid disease<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-9\" type=\"checkbox\" value=\"any lung disease\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-9\">any lung disease<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-10\" type=\"checkbox\" value=\"scarlet fever\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-10\">scarlet fever<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-11\" type=\"checkbox\" value=\"herpes\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-11\">herpes<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-12\" type=\"checkbox\" value=\"stomach\/intestinal problems\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-12\">stomach\/intestinal problems<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-13\" type=\"checkbox\" value=\"drug addiction\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-13\">drug addiction<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-14\" type=\"checkbox\" value=\"jaundice\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-14\">jaundice<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-15\" type=\"checkbox\" value=\"cancer\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-15\">cancer<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-16\" type=\"checkbox\" value=\"kidney disease\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-16\">kidney disease<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-17\" type=\"checkbox\" value=\"mental or nervous disorder\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-17\">mental or nervous disorder<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-18\" type=\"checkbox\" value=\"stroke\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-18\">stroke<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-19\" type=\"checkbox\" value=\"tuberculosis\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-19\">tuberculosis<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-20\" type=\"checkbox\" value=\"sinus trouble\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-20\">sinus trouble<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-21\" type=\"checkbox\" value=\"heart attack\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-21\">heart attack<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-22\" type=\"checkbox\" value=\"rheumatic fever\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-22\">rheumatic fever<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-23\" type=\"checkbox\" value=\"epilepsy or seizures\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-23\">epilepsy or seizures<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-24\" type=\"checkbox\" value=\"AIDS\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-24\">AIDS<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-25\" type=\"checkbox\" value=\"liver disease\" name=\"do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_or_have_you_ever_had_any_of_the_following_please_mark_anyall_that_apply-11-25\">liver disease<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"other:\">Other:<\/label><\/div><input type=\"text\" name=\"other:\" id=\"other:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever had any known contact with the Aids Virus?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_any_known_contact_with_the_aids_virus-63-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_ever_had_any_known_contact_with_the_Aids_Virus\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_any_known_contact_with_the_aids_virus-63-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_any_known_contact_with_the_aids_virus-63-1\" type=\"radio\" value=\"No\" name=\"Have_you_ever_had_any_known_contact_with_the_Aids_Virus\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_any_known_contact_with_the_aids_virus-63-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Has any member of your family had diabetes<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-has_any_member_of_your_family_had_diabetes-64-0\" type=\"radio\" value=\"Yes\" name=\"Has_any_member_of_your_family_had_diabetes\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-has_any_member_of_your_family_had_diabetes-64-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-has_any_member_of_your_family_had_diabetes-64-1\" type=\"radio\" value=\"No\" name=\"Has_any_member_of_your_family_had_diabetes\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-has_any_member_of_your_family_had_diabetes-64-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you bruise easily or bleed abnormally?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_bruise_easily_or_bleed_abnormally-65-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_bruise_easily_or_bleed_abnormally\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_bruise_easily_or_bleed_abnormally-65-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_bruise_easily_or_bleed_abnormally-65-1\" type=\"radio\" value=\"No\" name=\"Do_you_bruise_easily_or_bleed_abnormally\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_bruise_easily_or_bleed_abnormally-65-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do your ankles swell during the day?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_your_ankles_swell_during_the_day-66-0\" type=\"radio\" value=\"Yes\" name=\"Do_your_ankles_swell_during_the_day\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_your_ankles_swell_during_the_day-66-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_your_ankles_swell_during_the_day-66-1\" type=\"radio\" value=\"No\" name=\"Do_your_ankles_swell_during_the_day\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_your_ankles_swell_during_the_day-66-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you had any weight changes recently?