{"id":13,"date":"2019-08-18T00:33:00","date_gmt":"2019-08-18T00:33:00","guid":{"rendered":"https:\/\/permissionform.toothprotectors.org\/?page_id=13"},"modified":"2026-05-01T06:52:42","modified_gmt":"2026-05-01T11:52:42","slug":"13-2","status":"publish","type":"page","link":"https:\/\/permissionform.toothprotectors.org\/","title":{"rendered":"School Dental Hygiene Program Permission Form 2026-2027 School Year"},"content":{"rendered":"\n<style type=\"text\/css\">#nex-forms{display:none;}<\/style><div id=\"nf_form_34046\">\r\n\t\t\t\r\n\t\t\t<style type=\"text\/css\">\r\n\t\t\t\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-spinner div:after {background: #40C4FF; }\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-grid div {background: #40C4FF; }\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-ellipsis div { background: #40C4FF;}\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-default div {background: #40C4FF;}\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-roller div:after {background: #40C4FF;}\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-heart div,\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-heart div:after,\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-heart div:before {background: #40C4FF;}\r\n\t\r\n\t\t\t\t\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-facebook div {background: #40C4FF;}\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-circle > div {background: #40C4FF;}\r\n\t\t\t\t\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-dual-ring:after {border: 6px solid #40C4FF;border-color: #40C4FF transparent #40C4FF transparent;}\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-ring div {border: 8px solid #40C4FF;border-color: #40C4FF transparent transparent transparent;}\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-hourglass:after {border: 32px solid #40C4FF;border-color: #40C4FF transparent #40C4FF transparent;}\r\n\t\t\t\t#nex-forms.school_dental_hygiene_program_permission_form_2026-2027_school_year .nf-loader-lds-ripple div {border: 4px solid #40C4FF;}\r\n\t\t\t<\/style>\r\n\t\t\t\r\n\t\t\t\r\n\t\t\t<div id=\"nex-forms\" data-loader=\"ellipsis\" data-msg-hide-form=\"yes\" data-msg-position=\"top\" data-msg-placement=\"outside\"  class=\"nex-forms school_dental_hygiene_program_permission_form_2026-2027_school_year  \"><div class=\"pre_fill_fields\"><\/div><div class=\"set_form_theme theme-base\"><div class=\"nex_success_message msg_top msgv2 animated hidden\" style=\"display:none;\"><div class=\"nex_success_message_container\" style=\"background: #fff;box-shadow: #00000033 0px 7px 16px 0px;border-radius: 4px;padding: 30px;border-color:#ddd\"><div class=\"msg_text\"><div class=\"form_field all_fields icon html_fields wow bounceInUp\" style=\"margin-bottom: 15px\" id=\"_21501\" data-animation-name=\"bounceInUp\">\n\t\t\t\t\t\t\t  <div class=\"edit_mask\"><\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<div class=\"icon_container_wrapper icon_center\">\n\t\t\t\t\t\t\t\t  <div class=\"icon_container\" id=\"field_container\" style=\"border-width: 0px;background-color: transparent\">\n\t\t\t\t\t\t\t\t\t<div class=\"\">\n\t\t\t\t\t\t\t\t\t  <div class=\"input_container\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"the_input_element icon_element\" style=\"font-size: 50px;color: #8bc34a\"><span class=\"fas fa-check-circle\"><\/span><\/div>\n\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"form_field all_fields html html_fields wow fadeInDown\" style=\"margin-bottom: 15px;position: relative;left: 0px;top: 0px\" data-animation-name=\"fadeInDown\" data-wow-delay=\"0.5s\" id=\"_6279\">\n\t\t\t\t\t\t\t  <div class=\"edit_mask\"><\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t  <div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t\t  <div class=\"col-sm-12 input_container\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"the_input_element align_center\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\"><h2 style=\"text-align: center\"><strong>Thank You!<\/strong><\/h2><br><p style=\"text-align: center\">Thank you for filling out our School Dental Hygiene Program Permission Form. We will add your child to the list to be seen for dental services.<\/p><br><p>Please complete this form for each child you wish to be seen!<\/p><br><br><br><h3 style=\"text-align: center\"><strong>Pay Your Bill Online...<\/strong><\/h3><br><p>If you're using self pay, pay now using the link below or visit the website <a href=\"https:\/\/www.toothprotectors.org\/product-category\/schools\/\">toothprotectors.org\/pay<\/a> to pay your bill anytime!