{"id":931,"date":"2025-12-22T20:01:23","date_gmt":"2025-12-22T20:01:23","guid":{"rendered":"https:\/\/drorthodontistes.com\/?page_id=931"},"modified":"2026-04-14T09:22:00","modified_gmt":"2026-04-14T13:22:00","slug":"form","status":"publish","type":"page","link":"https:\/\/drorthodontistes.com\/en\/form\/","title":{"rendered":"Medical Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"931\" class=\"elementor elementor-931\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ec5597e e-con-full e-flex e-con e-parent\" data-id=\"ec5597e\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;shape_divider_bottom&quot;:&quot;opacity-tilt&quot;}\">\n\t\t\t\t<div class=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"false\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 2600 131.1\" preserveAspectRatio=\"none\">\n\t<path class=\"elementor-shape-fill\" d=\"M0 0L2600 0 2600 69.1 0 0z\"\/>\n\t<path class=\"elementor-shape-fill\" style=\"opacity:0.5\" d=\"M0 0L2600 0 2600 69.1 0 69.1z\"\/>\n\t<path class=\"elementor-shape-fill\" style=\"opacity:0.25\" d=\"M2600 0L0 0 0 130.1 2600 69.1z\"\/>\n<\/svg>\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-7dd8466 e-flex e-con-boxed e-con e-child\" data-id=\"7dd8466\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-14d8be3 elementor-widget elementor-widget-heading\" data-id=\"14d8be3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Medical Intake Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-2debda2 e-flex e-con-boxed e-con e-parent\" data-id=\"2debda2\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d5e3419 elementor-button-align-start elementor-widget elementor-widget-form\" data-id=\"d5e3419\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t\t<template id=\"cfef_logic_data_d5e3419\" class=\"cfef_logic_data_js\" data-form-id=\"d5e3419\">{&quot;field_27d09a6&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;549b823&quot;}]},&quot;field_a043015&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;d2cb14e&quot;}]},&quot;field_215bd96&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;d2cb14e&quot;}]},&quot;field_e1b59da&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;d2cb14e&quot;}]},&quot;field_ba2ca09&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;e30cb0e&quot;}]},&quot;field_90a1ea7&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;1216983&quot;}]},&quot;field_84fe0f1&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;21ecd86&quot;}]},&quot;field_a900c02&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;f57a798&quot;}]},&quot;field_b771167&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;549b823&quot;}]},&quot;field_822b8a2&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;d2cb14e&quot;}]},&quot;field_33e12ca&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;d2cb14e&quot;}]},&quot;field_3c0174e&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;d2cb14e&quot;}]},&quot;field_a51c512&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;e30cb0e&quot;}]},&quot;field_15c2a86&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;1216983&quot;}]},&quot;field_de0c88d&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;21ecd86&quot;}]},&quot;field_7b74876&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;calculated_age&quot;,&quot;cfef_logic_field_is&quot;:&quot;&lt;&quot;,&quot;cfef_logic_compare_value&quot;:&quot;18&quot;,&quot;_id&quot;:&quot;f57a798&quot;}]},&quot;field_6a9380f&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;second_address&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;a637e7c&quot;}]},&quot;field_1dc7513&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;second_address&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;8f30df1&quot;}]},&quot;field_8d0577f&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;second_address&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;55b8a4f&quot;}]},&quot;field_80160e5&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;second_address&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;aefd34e&quot;}]},&quot;field_78b6a75&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;second_address&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;096a07e&quot;}]},&quot;field_57c1182&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;second_address&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;0529994&quot;}]},&quot;field_e44e636&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;see_doc&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;8ce2bee&quot;}]},&quot;field_4da3e80&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;see_doc&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;8ce2bee&quot;}]},&quot;field_824513d&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;meds&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;8ce2bee&quot;}]},&quot;field_5c46e54&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;tonsils_adenoids&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;8ce2bee&quot;}]},&quot;field_379ef9c&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;allergies&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;8ce2bee&quot;}]},&quot;field_cb23001&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;family&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;e0acc88&quot;}]}}<\/template>\t\t<form class=\"elementor-form\" method=\"post\" id=\"medical_intake\" name=\"New Form\" aria-label=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"931\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"d5e3419\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Medical Intake Form - Dr. Luigi Di Battista \u2013 Orthodontistes Montr\u00e9al\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"931\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-date elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-date\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of Appointment\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[date]\" id=\"form-field-date\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7c58a63 elementor-col-100\">\n\t\t\t\t\t<h1><br>Patient Information<\/h1>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1d7db49 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1d7db49\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1d7db49]\" id=\"form-field-field_1d7db49\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7838563 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7838563\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7838563]\" id=\"form-field-field_7838563\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_254aec4 