{"id":5997,"date":"2022-07-08T11:56:13","date_gmt":"2022-07-08T11:56:13","guid":{"rendered":"https:\/\/n6z.673.myftpupload.com\/?page_id=5997"},"modified":"2022-07-08T12:00:09","modified_gmt":"2022-07-08T12:00:09","slug":"patient-pre-registration","status":"publish","type":"page","link":"\/\/www.abcchristmas.com\/patient-pre-registration\/","title":{"rendered":"Patient Pre-Registration Application FORM"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f5999-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/5997#wpcf7-f5999-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"5999\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.4\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f5999-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<p><label> Patient Full Name*<br \/>\n<i>First Name, Middle Initial, Last Name<\/i> <span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span><\/label>\n<\/p>\n<p><label> Primary Physician*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"primary-physician\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary-physician\" \/><\/span> <\/label>\n<\/p>\n<p><label> Today's Date*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date\" \/><\/span><\/label>\n<\/p>\n<p><label> Street Address*<br \/>\n<i>Full Street Address or P.O Box<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"address\" \/><\/span> <\/label>\n<\/p>\n<p><label> City*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"city\" \/><\/span> <\/label>\n<\/p>\n<p><label> County*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"county\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"county\" \/><\/span> <\/label>\n<\/p>\n<p><label> State*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"state\" \/><\/span> <\/label>\n<\/p>\n<p><label> Zip Code*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"zipcode\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zipcode\" \/><\/span> <\/label>\n<\/p>\n<p><label> Telephone*<br \/>\n<i>Area Code and 7 Digit Number<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"telephone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"telephone\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email Address*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Date of Birth*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"birthday\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"birthday\" \/><\/span> <\/label>\n<\/p>\n<p><label> Marital Status* <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"marital-status\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"marital-status[]\" value=\"Single\" \/><span class=\"wpcf7-list-item-label\">Single<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"marital-status[]\" value=\"Married\" \/><span class=\"wpcf7-list-item-label\">Married<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"marital-status[]\" value=\"Divorced\" \/><span class=\"wpcf7-list-item-label\">Divorced<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Sex* <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sex\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"sex[]\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"sex[]\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Race* <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"race\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"race[]\" value=\"Black\" \/><span class=\"wpcf7-list-item-label\">Black<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"race[]\" value=\"White\" \/><span class=\"wpcf7-list-item-label\">White<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"race[]\" value=\"Asian\" \/><span class=\"wpcf7-list-item-label\">Asian<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"race[]\" value=\"Indian\" \/><span class=\"wpcf7-list-item-label\">Indian<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Last 4 Digits of Social Security Number*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ssn\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ssn\" \/><\/span> <\/label>\n<\/p>\n<p><label> Religion<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"religion\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"religion\" \/><\/span> <\/label>\n<\/p>\n<p><label> Are you Employed?* <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"employed-yes-no\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"employed-yes-no[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"employed-yes-no[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Employer's Name<br \/>\n<i>If you are employed please list your major employer's business name.<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emp-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emp-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Employer's Street Address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emp-street-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emp-street-address\" \/><\/span> <\/label>\n<\/p>\n<p><label> City<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"city2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"city2\" \/><\/span> <\/label>\n<\/p>\n<p><label> State<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"state2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"state2\" \/><\/span> <\/label>\n<\/p>\n<p><label> Zip Code<br \/>\n<i>Five Digit Zip Code<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"zipcode2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zipcode2\" \/><\/span> <\/label>\n<\/p>\n<p><label> Employer Phone Number<br \/>\n<i>Area Code Plus 7 Digit Number<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"employer-phone-number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employer-phone-number\" \/><\/span> <\/label>\n<\/p>\n<p><label> Type of Position <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"typeofposition\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"typeofposition[]\" value=\"Full Time\" \/><span class=\"wpcf7-list-item-label\">Full Time<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"typeofposition[]\" value=\"Part Time\" \/><span class=\"wpcf7-list-item-label\">Part Time<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Occupation<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"occupation\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"occupation\" \/><\/span> <\/label>\n<\/p>\n<p><label> Retirement Date<br \/>\n<i>Fill In This Field Only If You Expect To Retire<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"retirement-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"retirement-date\" \/><\/span><\/label>\n<\/p>\n<p><label> When Paying Healthcare Bills...How Do You Plan To Pay?