<\/p><br><h3 style=\"text-align: center\"><span style=\"text-decoration: underline\"><span style=\"color: #339966\"><a style=\"color: #339966;text-decoration: underline\" href=\"https:\/\/www.toothprotectors.org\/product-category\/schools\/\">PAY NOW<\/a><\/span><\/span><\/h3><\/div>\n\t\t\t\t\t\t\t\t\t\t<div style=\"clear:both\"><\/div>\n\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div data-timer-start=\"1\" data-timer-end=\"0\" class=\"inner-canvas-container ui-nex-forms-container ui-nex-forms-container-fe  bootstrap\" id=\"ui-nex-forms-container-60\"  ><div class=\"current_step\" style=\"display:none;\">1<\/div><div class=\"last_visited_step\" style=\"display:none;\">1<\/div><div class=\"nex-forms-header-footer nex-forms-header timer_inline timer_right \"><div class=\"bc-outer-container \"><div style=\"\" class=\"nf_ms_breadcrumb  bc-gutter-20 bc-top bc-solid bc-connected bc-unfolded pilled \">\n\t\t\t\t\t\t\t\t\t\t<ul class=\"the_br align_left pilled md-color-light-blue has-no-descriptions\" data-align-crumb=\"align_left\" data-text-pos=\"text-bottom\" data-breadcrumb-type=\"pilled\" data-theme=\"light-blue\" data-show-front-end=\"yes\" data-show-inside=\"no\"><li class=\"no-description no-icon current\"><div class=\"crumb_container\"><div class=\"step_number_container\"><span class=\"the_step_num\">1<\/span><span class=\"the_step_icon \"><\/span><\/div><a href=\"#\" rel=\"nofollow\" data-show-step=\"1\"><div class=\"sreader\">1<\/div><div class=\"step_title\">General Information<\/div><div class=\"step_description\"><\/div><\/a><div class=\"step_connecter\" style=\"display:none\"><\/div><\/div><\/li><li class=\"no-description no-icon\"><div class=\"crumb_container\"><div class=\"step_number_container\"><span class=\"the_step_num\">2<\/span><span class=\"the_step_icon \"><\/span><\/div><a href=\"#\" rel=\"nofollow\" data-show-step=\"2\"><div class=\"sreader\">2<\/div><div class=\"step_title\">Dental Services<\/div><div class=\"step_description\"><\/div><\/a><div class=\"step_connecter\" style=\"display:none\"><\/div><\/div><\/li><li class=\"no-description no-icon current-prev\"><div class=\"crumb_container\"><div class=\"step_number_container\"><span class=\"the_step_num\">3<\/span><span class=\"the_step_icon \"><\/span><\/div><a href=\"#\" rel=\"nofollow\" data-show-step=\"3\"><div class=\"sreader\">3<\/div><div class=\"step_title\">Insurance Coverage<\/div><div class=\"step_description\"><\/div><\/a><div class=\"step_connecter\" style=\"display:none\"><\/div><\/div><\/li><li class=\"no-description no-icon\"><div class=\"crumb_container\"><div class=\"step_number_container\"><span class=\"the_step_num\">4<\/span><span class=\"the_step_icon \"><\/span><\/div><a href=\"#\" rel=\"nofollow\" data-show-step=\"4\"><div class=\"sreader\">4<\/div><div class=\"step_title\">Medical \/ Dental History<\/div><div class=\"step_description\"><\/div><\/a><div class=\"step_connecter\" style=\"display:none\"><\/div><\/div><\/li><\/ul>\n\t\t\t\t\t\t\t\t\t\t<div class=\"nf_progressbar the_br\" style=\"display:none\" data-text-pos=\"text-bottom\" data-breadcrumb-type=\"pilled\" data-theme=\"light-blue\" data-show-front-end=\"yes\" data-show-inside=\"no\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"nf_progressbar_percentage md-color-light-blue\" style=\"width:5%\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span>0%<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t<div style=\"clear:both\"><\/div>\n\t\t\t\t\t\t\t\t\t<\/div><\/div><\/div><div id=\"the_plugin_url\" style=\"display:none;\">https:\/\/permissionform.toothprotectors.org\/wp-content\/plugins\/nex-forms-express-wp-form-builder<\/div><div id=\"nf_save_form_progress\" style=\"display:none;\">true<\/div><div id=\"confirmation_page\" class=\"confirmation_page\" style=\"display:none;\"><\/div><div id=\"on_form_submmision\" class=\"on_form_submmision\" style=\"display:none;\">message<\/div><div class=\"hidden\" id=\"nf_ajax_url\" style=\"display:none;\">https:\/\/permissionform.toothprotectors.org\/wp-admin\/admin-ajax.php<\/div><div class=\"hidden\" id=\"paypal_return_url\" style=\"display:none;\">https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/pages\/13<\/div><div class=\"hidden\" id=\"ms_scroll_to_top\" style=\"display:none;\">yes<\/div><div class=\"v7_container form_type_normal   \" style=\"width: 100%;border-color: #c0c0c0;background: #ffffff;border-width: 0px\"><div class=\"current_field_on_focus\" style=\"display:none\">1<\/div><form id=\"60\" class=\"submit-nex-form nex-forms-60\" data-form-id=\"60\" name=\"nex_form\" action=\"https:\/\/permissionform.toothprotectors.org\/wp-admin\/admin-ajax.php\" method=\"post\" enctype=\"multipart\/form-data\"><div