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_254aec4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGender at Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_254aec4]\" id=\"form-field-field_254aec4\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Male\">Male<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Female\">Female<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_6606b7c elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6606b7c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChosen Gender\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_6606b7c]\" id=\"form-field-field_6606b7c\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Male\">Male<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Female\">Female<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_af17173 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_af17173\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReferred by\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_af17173]\" id=\"form-field-field_af17173\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e4014f5 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e4014f5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName of Dentist\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e4014f5]\" id=\"form-field-field_e4014f5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d71e9b6 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d71e9b6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReason for your visit\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d71e9b6]\" id=\"form-field-field_d71e9b6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_c5e02f3 elementor-col-100\">\n\t\t\t\t\t<b><br>Primary Address & Contact Information<\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bd42e6b elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bd42e6b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStreet Address 1\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bd42e6b]\" id=\"form-field-field_bd42e6b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_580a0a4 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_580a0a4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStreet Address 2\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_580a0a4]\" id=\"form-field-field_580a0a4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7022a72 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7022a72\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7022a72]\" id=\"form-field-field_7022a72\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_fef433a elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fef433a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProvince\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_fef433a]\" id=\"form-field-field_fef433a\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Quebec\" selected=\"selected\">Quebec<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alberta\">Alberta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"British Columbia\">British Columbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Manitoba\">Manitoba<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Brunswick\">New Brunswick<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Newfoundland and Labrador\">Newfoundland and Labrador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Northwest Territories\">Northwest Territories<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nova Scotia\">Nova Scotia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nunavut\">Nunavut<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ontario\">Ontario<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prince Edward Island\">Prince Edward Island<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saskatchewan\">Saskatchewan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yukon\">Yukon<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_fcd9d2e elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fcd9d2e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPostal Code\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_fcd9d2e]\" id=\"form-field-field_fcd9d2e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2680267 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2680267\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPrimary Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2680267]\" id=\"form-field-field_2680267\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5ef16a6 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5ef16a6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSecondary Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5ef16a6]\" id=\"form-field-field_5ef16a6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_23f6c0b elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_23f6c0b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_23f6c0b]\" id=\"form-field-field_23f6c0b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_ed78237 elementor-col-100\">\n\t\t\t\t\t<b><br>Patient Profile Information<\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-user_dob elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-user_dob\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[user_dob]\" id=\"form-field-user_dob\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-calculated_age elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-calculated_age\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAge\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[calculated_age]\" id=\"form-field-calculated_age\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" min=\"1\" max=\"120\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_27d09a6 elementor-col-100\">\n\t\t\t\t\t<b><br>Parent \/ Legal Guardian 1<\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_a043015 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a043015\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPayment\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Responsible for payment?\" id=\"form-field-field_a043015-0\" name=\"form_fields[field_a043015]\"> <label for=\"form-field-field_a043015-0\">Responsible for payment?