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_had_any_weight_changes_recently-67-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_had_any_weight_changes_recently\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_had_any_weight_changes_recently-67-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_had_any_weight_changes_recently-67-1\" type=\"radio\" value=\"No\" name=\"Have_you_had_any_weight_changes_recently\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_had_any_weight_changes_recently-67-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any blood disorders such as anaemia (thin blood)?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)-68-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)-68-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)-68-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_blood_disorders_such_as_anaemia_(thin_blood)-68-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever had radiation treatment or chemotherapy?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_radiation_treatment_or_chemotherapy-69-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_ever_had_radiation_treatment_or_chemotherapy\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_radiation_treatment_or_chemotherapy-69-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_radiation_treatment_or_chemotherapy-69-1\" type=\"radio\" value=\"No\" name=\"Have_you_ever_had_radiation_treatment_or_chemotherapy\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_radiation_treatment_or_chemotherapy-69-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_please_explain:\">If yes, please explain:<\/label><\/div><input type=\"text\" name=\"if_yes_please_explain:\" id=\"if_yes_please_explain:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever had any injury, surgery or x-ray therapy to your face or jaws?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws-70-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws-70-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws-70-1\" type=\"radio\" value=\"No\" name=\"Have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_had_any_injury,_surgery_or_x-ray_therapy_to_your_face_or_jaws-70-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have frequent severe headaches?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_frequent_severe_headaches-71-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_frequent_severe_headaches\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_frequent_severe_headaches-71-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_frequent_severe_headaches-71-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_frequent_severe_headaches\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_frequent_severe_headaches-71-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have frequent earaches, ear\/throat infections or any hearing difficulties?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_frequent_earaches,_ear\/throat_infections_or_any_hearing_difficulties-72-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_frequent_earaches,_ear\/throat_infections_or_any_hearing_difficulties\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_frequent_earaches,_ear\/throat_infections_or_any_hearing_difficulties-72-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_frequent_earaches,_ear\/throat_infections_or_any_hearing_difficulties-72-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_frequent_earaches,_ear\/throat_infections_or_any_hearing_difficulties\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_frequent_earaches,_ear\/throat_infections_or_any_hearing_difficulties-72-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Is your eyesight:<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-is_your_eyesight:-73-0\" type=\"radio\" value=\"Good\" name=\"is_your_eyesight:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-is_your_eyesight:-73-0\">Good<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-is_your_eyesight:-73-1\" type=\"radio\" value=\"Adequate\" name=\"is_your_eyesight:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-is_your_eyesight:-73-1\">Adequate<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-is_your_eyesight:-73-2\" type=\"radio\" value=\"Poor\" name=\"is_your_eyesight:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-is_your_eyesight:-73-2\">Poor<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you on a special diet?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_on_a_special_diet-74-0\" type=\"radio\" value=\"Yes\" name=\"Are_you_on_a_special_diet\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_on_a_special_diet-74-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_on_a_special_diet-74-1\" type=\"radio\" value=\"No\" name=\"Are_you_on_a_special_diet\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_on_a_special_diet-74-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_please_explain:\">If yes, please explain:<\/label><\/div><input type=\"text\" name=\"if_yes_please_explain:\" id=\"if_yes_please_explain:\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever fainted?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_fainted-75-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_ever_fainted\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_fainted-75-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_ever_fainted-75-1\" type=\"radio\" value=\"No\" name=\"Have_you_ever_fainted\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_ever_fainted-75-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you ever experience shortness of breath or pain in your chest when taking a walk or climbing stairs?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs-76-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs-76-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs-76-1\" type=\"radio\" value=\"No\" name=\"Do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_ever_experience_shortness_of_breath_or_pain_in_your_chest_when_taking_a_walk_or_climbing_stairs-76-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any medical or dental implants?