class=\"step_transition_in\" style=\"display:none;\">fadeIn<\/div><div class=\"step_transition_out\" style=\"display:none;\">fadeOut<\/div><input type=\"hidden\" name=\"nex_forms_Id\" value=\"60\"><input type=\"hidden\" name=\"page\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/13\"><input type=\"hidden\" name=\"ip\" value=\"192.168.40.34\"><input type=\"hidden\" name=\"nf_page_id\" value=\"13\"><input type=\"hidden\" name=\"nf_page_title\" value=\"School Dental Hygiene Program Permission Form 2026-2027 School Year\"><input type=\"text\" name=\"company_url\" value=\"\" placeholder=\"enter company url\" class=\"form-control req\">\n\t\t\t\t\t\t\t<div class=\"form_field hidden bootstrap_field\" data-id=\"_1610\" id=\"_1610\">\n\t\t\t\t\t\t\t\t<input class=\"ms_current_step\" value=\"1\" name=\"ms_current_step\" type=\"hidden\" id=\"_1610__ms_current_step\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"custom-fields step bootstrap_field has_prefix_icon nf_multi_step_1 is_grid\" data-step-name=\"General Information\" data-step-num=\"1\" data-id=\"_51568\" id=\"_51568\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"form_field all_fields heading html_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_83820\" id=\"_83820\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_83820__math_result\"><h1 class=\"the_input_element align_center\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">General Information<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph html_fields\" style=\"margin-bottom: 15px\" id=\"_60381\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_60381__math_result\"><div class=\"the_input_element align_center style_underline\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\" style=\"color: #000000\">Please have your insurance or credit\/debit card available as it is needed to complete this form.<\/div><div style=\"clear:both\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph html_fields\" style=\"margin-bottom: 15px\" id=\"_30930\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_30930__math_result\"><div class=\"the_input_element align_center style_underline style_bold\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\" style=\"color: #000000\">THIS FORM PROVIDES PERMISSION FOR YOUR CHILD TO BE SEEN TWO TIMES DURING THIS<br>SCHOOL YEAR FOR DENTAL CARE<\/div><div style=\"clear:both\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph html_fields\" style=\"margin-bottom: 15px\" id=\"_46513\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_46513__math_result\"><div class=\"the_input_element align_center style_bold style_underline\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\" style=\"color: #000000\">PLEASE FILL OUT ONE FORM PER CHILD TO BE SEEN<\/div><div style=\"clear:both\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider html_fields bootstrap_field\" style=\"position: relative;left: 0px;top: 0px\" data-id=\"_50487\" id=\"_50487\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><hr class=\"the_input_element\" style=\"border-width: 3px 0px\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 bootstrap_field is_grid\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_91724\" id=\"_91724\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_91724  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields required bootstrap_field\" style=\"z-index: 1000000\" data-id=\"_98587\" id=\"_98587\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__98587\"><span class=\"the_label style_bold\" style=\"color: #000000\">*School's Full Name<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"schools_full_name\" class=\"form-control error_message the_input_element  aling_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__98587\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_91724  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields required bootstrap_field\" style=\"position: relative;left: 0px;top: 0px\" data-id=\"_37220\" id=\"_37220\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__37220\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Grade<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"grade\" class=\"form-control error_message the_input_element  aling_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__37220\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_91724  col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"form_field all_fields text common_fields bootstrap_field\" style=\"position: relative;left: 0px;top: 0px\" data-id=\"_76662\" id=\"_76662\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__76662\"><span