<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_215bd96 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_215bd96\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelationship to Patient\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_215bd96]\" id=\"form-field-field_215bd96\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e1b59da elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e1b59da\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e1b59da]\" id=\"form-field-field_e1b59da\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ba2ca09 elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ba2ca09\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ba2ca09]\" id=\"form-field-field_ba2ca09\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_90a1ea7 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_90a1ea7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPrimary Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_90a1ea7]\" id=\"form-field-field_90a1ea7\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_84fe0f1 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_84fe0f1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSecondary Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_84fe0f1]\" id=\"form-field-field_84fe0f1\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_a900c02 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a900c02\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_a900c02]\" id=\"form-field-field_a900c02\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_b771167 elementor-col-100\">\n\t\t\t\t\t<b><br>Parent \/ Legal Guardian 2<\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_822b8a2 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_822b8a2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPayment 2\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Responsible for payment?\" id=\"form-field-field_822b8a2-0\" name=\"form_fields[field_822b8a2]\"> <label for=\"form-field-field_822b8a2-0\">Responsible for payment?<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_33e12ca elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_33e12ca\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelationship to Patient\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_33e12ca]\" id=\"form-field-field_33e12ca\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3c0174e elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3c0174e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3c0174e]\" id=\"form-field-field_3c0174e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a51c512 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a51c512\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a51c512]\" id=\"form-field-field_a51c512\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_15c2a86 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_15c2a86\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPrimary Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_15c2a86]\" id=\"form-field-field_15c2a86\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_de0c88d elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_de0c88d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSecondary Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_de0c88d]\" id=\"form-field-field_de0c88d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_7b74876 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7b74876\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_7b74876]\" id=\"form-field-field_7b74876\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-second_address elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-second_address\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDoes the patient have a secondary address?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-second_address-0\" name=\"form_fields[second_address]\" required=\"required\"> <label for=\"form-field-second_address-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-second_address-1\" name=\"form_fields[second_address]\" required=\"required\"> <label for=\"form-field-second_address-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6a9380f elementor-col-100\">\n\t\t\t\t\t<b><br>Secondary Address <\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1dc7513 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1dc7513\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStreet Address 1\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1dc7513]\" id=\"form-field-field_1dc7513\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8d0577f elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8d0577f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStreet Address 2\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8d0577f]\" id=\"form-field-field_8d0577f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_80160e5 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_80160e5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_80160e5]\" id=\"form-field-field_80160e5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_78b6a75 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_78b6a75\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProvince\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_78b6a75]\" id=\"form-field-field_78b6a75\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Quebec\" selected=\"selected\">Quebec<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alberta\">Alberta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"British Columbia\">British Columbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Manitoba\">Manitoba<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Brunswick\">New Brunswick<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Newfoundland and Labrador\">Newfoundland and Labrador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Northwest Territories\">Northwest Territories<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nova Scotia\">Nova Scotia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nunavut\">Nunavut<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ontario\">Ontario<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prince Edward Island\">Prince Edward Island<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saskatchewan\">Saskatchewan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yukon\">Yukon<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_57c1182 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_57c1182\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPostal Code\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_57c1182]\" id=\"form-field-field_57c1182\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_484d0e5 elementor-col-100\">\n\t\t\t\t\t<h1>Medical History<\/h1>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8f4e8a4 elementor-col-100\">\n\t\t\t\t\t<b>Are you currently, or