* <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"healthcare-bills\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"healthcare-bills[]\" value=\"Insurance\" \/><span class=\"wpcf7-list-item-label\">Insurance<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"healthcare-bills[]\" value=\"Cash\" \/><span class=\"wpcf7-list-item-label\">Cash<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"healthcare-bills[]\" value=\"Medicaid\" \/><span class=\"wpcf7-list-item-label\">Medicaid<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"healthcare-bills[]\" value=\"Medicare\" \/><span class=\"wpcf7-list-item-label\">Medicare<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Responsible Party's Information<br \/>\n<i>Fill Out Below If The Patient Is Not The Responsible Party<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"responsible-party-information\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"responsible-party-information\" \/><\/span> <\/label>\n<\/p>\n<p><label> Person Responsible For Bill<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"bill-responsible\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"bill-responsible\" \/><\/span> <\/label>\n<\/p>\n<p><label> Date of Birth<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"birthday2\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"birthday2\" \/><\/span> <\/label>\n<\/p>\n<p><label> Street Address or P.O. Box<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"street-adress-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"street-adress-2\" \/><\/span> <\/label>\n<\/p>\n<p><label> City<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"city3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"city3\" \/><\/span> <\/label>\n<\/p>\n<p><label> State<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"state3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"state3\" \/><\/span> <\/label>\n<\/p>\n<p><label> Zip Code<br \/>\n<i>Five Digit Zip Code<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"zipcode3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zipcode3\" \/><\/span> <\/label>\n<\/p>\n<p><label> Telephone<br \/>\n<i>Area Code and 7 Digit Number<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"telephone3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"telephone3\" \/><\/span> <\/label>\n<\/p>\n<p><label> Sex <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sex3\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"sex3[]\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"sex3[]\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Relationship To Patient<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"rel-to-patient\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rel-to-patient\" \/><\/span> <\/label>\n<\/p>\n<p><label> Last 4 Digits of Social Security Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ssn2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ssn2\" \/><\/span> <\/label>\n<\/p>\n<p><label> Employer's Name<br \/>\n<i>If you are employed please list your major employer's business name.<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"empname3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"empname3\" \/><\/span> <\/label>\n<\/p>\n<p><label> Employer's Street Address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"empstreet-adress-3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"empstreet-adress-3\" \/><\/span> <\/label>\n<\/p>\n<p><label> City<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"city4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"city4\" \/><\/span> <\/label>\n<\/p>\n<p><label> State<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"state4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"state4\" \/><\/span> <\/label>\n<\/p>\n<p><label> Zip Code<br \/>\n<i>Five Digit Zip Code<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"zipcode4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zipcode4\" \/><\/span> <\/label>\n<\/p>\n<p><label> Employer Phone Number<br \/>\n<i>Area Code Plus 7 Digit Number<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"empphone3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"empphone3\" \/><\/span> <\/label>\n<\/p>\n<p><label> Type of Position <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"typeofposition3\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"typeofposition3[]\" value=\"Full Time\" \/><span class=\"wpcf7-list-item-label\">Full Time<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"typeofposition3[]\" value=\"Part Time\" \/><span class=\"wpcf7-list-item-label\">Part Time<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Responsible Party's Occupation<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"responsible-party-occupation\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"responsible-party-occupation\" \/><\/span> <\/label>\n<\/p>\n<p><label> Person To Notify In Case Of An Emergency*<br \/>\n<i>Please Type in Full Name, Relationship, Address, Area Code & Telephone Number<\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-person\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency-person\" \/><\/span> <\/label>\n<\/p>\n<p><label>Insurance or Medicare\/Medicaid Numbers*<br \/>\nPlease Include Your Primary and Secondary Insurance Numbers or Medicare and Medicaid Numbers. We Need Your Basic Health Insurance Information. Make Sure You Include Your Group Number or Medicare Number. Please Also List Your Effective Date of Coverage.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"insuranceid-number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"insuranceid-number\" \/><\/span> <\/label>\n<\/p>\n<p><label>Drug Allergies*<br \/>\nPlease list all drugs and types of reaction<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"drug-allergies\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"drug-allergies\" \/><\/span> <\/label>\n<\/p>\n<p><label> Do you Smoke?