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_medical_or_dental_implants-77-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_any_medical_or_dental_implants\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_medical_or_dental_implants-77-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_medical_or_dental_implants-77-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_any_medical_or_dental_implants\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_medical_or_dental_implants-77-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"1671\"><label for=\"do_you_have_any_disease_condition_or_problem_not_listed_above_that_you_think_the_doctor_should_know_about\">Do you have any disease, condition or problem not listed above that you think the doctor should know about?<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"do_you_have_any_disease_condition_or_problem_not_listed_above_that_you_think_the_doctor_should_know_about\" name=\"do_you_have_any_disease_condition_or_problem_not_listed_above_that_you_think_the_doctor_should_know_about\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"1671\"><label for=\"is_there_anything_about_yourself_that_we_should_be_made_aware_of\">Is there anything about yourself that we should be made aware of?<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"is_there_anything_about_yourself_that_we_should_be_made_aware_of\" name=\"is_there_anything_about_yourself_that_we_should_be_made_aware_of\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">WOMEN ONLY - Are you pregnant?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-women_only_-_are_you_pregnant?-78-0\" type=\"radio\" value=\"Yes\" name=\"WOMEN_ONLY_-_Are_you_pregnant?\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-women_only_-_are_you_pregnant?-78-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-women_only_-_are_you_pregnant?-78-1\" type=\"radio\" value=\"No\" name=\"WOMEN_ONLY_-_Are_you_pregnant?\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-women_only_-_are_you_pregnant?-78-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"If_so_which_month_are_you_in\"> If so, which month are you in?<\/label><\/div><input type=\"text\" name=\"If_so_which_month_are_you_in\" id=\"If_so_which_month_are_you_in\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you taking any birth control pills?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_taking_any_birth_control_pills-79-0\" type=\"radio\" value=\"Yes\" name=\"Are_you_taking_any_birth_control_pills\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_taking_any_birth_control_pills-79-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_taking_any_birth_control_pills-79-1\" type=\"radio\" value=\"No\" name=\"Are_you_taking_any_birth_control_pills\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_taking_any_birth_control_pills-79-1\">No<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-128{width:100% !important;margin-top : 0px;margin-bottom : 38px;}.fusion-builder-nested-column-128 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 33px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-128{width:100% !important;order : 0;}.fusion-builder-nested-column-128 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-128{width:100% !important;order : 0;}.fusion-builder-nested-column-128 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><div class=\"fusion-alert alert notice alert-warning fusion-alert-left fusion-alert-capitalize alert-shadow fusion-animated\" style=\"background-color:#fcf8e3;color:rgba(217,185,23,1);border-color:rgba(217,185,23,1);border-width:1px;\" data-animationType=\"rubberBand\" data-animationDuration=\"1.4\" data-animationOffset=\"top-into-view\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa-lg fa-cog fa\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\"><b data-fusion-font=\"true\">IN ORDER TO AVOID COMPLICATIONS AS A RESULT OF A CHANGE IN YOUR MEDICAL CONDITION, IT IS IMPORTANT THAT YOU NOTIFY OUR OFFICE OF THESE CHANGES.<\/b><\/span><\/div><\/div><style type=\"text\/css\">@media only screen and (max-width:1024px) {.fusion-title.fusion-title-8{margin-top:35px!important; margin-right:0px!important;margin-bottom:!important;margin-left:0px!important;}}@media only screen and (max-width:640px) {.fusion-title.fusion-title-8{margin-top:0px!important; margin-right:0px!important;margin-bottom:20px!important; margin-left:0px!important;}}<\/style><div class=\"fusion-title title fusion-title-8 fusion-sep-none fusion-title-text fusion-title-size-three\" style=\"margin-top:35px;margin-right:0px;margin-left:0px;\"><h3 class=\"title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:34;line-height:1.29;\">Dental History<\/h3><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-129 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 16px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">How frequently do you see your dentist?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-how_frequently_do_you_see_your_dentist-80-0\" type=\"radio\" value=\"6 Months\" name=\"how_frequently_do_you_see_your_dentist\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-how_frequently_do_you_see_your_dentist-80-0\">6 Months<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-how_frequently_do_you_see_your_dentist-80-1\" type=\"radio\" value=\"Yearly\" name=\"how_frequently_do_you_see_your_dentist\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-how_frequently_do_you_see_your_dentist-80-1\">Yearly<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-how_frequently_do_you_see_your_dentist-80-2\" type=\"radio\" value=\"Other\" name=\"how_frequently_do_you_see_your_dentist\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-how_frequently_do_you_see_your_dentist-80-2\">Other<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-129{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-129 > .fusion-column-wrapper {padding-top : 16px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-129{width:100% !important;order : 0;}.fusion-builder-nested-column-129 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-129{width:100% !important;order : 0;}.fusion-builder-nested-column-129 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-130 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"last_dental_visit\">Last dental visit?