have you ever suffered from:<\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_baf332c elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_baf332c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tArthritis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_baf332c-0\" name=\"form_fields[field_baf332c]\"> <label for=\"form-field-field_baf332c-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_baf332c-1\" name=\"form_fields[field_baf332c]\"> <label for=\"form-field-field_baf332c-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_9bf669c elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9bf669c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAnemia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_9bf669c-0\" name=\"form_fields[field_9bf669c]\"> <label for=\"form-field-field_9bf669c-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_9bf669c-1\" name=\"form_fields[field_9bf669c]\"> <label for=\"form-field-field_9bf669c-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_c7e4413 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c7e4413\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAsthma\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_c7e4413-0\" name=\"form_fields[field_c7e4413]\"> <label for=\"form-field-field_c7e4413-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_c7e4413-1\" name=\"form_fields[field_c7e4413]\"> <label for=\"form-field-field_c7e4413-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_fb08cbf elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fb08cbf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDiabetes\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_fb08cbf-0\" name=\"form_fields[field_fb08cbf]\"> <label for=\"form-field-field_fb08cbf-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_fb08cbf-1\" name=\"form_fields[field_fb08cbf]\"> <label for=\"form-field-field_fb08cbf-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_742c28d elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_742c28d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDizziness\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_742c28d-0\" name=\"form_fields[field_742c28d]\"> <label for=\"form-field-field_742c28d-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_742c28d-1\" name=\"form_fields[field_742c28d]\"> <label for=\"form-field-field_742c28d-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_38d2260 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_38d2260\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEar Aches\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_38d2260-0\" name=\"form_fields[field_38d2260]\"> <label for=\"form-field-field_38d2260-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_38d2260-1\" name=\"form_fields[field_38d2260]\"> <label for=\"form-field-field_38d2260-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_73a26e3 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_73a26e3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEpilepsy\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_73a26e3-0\" name=\"form_fields[field_73a26e3]\"> <label for=\"form-field-field_73a26e3-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_73a26e3-1\" name=\"form_fields[field_73a26e3]\"> <label for=\"form-field-field_73a26e3-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_dbbe9d2 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dbbe9d2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFainting Spells\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_dbbe9d2-0\" name=\"form_fields[field_dbbe9d2]\"> <label for=\"form-field-field_dbbe9d2-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_dbbe9d2-1\" name=\"form_fields[field_dbbe9d2]\"> <label for=\"form-field-field_dbbe9d2-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_ce3f2b5 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ce3f2b5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFrequent Headaches\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_ce3f2b5-0\" name=\"form_fields[field_ce3f2b5]\"> <label for=\"form-field-field_ce3f2b5-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_ce3f2b5-1\" name=\"form_fields[field_ce3f2b5]\"> <label for=\"form-field-field_ce3f2b5-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_c1c749e elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c1c749e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHeart Disease\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_c1c749e-0\" name=\"form_fields[field_c1c749e]\"> <label for=\"form-field-field_c1c749e-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_c1c749e-1\" name=\"form_fields[field_c1c749e]\"> <label for=\"form-field-field_c1c749e-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_f052ee1 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f052ee1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHigh or Low Blood Pressure\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_f052ee1-0\" name=\"form_fields[field_f052ee1]\"> <label for=\"form-field-field_f052ee1-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_f052ee1-1\" name=\"form_fields[field_f052ee1]\"> <label for=\"form-field-field_f052ee1-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_aa31a63 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_aa31a63\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tKidney \/ Liver Disease\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_aa31a63-0\" name=\"form_fields[field_aa31a63]\"> <label for=\"form-field-field_aa31a63-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_aa31a63-1\" name=\"form_fields[field_aa31a63]\"> <label for=\"form-field-field_aa31a63-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_b2cc0ae elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b2cc0ae\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNervous Disorders\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_b2cc0ae-0\" name=\"form_fields[field_b2cc0ae]\"> <label for=\"form-field-field_b2cc0ae-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_b2cc0ae-1\" name=\"form_fields[field_b2cc0ae]\"> <label for=\"form-field-field_b2cc0ae-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_3c6b1cf elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3c6b1cf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOsteoporosis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_3c6b1cf-0\" name=\"form_fields[field_3c6b1cf]\"> <label for=\"form-field-field_3c6b1cf-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_3c6b1cf-1\" name=\"form_fields[field_3c6b1cf]\"> <label