* <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"smoke-yes-no\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"smoke-yes-no[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"smoke-yes-no[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label>If so:<br \/>\nHow many packs? Years Smoking? Have you stopped? Would you like Cessation Education?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"smoke-yes\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"smoke-yes\" \/><\/span> <\/label>\n<\/p>\n<p><label> Do you use other Tobacco products?* <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tobacco-products-yes-no\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"tobacco-products-yes-no[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"tobacco-products-yes-no[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label>If so:<br \/>\nWhat product? How long? Have you stopped?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tobacco-products-yes\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"tobacco-products-yes\" \/><\/span> <\/label>\n<\/p>\n<p><label> Do you drink Alcohol?* <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"alcohol-yes-no\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"alcohol-yes-no[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"alcohol-yes-no[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label>If so:<br \/>\nHow long? Last drink? Have you stopped?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"alcohol-yes\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"alcohol-yes\" \/><\/span> <\/label>\n<\/p>\n<p><label> Do you use illegal Drugs?* <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"illegal-drugs-yes-no\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"illegal-drugs-yes-no[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"illegal-drugs-yes-no[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label>If yes, what kind?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"illegal-drugs-yes\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"illegal-drugs-yes\" \/><\/span> <\/label>\n<\/p>\n<p><label> Do you drink caffeine?* <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caffeine-yes-no\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"caffeine-yes-no[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"caffeine-yes-no[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label>If yes, how much?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caffeine-yes\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"caffeine-yes\" \/><\/span> <\/label>\n<\/p>\n<h4><b> Family History<br \/>\nPlease indicate if any of your blood relatives have or have had any of the following:<\/b>\n<\/h4>\n<p><label> Check All that apply ? <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"diseases\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Great\" \/><span class=\"wpcf7-list-item-label\">Great<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"AIDS\/HIV\" \/><span class=\"wpcf7-list-item-label\">AIDS\/HIV<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Arthritis\" \/><span class=\"wpcf7-list-item-label\">Arthritis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Asthma\" \/><span class=\"wpcf7-list-item-label\">Asthma<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Bleeding Disorder\" \/><span class=\"wpcf7-list-item-label\">Bleeding Disorder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Bowel Disease\" \/><span class=\"wpcf7-list-item-label\">Bowel Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Cancer\" \/><span class=\"wpcf7-list-item-label\">Cancer<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Chemical Dependency\" \/><span class=\"wpcf7-list-item-label\">Chemical Dependency<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Depression\" \/><span class=\"wpcf7-list-item-label\">Depression<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Diabetes\" \/><span class=\"wpcf7-list-item-label\">Diabetes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Epilepsy\/Convulsions\" \/><span class=\"wpcf7-list-item-label\">Epilepsy\/Convulsions<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Glaucoma\" \/><span class=\"wpcf7-list-item-label\">Glaucoma<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Eye Disease\" \/><span class=\"wpcf7-list-item-label\">Eye Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Heart Disease\" \/><span class=\"wpcf7-list-item-label\">Heart Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"High Blood Pressure\" \/><span class=\"wpcf7-list-item-label\">High Blood Pressure<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Kidney Disease\" \/><span class=\"wpcf7-list-item-label\">Kidney Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Lung Disease\" \/><span class=\"wpcf7-list-item-label\">Lung Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Psychiatric Care\" \/><span class=\"wpcf7-list-item-label\">Psychiatric Care<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Stroke\" \/><span class=\"wpcf7-list-item-label\">Stroke<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Thyroid Problems\" \/><span class=\"wpcf7-list-item-label\">Thyroid Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Tuberculosis\" \/><span class=\"wpcf7-list-item-label\">Tuberculosis<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"diseases[]\" value=\"Other:\" \/><span class=\"wpcf7-list-item-label\">Other:<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label>If checked, please indicate the illness and your relationship to the relative.