<\/label><\/div><input type=\"text\" name=\"last_dental_visit\" id=\"last_dental_visit\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-130{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-130 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 5.76%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-130{width:100% !important;order : 0;}.fusion-builder-nested-column-130 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-130{width:100% !important;order : 0;}.fusion-builder-nested-column-130 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-131 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Last_cleaning\"> Last cleaning?<\/label><\/div><input type=\"text\" name=\"Last_cleaning\" id=\"Last_cleaning\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-131{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-131 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 0%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-131{width:100% !important;order : 0;}.fusion-builder-nested-column-131 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-131{width:100% !important;order : 0;}.fusion-builder-nested-column-131 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-132 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 0px 35px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"Last_full_mouth_series_of_x-rays\">Last full mouth series of x-rays?<\/label><\/div><input type=\"text\" name=\"Last_full_mouth_series_of_x-rays\" id=\"Last_full_mouth_series_of_x-rays\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-132{width:33.333333333333% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-132 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 5.76%;padding-bottom : 0px !important;padding-left : 35px !important;margin-left : 0%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-132{width:100% !important;order : 0;}.fusion-builder-nested-column-132 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-132{width:100% !important;order : 0;}.fusion-builder-nested-column-132 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-133 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 0px 35px 33px 35px;\"><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you been given oral hygiene instruction in:<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_been_given_oral_hygiene_instruction_in:-12-0\" type=\"checkbox\" value=\"Brushing\" name=\"Have_you_been_given_oral_hygiene_instruction_in:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_been_given_oral_hygiene_instruction_in:-12-0\">Brushing<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_been_given_oral_hygiene_instruction_in:-12-1\" type=\"checkbox\" value=\"Flossing\" name=\"Have_you_been_given_oral_hygiene_instruction_in:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_been_given_oral_hygiene_instruction_in:-12-1\">Flossing<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_been_given_oral_hygiene_instruction_in:-12-2\" type=\"checkbox\" value=\"Other\" name=\"Have_you_been_given_oral_hygiene_instruction_in:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_been_given_oral_hygiene_instruction_in:-12-2\">Other<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are any of your teeth sensitive to:<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-are_any_of_your_teeth_sensitive_to:-13-0\" type=\"checkbox\" value=\"Cold\" name=\"Are_any_of_your_teeth_sensitive_to:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-are_any_of_your_teeth_sensitive_to:-13-0\">Cold<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-are_any_of_your_teeth_sensitive_to:-13-1\" type=\"checkbox\" value=\"Sweets\" name=\"Are_any_of_your_teeth_sensitive_to:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-are_any_of_your_teeth_sensitive_to:-13-1\">Sweets<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-are_any_of_your_teeth_sensitive_to:-13-2\" type=\"checkbox\" value=\"Heat\" name=\"Are_any_of_your_teeth_sensitive_to:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-are_any_of_your_teeth_sensitive_to:-13-2\">Heat<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-are_any_of_your_teeth_sensitive_to:-13-3\" type=\"checkbox\" value=\"Other\" name=\"Are_any_of_your_teeth_sensitive_to:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-are_any_of_your_teeth_sensitive_to:-13-3\">Other<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do your gums bleed when:<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_your_gums_bleed_when:-14-0\" type=\"checkbox\" value=\"Brushing\" name=\"Do_your_gums_bleed_when:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_your_gums_bleed_when:-14-0\">Brushing<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_your_gums_bleed_when:-14-1\" type=\"checkbox\" value=\"Flossing\" name=\"Do_your_gums_bleed_when:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_your_gums_bleed_when:-14-1\">Flossing<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_your_gums_bleed_when:-14-2\" type=\"checkbox\" value=\"Spontaneously\" name=\"Do_your_gums_bleed_when:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_your_gums_bleed_when:-14-2\">Spontaneously<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you ever