for=\"form-field-field_3c6b1cf-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_cc16c82 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cc16c82\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRadiation Treatment (Cancer)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_cc16c82-0\" name=\"form_fields[field_cc16c82]\"> <label for=\"form-field-field_cc16c82-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_cc16c82-1\" name=\"form_fields[field_cc16c82]\"> <label for=\"form-field-field_cc16c82-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_c2dddc4 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c2dddc4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRheumatic Fever\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_c2dddc4-0\" name=\"form_fields[field_c2dddc4]\"> <label for=\"form-field-field_c2dddc4-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_c2dddc4-1\" name=\"form_fields[field_c2dddc4]\"> <label for=\"form-field-field_c2dddc4-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_32b18c6 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_32b18c6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tThyroid Problem\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_32b18c6-0\" name=\"form_fields[field_32b18c6]\"> <label for=\"form-field-field_32b18c6-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_32b18c6-1\" name=\"form_fields[field_32b18c6]\"> <label for=\"form-field-field_32b18c6-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_c4831d3 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c4831d3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTuberculosis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_c4831d3-0\" name=\"form_fields[field_c4831d3]\"> <label for=\"form-field-field_c4831d3-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_c4831d3-1\" name=\"form_fields[field_c4831d3]\"> <label for=\"form-field-field_c4831d3-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_a82998c elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a82998c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>Do you take any bisphosphonates?<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_a82998c-0\" name=\"form_fields[field_a82998c]\"> <label for=\"form-field-field_a82998c-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_a82998c-1\" name=\"form_fields[field_a82998c]\"> <label for=\"form-field-field_a82998c-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_117304b elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_117304b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>Do you snore or have you been told you do?<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_117304b-0\" name=\"form_fields[field_117304b]\"> <label for=\"form-field-field_117304b-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_117304b-1\" name=\"form_fields[field_117304b]\"> <label for=\"form-field-field_117304b-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-see_doc elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-see_doc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>Are you currently under a doctor's care?<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-see_doc-0\" name=\"form_fields[see_doc]\"> <label for=\"form-field-see_doc-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-see_doc-1\" name=\"form_fields[see_doc]\"> <label for=\"form-field-see_doc-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e44e636 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e44e636\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>If YES, for what reason?<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e44e636]\" id=\"form-field-field_e44e636\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4da3e80 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4da3e80\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>Name your physician<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4da3e80]\" id=\"form-field-field_4da3e80\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-meds elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-meds\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>Are you currently taking any medications, or have you taken any in the last six months?<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-meds-0\" name=\"form_fields[meds]\"> <label for=\"form-field-meds-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-meds-1\" name=\"form_fields[meds]\"> <label for=\"form-field-meds-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_824513d elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_824513d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>If YES, which medication(s)?<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_824513d]\" id=\"form-field-field_824513d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_33193d4 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_33193d4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>Are you HIV Positive?<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_33193d4-0\" name=\"form_fields[field_33193d4]\"> <label for=\"form-field-field_33193d4-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_33193d4-1\" name=\"form_fields[field_33193d4]\"> <label for=\"form-field-field_33193d4-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_23c18bb elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_23c18bb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>Do you bleed abnormally when injured?<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_23c18bb-0\" name=\"form_fields[field_23c18bb]\"> <label for=\"form-field-field_23c18bb-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_23c18bb-1\" name=\"form_fields[field_23c18bb]\"> <label for=\"form-field-field_23c18bb-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_3991905 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3991905\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>Do you have frequent colds?<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_3991905-0\" name=\"form_fields[field_3991905]\"> <label for=\"form-field-field_3991905-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_3991905-1\" name=\"form_fields[field_3991905]\"> <label for=\"form-field-field_3991905-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-tonsils_adenoids elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-tonsils_adenoids\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>Have your tonsils and\/or adenoids been removed?