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"relative-illness\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"relative-illness\" \/><\/span> <\/label>\n<\/p>\n<h4><b> Problem List<br \/>\nPlease check all medical conditions you have or have had in the past:<\/b>\n<\/h4>\n<p><label> Check All that apply? <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"diseases2\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Colitis\" \/><span class=\"wpcf7-list-item-label\">Colitis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Cirrhosis\" \/><span class=\"wpcf7-list-item-label\">Cirrhosis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Crohns\" \/><span class=\"wpcf7-list-item-label\">Crohns<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Lupus Erythematosus\" \/><span class=\"wpcf7-list-item-label\">Lupus Erythematosus<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Myasthenia\" \/><span class=\"wpcf7-list-item-label\">Myasthenia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Multiple Sclerosis\" \/><span class=\"wpcf7-list-item-label\">Multiple Sclerosis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Alcoholism\" \/><span class=\"wpcf7-list-item-label\">Alcoholism<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Arthritis\" \/><span class=\"wpcf7-list-item-label\">Arthritis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Asthma\" \/><span class=\"wpcf7-list-item-label\">Asthma<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"AIDS\/HIV\" \/><span class=\"wpcf7-list-item-label\">AIDS\/HIV<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Anemia\" \/><span class=\"wpcf7-list-item-label\">Anemia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Anxiety\" \/><span class=\"wpcf7-list-item-label\">Anxiety<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Bleeding Disorder\" \/><span class=\"wpcf7-list-item-label\">Bleeding Disorder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Breast Mass\" \/><span class=\"wpcf7-list-item-label\">Breast Mass<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Bronchitis\" \/><span class=\"wpcf7-list-item-label\">Bronchitis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Bulima\" \/><span class=\"wpcf7-list-item-label\">Bulima<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Clotting Problems\" \/><span class=\"wpcf7-list-item-label\">Clotting Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Cancer\" \/><span class=\"wpcf7-list-item-label\">Cancer<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Chronic Pancreatitis\" \/><span class=\"wpcf7-list-item-label\">Chronic Pancreatitis<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"diseases2[]\" value=\"Chemical\/Drug Dependent\" \/><span class=\"wpcf7-list-item-label\">Chemical\/Drug Dependent<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"diseases4\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Deep Vein Thrombosis\" \/><span class=\"wpcf7-list-item-label\">Deep Vein Thrombosis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Back Pain\" \/><span class=\"wpcf7-list-item-label\">Back Pain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Blood Clots\" \/><span class=\"wpcf7-list-item-label\">Blood Clots<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Breast Cancer\" \/><span class=\"wpcf7-list-item-label\">Breast Cancer<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Colon Cancer\" \/><span class=\"wpcf7-list-item-label\">Colon Cancer<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Depression\" \/><span class=\"wpcf7-list-item-label\">Depression<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Diabetes\/Pre-Diabetes\" \/><span class=\"wpcf7-list-item-label\">Diabetes\/Pre-Diabetes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Esophageal Dysmotility\" \/><span class=\"wpcf7-list-item-label\">Esophageal Dysmotility<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Emphysema\" \/><span class=\"wpcf7-list-item-label\">Emphysema<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Epilepsy\" \/><span class=\"wpcf7-list-item-label\">Epilepsy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Fibromyalgia\" \/><span class=\"wpcf7-list-item-label\">Fibromyalgia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Goiter\" \/><span class=\"wpcf7-list-item-label\">Goiter<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Gonorrhea\" \/><span class=\"wpcf7-list-item-label\">Gonorrhea<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Gout\" \/><span class=\"wpcf7-list-item-label\">Gout<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Heart Murmur\" \/><span class=\"wpcf7-list-item-label\">Heart Murmur<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Hepatitis\" \/><span class=\"wpcf7-list-item-label\">Hepatitis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Herpes\" \/><span class=\"wpcf7-list-item-label\">Herpes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Immune System Disorder\" \/><span class=\"wpcf7-list-item-label\">Immune System Disorder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Irregular Heart Beat\" \/><span class=\"wpcf7-list-item-label\">Irregular Heart Beat<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Gallbladder Disease\" \/><span class=\"wpcf7-list-item-label\">Gallbladder Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"diseases4[]\" value=\"Heart Disease\" \/><span class=\"wpcf7-list-item-label\">Heart Disease<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"diseases3\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Irritable Bowel\" \/><span class=\"wpcf7-list-item-label\">Irritable Bowel<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Heartburn\/Reflux\" \/><span class=\"wpcf7-list-item-label\">Heartburn\/Reflux<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Hiatal Hernia\" \/><span class=\"wpcf7-list-item-label\">Hiatal Hernia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"High Blood Pressure\" \/><span class=\"wpcf7-list-item-label\">High Blood Pressure<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"High Colesterol\" \/><span class=\"wpcf7-list-item-label\">High Colesterol<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"High Triglycerides\" \/><span class=\"wpcf7-list-item-label\">High Triglycerides<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Hip Problems\" \/><span class=\"wpcf7-list-item-label\">Hip Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Knee Problems\" \/><span class=\"wpcf7-list-item-label\">Knee Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Ankle Problems\" \/><span