had any of the following:<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_had_any_of_the_following:-15-0\" type=\"checkbox\" value=\"Oral surgery\" name=\"Have_you_ever_had_any_of_the_following:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_had_any_of_the_following:-15-0\">Oral surgery<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_had_any_of_the_following:-15-1\" type=\"checkbox\" value=\"Peridontal treatment\" name=\"Have_you_ever_had_any_of_the_following:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_had_any_of_the_following:-15-1\">Peridontal treatment<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_had_any_of_the_following:-15-2\" type=\"checkbox\" value=\"Orthodontic treatment\" name=\"Have_you_ever_had_any_of_the_following:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_had_any_of_the_following:-15-2\">Orthodontic treatment<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_had_any_of_the_following:-15-3\" type=\"checkbox\" value=\"Bite adjustment\" name=\"Have_you_ever_had_any_of_the_following:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_had_any_of_the_following:-15-3\">Bite adjustment<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-have_you_ever_had_any_of_the_following:-15-4\" type=\"checkbox\" value=\"Bite plate or other appliance\" name=\"Have_you_ever_had_any_of_the_following:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-have_you_ever_had_any_of_the_following:-15-4\">Bite plate or other appliance<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any dental implants?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_dental_implants-81-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_any_dental_implants\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_dental_implants-81-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_dental_implants-81-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_any_dental_implants\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_dental_implants-81-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you suffer from pain and\/or swelling of your gums?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_suffer_from_pain_and\/or_swelling_of_your_gums-82-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_suffer_from_pain_and\/or_swelling_of_your_gums\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_suffer_from_pain_and\/or_swelling_of_your_gums-82-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_suffer_from_pain_and\/or_swelling_of_your_gums-82-1\" type=\"radio\" value=\"No\" name=\"Do_you_suffer_from_pain_and\/or_swelling_of_your_gums\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_suffer_from_pain_and\/or_swelling_of_your_gums-82-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you aware of any loose teeth?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_aware_of_any_loose_teeth-83-0\" type=\"radio\" value=\"Yes\" name=\"Are_you_aware_of_any_loose_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_aware_of_any_loose_teeth-83-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_aware_of_any_loose_teeth-83-1\" type=\"radio\" value=\"No\" name=\"Are_you_aware_of_any_loose_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_aware_of_any_loose_teeth-83-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_where\">If yes, where?<\/label><\/div><input type=\"text\" name=\"if_yes_where\" id=\"if_yes_where\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you chew on only one side of your mouth?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_chew_on_only_one_side_of_your_mouth-84-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_chew_on_only_one_side_of_your_mouth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_chew_on_only_one_side_of_your_mouth-84-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_chew_on_only_one_side_of_your_mouth-84-1\" type=\"radio\" value=\"No\" name=\"Do_you_chew_on_only_one_side_of_your_mouth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_chew_on_only_one_side_of_your_mouth-84-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"If_so_why\">If so, why?<\/label><\/div><input type=\"text\" name=\"If_so_why\" id=\"If_so_why\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you grind or clench your teeth during the day or night?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_grind_or_clench_your_teeth_during_the_day_or_night-85-0\" type=\"radio\" value=\"Yes\" name=\"do_you_grind_or_clench_your_teeth_during_the_day_or_night\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_grind_or_clench_your_teeth_during_the_day_or_night-85-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_grind_or_clench_your_teeth_during_the_day_or_night-85-1\" type=\"radio\" value=\"No\" name=\"do_you_grind_or_clench_your_teeth_during_the_day_or_night\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_grind_or_clench_your_teeth_during_the_day_or_night-85-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you mouth breathe while awake or asleep?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_mouth_breathe_while_awake_or_asleep-86-0\" type=\"radio\" value=\"Yes\" name=\"do_you_mouth_breathe_while_awake_or_asleep\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_mouth_breathe_while_awake_or_asleep-86-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_mouth_breathe_while_awake_or_asleep-86-1\" type=\"radio\" value=\"No\" name=\"do_you_mouth_breathe_while_awake_or_asleep\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_mouth_breathe_while_awake_or_asleep-86-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you bite your lips or cheeks regularly?