<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-tonsils_adenoids-0\" name=\"form_fields[tonsils_adenoids]\"> <label for=\"form-field-tonsils_adenoids-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-tonsils_adenoids-1\" name=\"form_fields[tonsils_adenoids]\"> <label for=\"form-field-tonsils_adenoids-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5c46e54 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5c46e54\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>If YES, when?<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5c46e54]\" id=\"form-field-field_5c46e54\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-allergies elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-allergies\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>Do you suffer from any allergies (respiratory, food or dietary, medication or other)?<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-allergies-0\" name=\"form_fields[allergies]\"> <label for=\"form-field-allergies-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-allergies-1\" name=\"form_fields[allergies]\"> <label for=\"form-field-allergies-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_379ef9c elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_379ef9c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>If YES, please specify<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_379ef9c]\" id=\"form-field-field_379ef9c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_9059219 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9059219\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b><br>Please add anything else you'd like to mention about your medical history:<\/b>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_9059219]\" id=\"form-field-field_9059219\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7cb3999 elementor-col-100\">\n\t\t\t\t\t<h1>Dental History<\/h1>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_309f7f4 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_309f7f4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of your last Dentist's Examination\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_309f7f4]\" id=\"form-field-field_309f7f4\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0ddcb01 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0ddcb01\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow many times a year do you visit the dentist?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0ddcb01]\" id=\"form-field-field_0ddcb01\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9d149f4 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9d149f4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow many times do you brush your teeth per day?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9d149f4]\" id=\"form-field-field_9d149f4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_7dddfbd elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7dddfbd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you ever had an accident to your face?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_7dddfbd-0\" name=\"form_fields[field_7dddfbd]\"> <label for=\"form-field-field_7dddfbd-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_7dddfbd-1\" name=\"form_fields[field_7dddfbd]\"> <label for=\"form-field-field_7dddfbd-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_382381b elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_382381b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you ever had an accident to your head or jaw bones?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_382381b-0\" name=\"form_fields[field_382381b]\"> <label for=\"form-field-field_382381b-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_382381b-1\" name=\"form_fields[field_382381b]\"> <label for=\"form-field-field_382381b-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_247ad82 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_247ad82\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDid you ever have an orthodontic treatment?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_247ad82-0\" name=\"form_fields[field_247ad82]\"> <label for=\"form-field-field_247ad82-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_247ad82-1\" name=\"form_fields[field_247ad82]\"> <label for=\"form-field-field_247ad82-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_3ea7ff5 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3ea7ff5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you hear any cracking noises in your jaw joints?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_3ea7ff5-0\" name=\"form_fields[field_3ea7ff5]\"> <label for=\"form-field-field_3ea7ff5-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_3ea7ff5-1\" name=\"form_fields[field_3ea7ff5]\"> <label for=\"form-field-field_3ea7ff5-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_0af3782 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0af3782\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you experience painful or bleeding gums?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_0af3782-0\" name=\"form_fields[field_0af3782]\"> <label for=\"form-field-field_0af3782-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_0af3782-1\" name=\"form_fields[field_0af3782]\"> <label for=\"form-field-field_0af3782-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_0ec3b47 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0ec3b47\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you undergone treatments for your gums (grafts, deep scaling)?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_0ec3b47-0\" name=\"form_fields[field_0ec3b47]\"> <label for=\"form-field-field_0ec3b47-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_0ec3b47-1\" name=\"form_fields[field_0ec3b47]\"> <label for=\"form-field-field_0ec3b47-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_08c7b39 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_08c7b39\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you bite your finger nails?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_08c7b39-0\" name=\"form_fields[field_08c7b39]\"> <label for=\"form-field-field_08c7b39-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_08c7b39-1\" name=\"form_fields[field_08c7b39]\"> <label for=\"form-field-field_08c7b39-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_8691c8e elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8691c8e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you grind your teeth?