class=\"wpcf7-list-item-label\">Ankle Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Foot Problems\" \/><span class=\"wpcf7-list-item-label\">Foot Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Infertility\" \/><span class=\"wpcf7-list-item-label\">Infertility<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Liver Disease\" \/><span class=\"wpcf7-list-item-label\">Liver Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Kidney Disease\" \/><span class=\"wpcf7-list-item-label\">Kidney Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Migraines\/Headaches\" \/><span class=\"wpcf7-list-item-label\">Migraines\/Headaches<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Pace Maker\" \/><span class=\"wpcf7-list-item-label\">Pace Maker<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Pneumonia\" \/><span class=\"wpcf7-list-item-label\">Pneumonia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Prostrate Problems\" \/><span class=\"wpcf7-list-item-label\">Prostrate Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Psychiatric Care\" \/><span class=\"wpcf7-list-item-label\">Psychiatric Care<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Pulmonary Embolism\" \/><span class=\"wpcf7-list-item-label\">Pulmonary Embolism<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Reaction to Anesthesia\" \/><span class=\"wpcf7-list-item-label\">Reaction to Anesthesia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Rheumatic Fever\" \/><span class=\"wpcf7-list-item-label\">Rheumatic Fever<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Scleroderma\" \/><span class=\"wpcf7-list-item-label\">Scleroderma<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"STD\" \/><span class=\"wpcf7-list-item-label\">STD<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Polyscystic Ovarian Syndrome\" \/><span class=\"wpcf7-list-item-label\">Polyscystic Ovarian Syndrome<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Prostrate Cancer\" \/><span class=\"wpcf7-list-item-label\">Prostrate Cancer<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Shortness of Breath w\/Exertion\" \/><span class=\"wpcf7-list-item-label\">Shortness of Breath w\/Exertion<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Sleep Apnea\" \/><span class=\"wpcf7-list-item-label\">Sleep Apnea<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Stroke\" \/><span class=\"wpcf7-list-item-label\">Stroke<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Thyroid Disease\" \/><span class=\"wpcf7-list-item-label\">Thyroid Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Urinary Stress Incontinence\" \/><span class=\"wpcf7-list-item-label\">Urinary Stress Incontinence<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Uternine Cancer\" \/><span class=\"wpcf7-list-item-label\">Uternine Cancer<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Varicose Veins\" \/><span class=\"wpcf7-list-item-label\">Varicose Veins<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Seizure Disorder\" \/><span class=\"wpcf7-list-item-label\">Seizure Disorder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Sinus Infections\" \/><span class=\"wpcf7-list-item-label\">Sinus Infections<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Sjogrens Syndrome\" \/><span class=\"wpcf7-list-item-label\">Sjogrens Syndrome<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Stomach Ulcers\" \/><span class=\"wpcf7-list-item-label\">Stomach Ulcers<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Suicide Attempts\" \/><span class=\"wpcf7-list-item-label\">Suicide Attempts<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Thyroid Problems\" \/><span class=\"wpcf7-list-item-label\">Thyroid Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Tuberculosis\" \/><span class=\"wpcf7-list-item-label\">Tuberculosis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Vaginal Infections\" \/><span class=\"wpcf7-list-item-label\">Vaginal Infections<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Venereal Disease\" \/><span class=\"wpcf7-list-item-label\">Venereal Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"diseases3[]\" value=\"Other:\" \/><span class=\"wpcf7-list-item-label\">Other:<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label>Surgical History*<br \/>\nPlease list all surgical procedures you have had in the past. Include the name\/type of operation and the year the procedure was conducted.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"surgical-history\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"surgical-history\" \/><\/span> <\/label>\n<\/p>\n<p><label>Preferred Pharmacy*<br \/>\nPlease give name, location, and phone number.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"preferred-pharmacy\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"preferred-pharmacy\" \/><\/span> <\/label>\n<\/p>\n<p><label>Current Medications*<br \/>\nList Drug name, dose, frequency, route, and reason for taking. Include Herbal and Over the Counter Medications.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications\" \/><\/span> <\/label>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"fusion-alert alert custom alert-custom fusion-alert-center wpcf7-response-output awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" style=\"--awb-border-size:1px;--awb-border-top-left-radius:0px;--awb-border-top-right-radius:0px;--awb-border-bottom-left-radius:0px;--awb-border-bottom-right-radius:0px;\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"fusion-alert-content\"><\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div>\n<\/form>\n<\/div>\n\n<\/div><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","footnotes":""},"_links":{"self":[{"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/pages\/5997"}],"collection":[{"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/comments?post=5997"}],"version-history":[{"count":2,"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/pages\/5997\/revisions"}],"predecessor-version":[{"id":6000,"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/pages\/5997\/revisions\/6000"}],"wp:attachment":[{"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/media?parent=5997"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}