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_bite_your_lips_or_cheeks_regularly-87-0\" type=\"radio\" value=\"Yes\" name=\"do_you_bite_your_lips_or_cheeks_regularly\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_bite_your_lips_or_cheeks_regularly-87-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_bite_your_lips_or_cheeks_regularly-87-1\" type=\"radio\" value=\"No\" name=\"do_you_bite_your_lips_or_cheeks_regularly\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_bite_your_lips_or_cheeks_regularly-87-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you hold any foreign objects with your teeth?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_hold_any_foreign_objects_with_your_teeth-88-0\" type=\"radio\" value=\"Yes\" name=\"do_you_hold_any_foreign_objects_with_your_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_hold_any_foreign_objects_with_your_teeth-88-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_hold_any_foreign_objects_with_your_teeth-88-1\" type=\"radio\" value=\"No\" name=\"do_you_hold_any_foreign_objects_with_your_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_hold_any_foreign_objects_with_your_teeth-88-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Does any part of your mouth hurt when clenched?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-does_any_part_of_your_mouth_hurt_when_clenched-89-0\" type=\"radio\" value=\"Yes\" name=\"Does_any_part_of_your_mouth_hurt_when_clenched\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-does_any_part_of_your_mouth_hurt_when_clenched-89-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-does_any_part_of_your_mouth_hurt_when_clenched-89-1\" type=\"radio\" value=\"No\" name=\"Does_any_part_of_your_mouth_hurt_when_clenched\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-does_any_part_of_your_mouth_hurt_when_clenched-89-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Does your jaw crack or pop when opened widely?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-does_your_jaw_crack_or_pop_when_opened_widely-90-0\" type=\"radio\" value=\"Yes\" name=\"Does_your_jaw_crack_or_pop_when_opened_widely\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-does_your_jaw_crack_or_pop_when_opened_widely-90-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-does_your_jaw_crack_or_pop_when_opened_widely-90-1\" type=\"radio\" value=\"No\" name=\"Does_your_jaw_crack_or_pop_when_opened_widely\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-does_your_jaw_crack_or_pop_when_opened_widely-90-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any difficulty in opening or closing your jaw?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_difficulty_in_opening_or_closing_your_jaw-91-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_any_difficulty_in_opening_or_closing_your_jaw\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_difficulty_in_opening_or_closing_your_jaw-91-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_difficulty_in_opening_or_closing_your_jaw-91-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_any_difficulty_in_opening_or_closing_your_jaw\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_difficulty_in_opening_or_closing_your_jaw-91-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any pain in your ears?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_pain_in_your_ears-92-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_have_any_pain_in_your_ears\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_pain_in_your_ears-92-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_have_any_pain_in_your_ears-92-1\" type=\"radio\" value=\"No\" name=\"Do_you_have_any_pain_in_your_ears\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_have_any_pain_in_your_ears-92-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you gag easily?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_gag_easily-93-0\" type=\"radio\" value=\"Yes\" name=\"Do_you_gag_easily\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_gag_easily-93-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-do_you_gag_easily-93-1\" type=\"radio\" value=\"No\" name=\"Do_you_gag_easily\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-do_you_gag_easily-93-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you experienced any growth or sore spots in your mouth?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_experienced_any_growth_or_sore_spots_in_your_mouth-94-0\" type=\"radio\" value=\"Yes\" name=\"Have_you_experienced_any_growth_or_sore_spots_in_your_mouth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_experienced_any_growth_or_sore_spots_in_your_mouth-94-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-have_you_experienced_any_growth_or_sore_spots_in_your_mouth-94-1\" type=\"radio\" value=\"No\" name=\"Have_you_experienced_any_growth_or_sore_spots_in_your_mouth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-have_you_experienced_any_growth_or_sore_spots_in_your_mouth-94-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"is_yes_where\">Is yes, where?<\/label><\/div><input type=\"text\" name=\"is_yes_where\" id=\"is_yes_where\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Are you concerned about the appearance of your teeth?<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_concerned_about_the_appearance_of_your_teeth-95-0\" type=\"radio\" value=\"Yes\" name=\"Are_you_concerned_about_the_appearance_of_your_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_concerned_about_the_appearance_of_your_teeth-95-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-are_you_concerned_about_the_appearance_of_your_teeth-95-1\" type=\"radio\" value=\"No\" name=\"Are_you_concerned_about_the_appearance_of_your_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-are_you_concerned_about_the_appearance_of_your_teeth-95-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"if_yes_what_would_you_like_to_see_changed\">If yes, what would you like to see changed?