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_8691c8e-0\" name=\"form_fields[field_8691c8e]\"> <label for=\"form-field-field_8691c8e-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_8691c8e-1\" name=\"form_fields[field_8691c8e]\"> <label for=\"form-field-field_8691c8e-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_a870184 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a870184\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you chew gum for more than 15 minutes per day?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_a870184-0\" name=\"form_fields[field_a870184]\"> <label for=\"form-field-field_a870184-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_a870184-1\" name=\"form_fields[field_a870184]\"> <label for=\"form-field-field_a870184-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_4b057ec elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4b057ec\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you still suck your thumb?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_4b057ec-0\" name=\"form_fields[field_4b057ec]\"> <label for=\"form-field-field_4b057ec-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_4b057ec-1\" name=\"form_fields[field_4b057ec]\"> <label for=\"form-field-field_4b057ec-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_e3d32e0 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e3d32e0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you wish to correct the aesthetic appearance of your teeth?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_e3d32e0-0\" name=\"form_fields[field_e3d32e0]\"> <label for=\"form-field-field_e3d32e0-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_e3d32e0-1\" name=\"form_fields[field_e3d32e0]\"> <label for=\"form-field-field_e3d32e0-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_016c183 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_016c183\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you ever seen a speech therapist?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_016c183-0\" name=\"form_fields[field_016c183]\"> <label for=\"form-field-field_016c183-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_016c183-1\" name=\"form_fields[field_016c183]\"> <label for=\"form-field-field_016c183-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-family elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-family\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHas any other member of the family had an orthodontic treatment?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-family-0\" name=\"form_fields[family]\"> <label for=\"form-field-family-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-family-1\" name=\"form_fields[family]\"> <label for=\"form-field-family-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cb23001 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cb23001\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf YES, indicate the name of the professional who did the correction:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cb23001]\" id=\"form-field-field_cb23001\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_41c48f6 elementor-col-100\">\n\t\t\t\t\t<em><br>By clicking on the \"Submit\" button below, you acknowledge that you have read and accept our <a href=\"..\/privacy-policy\">Privacy Policy<\/a>.<\/em><br>&nbsp;\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-recaptcha_v3 elementor-field-group elementor-column elementor-field-group-field_722a6f5 elementor-col-100 recaptcha_v3-bottomright\">\n\t\t\t\t\t<div class=\"elementor-field\" id=\"form-field-field_722a6f5\"><div class=\"elementor-g-recaptcha\" data-sitekey=\"6LcQWpksAAAAACGIo4yC2hudBw-GoZqmK0jCwjVz\" data-type=\"v3\" data-action=\"Form\" data-badge=\"bottomright\" data-size=\"invisible\"><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-arrow-alt-circle-right\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M256 8c137 0 248 111 248 248S393 504 256 504 8 393 8 256 119 8 256 8zM140 300h116v70.9c0 10.7 13 16.1 20.5 8.5l114.3-114.9c4.7-4.7 4.7-12.2 0-16.9l-114.3-115c-7.6-7.6-20.5-2.2-20.5 8.5V212H140c-6.6 0-12 5.4-12 12v64c0 6.6 5.4 12 12 12z\"><\/path><\/svg>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Submit<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b8e01a8 elementor-widget elementor-widget-html\" data-id=\"b8e01a8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t\t<script src=\"https:\/\/code.jquery.com\/jquery-3.6.0.min.js\"><\/script>\n<script>\njQuery(document).ready(function($) {\n    \/\/ 1. Identify the fields using Elementor's ID structure\n    \/\/ Elementor adds \"form-field-\" before the ID you entered in the settings\n    var $dobField = $('#form-field-user_dob');\n    var $ageField = $('#form-field-calculated_age');\n\n    \/\/ 2. Listen for a change in the Date field\n    $dobField.on('change', function() {\n        var dobVal = $(this).val();\n        \n        if (dobVal) {\n            var dob = new Date(dobVal);\n            var today = new Date();\n            \n            \/\/ Calculate age based on year difference\n            var age = today.getFullYear() - dob.getFullYear();\n            var m = today.getMonth() - dob.getMonth();\n            \n            \/\/ Adjust if the birthday hasn't happened yet this year\n            if (m < 0 || (m === 0 && today.getDate() < dob.getDate())) {\n                age--;\n            }\n\n            \/\/ 3. Update the Age field and TRIGGER the change event\n            \/\/ The .trigger('change') is crucial for the Conditional Fields plugin to \"see\" the update\n            $ageField.val(age).trigger('change');\n        }\n    });\n});\n<\/script>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Medical Intake Form<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-931","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/drorthodontistes.com\/en\/wp-json\/wp\/v2\/pages\/931","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drorthodontistes.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/drorthodontistes.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/drorthodontistes.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/drorthodontistes.com\/en\/wp-json\/wp\/v2\/comments?post=931"}],"version-history":[{"count":3,"href":"https:\/\/drorthodontistes.com\/en\/wp-json\/wp\/v2\/pages\/931\/revisions"}],"predecessor-version":[{"id":2009,"href":"https:\/\/drorthodontistes.com\/en\/wp-json\/wp\/v2\/pages\/931\/revisions\/2009"}],"wp:attachment":[{"href":"https:\/\/drorthodontistes.com\/en\/wp-json\/wp\/v2\/media?parent=931"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}