<\/label><\/div><input type=\"text\" name=\"if_yes_what_would_you_like_to_see_changed\" id=\"if_yes_what_would_you_like_to_see_changed\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Would you rate your current dental health as:<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-would_you_rate_your_current_dental_health_as-96-0\" type=\"radio\" value=\"Excellent\" name=\"Would_you_rate_your_current_dental_health_as\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-would_you_rate_your_current_dental_health_as-96-0\">Excellent<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-would_you_rate_your_current_dental_health_as-96-1\" type=\"radio\" value=\"Good\" name=\"Would_you_rate_your_current_dental_health_as\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-would_you_rate_your_current_dental_health_as-96-1\">Good<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-would_you_rate_your_current_dental_health_as-96-2\" type=\"radio\" value=\"Fair\" name=\"Would_you_rate_your_current_dental_health_as\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-would_you_rate_your_current_dental_health_as-96-2\">Fair<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-would_you_rate_your_current_dental_health_as-96-3\" type=\"radio\" value=\"Poor\" name=\"Would_you_rate_your_current_dental_health_as\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-would_you_rate_your_current_dental_health_as-96-3\">Poor<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Is your sugar intake:<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-is_your_sugar_intake-97-0\" type=\"radio\" value=\"High\" name=\"Is_your_sugar_intake\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-is_your_sugar_intake-97-0\">High<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-is_your_sugar_intake-97-1\" type=\"radio\" value=\"Medium\" name=\"Is_your_sugar_intake\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-is_your_sugar_intake-97-1\">Medium<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-is_your_sugar_intake-97-2\" type=\"radio\" value=\"Low\" name=\"Is_your_sugar_intake\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-is_your_sugar_intake-97-2\">Low<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Brushing: <\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-brushing-98-0\" type=\"radio\" value=\"Vigorous\" name=\"Brushing\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-brushing-98-0\">Vigorous<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-brushing-98-1\" type=\"radio\" value=\"Light\" name=\"Brushing\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-brushing-98-1\">Light<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><label for=\"how_often\">How often?<\/label><\/div><input type=\"text\" name=\"how_often\" id=\"how_often\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Cleaning aids presently used:<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-cleaning_aids_presently_used:-16-0\" type=\"checkbox\" value=\"Floss\" name=\"cleaning_aids_presently_used:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-cleaning_aids_presently_used:-16-0\">Floss<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-cleaning_aids_presently_used:-16-1\" type=\"checkbox\" value=\"Toothpick\" name=\"cleaning_aids_presently_used:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-cleaning_aids_presently_used:-16-1\">Toothpick<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-cleaning_aids_presently_used:-16-2\" type=\"checkbox\" value=\"Other\" name=\"cleaning_aids_presently_used:[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-cleaning_aids_presently_used:-16-2\">Other<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have any emotional concerns regarding your dental visit?<\/span><\/div><fieldset><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-17-0\" type=\"checkbox\" value=\"Fear\" name=\"Do_you_have_any_emotional_concerns_regarding_your_dental_visit[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-17-0\">Fear<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-17-1\" type=\"checkbox\" value=\"Pain\" name=\"Do_you_have_any_emotional_concerns_regarding_your_dental_visit[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-17-1\">Pain<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-17-2\" type=\"checkbox\" value=\"Money\" name=\"Do_you_have_any_emotional_concerns_regarding_your_dental_visit[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-17-2\">Money<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-17-3\" type=\"checkbox\" value=\"Embarrassment\" name=\"Do_you_have_any_emotional_concerns_regarding_your_dental_visit[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-17-3\">Embarrassment<\/label><\/div><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-17-4\" type=\"checkbox\" value=\"Other\" name=\"Do_you_have_any_emotional_concerns_regarding_your_dental_visit[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-do_you_have_any_emotional_concerns_regarding_your_dental_visit-17-4\">Other<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-133{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-nested-column-133 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 33px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-133{width:100% !important;order : 0;}.fusion-builder-nested-column-133 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-133{width:100% !important;order : 0;}.fusion-builder-nested-column-133 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">@media only screen and (max-width:1024px) {.fusion-title.fusion-title-9{margin-top:35px!important; margin-right:0px!important;margin-bottom:!important;margin-left:0px!important;}}@media only screen and (max-width:640px) {.fusion-title.fusion-title-9{margin-top:0px!important; margin-right:0px!important;margin-bottom:20px!important; margin-left:0px!important;}}<\/style><div class=\"fusion-title title fusion-title-9 fusion-sep-none fusion-title-text fusion-title-size-three\" style=\"margin-top:35px;margin-right:0px;margin-left:0px;\"><h3 class=\"title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:34;line-height:1.29;\">General Release<\/h3><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-134 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#ffffff;padding: 35px 35px 26px 35px;\"><div class=\"fusion-text fusion-text-9\"><p>I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. <b>Should there be any change in either my health status or any other information I have provided, I will advise this dental office.<\/b> I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.<\/p>\n<p><b>By clicking submit you agree to certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician being contacted if necessary, as this information may be required for my dental care.<\/b><\/p>\n<\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"1671\"><fieldset><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox--18-0\" type=\"checkbox\" value=\"I confirm that all of the medical and dental information provided above is true to the best of my knowledge.\" name=\"[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox--18-0\">I confirm that all of the medical and dental information provided above is true to the best of my knowledge.<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-nested-column-134{width:100% !important;margin-top : 0px;margin-bottom : 40px;}.fusion-builder-nested-column-134 > .fusion-column-wrapper {padding-top : 35px !important;padding-right : 35px !important;margin-right : 1.92%;padding-bottom : 26px !important;padding-left : 35px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-nested-column-134{width:100% !important;order : 0;}.fusion-builder-nested-column-134 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-nested-column-134{width:100% !important;order : 0;}.fusion-builder-nested-column-134 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><div class=\"fusion-form-field fusion-form-submit-field fusion-form-label-above\" data-form-id=\"1671\"><div ><style>.fusion-button.button-2{border-color:#ffffff;border-radius:0px 0px 0px 0px;background:#3d434c;}.fusion-button.button-2 .fusion-button-text,.fusion-button.button-2 i,.fusion-button.button-2:hover .fusion-button-text,.fusion-button.button-2:hover i,.fusion-button.button-2:focus .fusion-button-text,.fusion-button.button-2:focus i,.fusion-button.button-2:active .fusion-button-text,.fusion-button.button-2:active i{color:#ffffff;}.fusion-button.button-2:hover,.fusion-button.button-2:active,.fusion-button.button-2:focus{border-color:#ffffff;background:#dbb55f;}<\/style><button type=\"submit\" class=\"fusion-button button-flat button-xlarge button-custom button-2 fusion-button-span-yes  form-form-submit button-default\" data-form-number=\"1671\" style=\"margin-top:16px;margin-bottom:30px;\" tabindex=\"\"><span class=\"fusion-button-text\">Submit New Patient Form<\/span><\/button><\/div><\/div><div class=\"form-submission-notices\" id=\"fusion-notices-2\"><div class=\"fusion-alert alert success alert-success fusion-alert-center fusion-form-response fusion-form-response-success fusion-alert-capitalize alert-dismissable\" style=\"background-color:#dff0d8;color:rgba(92,163,64,1);border-color:rgba(92,163,64,1);border-width:1px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa fa-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Thank you for submitting your information - it has been sent to us for review.<\/span><\/div><\/div><div class=\"fusion-alert alert error alert-danger fusion-alert-center fusion-form-response fusion-form-response-error fusion-alert-capitalize alert-dismissable\" style=\"background-color:#f2dede;color:rgba(166,66,66,1);border-color:rgba(166,66,66,1);border-width:1px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa fa-exclamation-triangle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">There was an error trying to send your message. Please try again later.<\/span><\/div><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-2{width:100% !important;margin-top : 0px;margin-bottom : 40px;}.fusion-builder-column-2 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-2{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><input type=\"hidden\" name=\"fusion_privacy_store_ip_ua\" value=\"false\"><input type=\"hidden\" name=\"fusion_privacy_expiration_interval\" value=\"48\"><input type=\"hidden\" name=\"privacy_expiration_action\" value=\"anonymize\"><\/form><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-0{width:100% !important;margin-top : 0px;margin-bottom : 40px;}.fusion-builder-column-0 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 90px !important;margin-right : 0px;padding-bottom : 0px !important;padding-left : 90px !important;margin-left : 0px;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-0{width:100% !important;order : 0;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 0px;margin-left : 0px;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-0{width:100% !important;order : 0;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 0px;margin-left : 0px;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-fullwidth.fusion-builder-row-1 { z-index:0 !important; }.fusion-body .fusion-flex-container.fusion-builder-row-1{ padding-top : 100px;margin-top : 0px;padding-right : 5%;padding-bottom : 50px;margin-bottom : 0px;padding-left : 5%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-flex-container.fusion-builder-row-1{ padding-top : 50px;padding-bottom : 32px;}}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"max-width:1289.6px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-2{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"_mi_skip_tracking":false,"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v19.1 - 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