class=\"the_label style_bold\" style=\"color: #000000\">Teacher<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"teacher\" class=\"form-control error_message the_input_element  aling_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__76662\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 bootstrap_field has_prefix_icon is_grid\" style=\"position: relative;top: 0px\" data-id=\"_46771\" id=\"_46771\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_46771  col-sm-12 grid-target-0\" data-grid-width=\"12\" data-grid-num=\"0\"><div class=\"grid-system-2 has_prefix_icon is_grid\" style=\"position: relative;top: 0px\" data-id=\"_24104\" id=\"_24104\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_24104  col-sm-9 grid-target-0\" data-grid-width=\"9\" data-grid-num=\"0\"><div class=\"form_field all_fields name preset_fields required bootstrap_field has_prefix_icon\" style=\"position: relative;top: 0px\" data-id=\"_39272\" id=\"_39272\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__39272\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Child's Full Legal Name<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix\" style=\"color: #000000;border-color: #000000\"><span class=\"fa fa-user\"><\/span><\/span><input type=\"text\" name=\"childs_full_legal_name\" class=\"error_message required  form-control the_input_element  aling_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__39272\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_24104  col-sm-3 grid-target-1\" data-grid-width=\"3\" data-grid-num=\"1\"><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field required\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_68260\" id=\"_68260\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">*Gender as marked on insurance<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 input_container error_message the-radios align_center\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-layout=\"\"><label class=\"radio-inline \" for=\"__60__68260_gender_as_marked_on_insurance_Female_female\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"gender_as_marked_on_insurance\" id=\"__60__68260_gender_as_marked_on_insurance_Female_female\" value=\"Female\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Female<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__60__68260_gender_as_marked_on_insurance_Male_male\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"gender_as_marked_on_insurance\" id=\"__60__68260_gender_as_marked_on_insurance_Male_male\" value=\"Male\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Male<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields date special_fields required has_prefix_icon\" style=\"position: relative;top: 0px\" data-id=\"_8885\" id=\"_8885\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let align_center col-sm-12\"><label class=\"nf_title \" for=\"input__8885\"><span class=\"the_label style_bold\" style=\"color: #000000\">* Date of Birth:<\/span><\/label><\/div><div class=\"input_container col-sm-12\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"MM\/DD\/YYYY\" data-language=\"en\" data-max-date=\"2021\/01\/01\"><span class=\"input-group-addon prefix\" style=\"border-color: #000000;color: #000000\"><span class=\"fa fa-calendar-o\"><\/span><\/span><input type=\"text\" name=\"_date_of_birth:\" class=\"error_message form-control the_input_element  aling_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"border-color: #000000\" id=\"input__8885\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields is_focused numbers_only\" style=\"margin-bottom: 15px;position: relative;left: 0px;top: 0px\" data-id=\"_90367\" id=\"_90367\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_left\"><label class=\"nf_title \" for=\"input__90367\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #000000\">Age<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"age\" class=\"form-control error_message the_input_element aling_left align_left numbers_only\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Only numbers are allowed\" title=\"\" style=\"font-size: 13px;color: #000000;background: #ffffff none repeat scroll 0% 0%;border-color: #444444\" placeholder=\"Enter child's current age in years\" minlength=\"1\" id=\"input__90367\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 bootstrap_field is_grid\" style=\"position: relative;left: 0px;top: 0px\" data-id=\"_73496\" id=\"_73496\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_73496  col-sm-12 grid-target-0\" data-grid-width=\"12\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields bootstrap_field\" style=\"position: relative;top: 0px\" data-id=\"_96651\" id=\"_96651\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__96651\"><span class=\"the_label style_bold\" style=\"color: #000000\">Mailing Address<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"mailing_address\" class=\"form-control error_message the_input_element  aling_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__96651\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_11695\" id=\"_11695\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__11695\"><span class=\"the_label style_bold\" style=\"color: #000000\">Town<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"town\" class=\"form-control error_message the_input_element  aling_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__11695\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields numbers_only bootstrap_field\" style=\"position: relative;top: 0px\" data-id=\"_56063\" id=\"_56063\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__56063\"><span class=\"the_label style_bold\" style=\"color: #000000\">Zip Code<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"zip_code\" class=\"form-control error_message the_input_element  aling_left numbers_only\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Only numbers are allowed\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__56063\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 bootstrap_field has_prefix_icon is_grid\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_83582\" id=\"_83582\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_83582  col-sm-5 grid-target-0\" data-grid-width=\"5\" data-grid-num=\"0\"><div class=\"form_field all_fields phone_number phone_number preset_fields required bootstrap_field has_prefix_icon\" data-id=\"_26892\" id=\"_26892\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__26892\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Home Phone<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix\" style=\"color: #000000;border-color: #000000\"><span class=\"fa fa-phone\"><\/span><\/span><input type=\"text\" name=\"home_phone\" class=\"error_message required phone_number form-control the_input_element  aling_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid phone number\" style=\"color: #444444;background: #ffffff;border-color: #000000\" minlength=\"10\" maxlength=\"10\" data-length=\"10\" id=\"input__26892\"><span class=\"character-counter\" style=\"float: right;font-size: 12px;height: 1px\"><\/span><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_83582  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields phone_number phone_number preset_fields required bootstrap_field has_prefix_icon\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_5237\" id=\"_5237\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__5237\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Cell Phone<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix\" style=\"color: #000000;border-color: #000000\"><span class=\"fa fa-phone\"><\/span><\/span><input type=\"text\" name=\"cell_phone\" class=\"error_message required phone_number form-control the_input_element  aling_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid phone number\" style=\"color: #444444;background: #ffffff;border-color: #000000\" maxlength=\"10\" data-length=\"10\" minlength=\"10\" id=\"input__5237\"><span class=\"character-counter\" style=\"float: right;font-size: 12px;height: 1px\"><\/span><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_83582  col-sm-3 grid-target-2\" data-grid-width=\"3\" data-grid-num=\"2\"><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field\" style=\"position: relative;left: 0px;top: 0px\" data-id=\"_65419\" id=\"_65419\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">Does the phone take texts?  <\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 input_container error_message the-radios\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline  \" for=\"__60__65419_does_the_phone_take_texts___Yes_yes\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"does_the_phone_take_texts__\" id=\"__60__65419_does_the_phone_take_texts___Yes_yes\" value=\"Yes\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Yes<\/span><\/span><\/label><label class=\"radio-inline  \" for=\"__60__65419_does_the_phone_take_texts___No_no\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"does_the_phone_take_texts__\" id=\"__60__65419_does_the_phone_take_texts___No_no\" value=\"No\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">No<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 has_prefix_icon is_grid\" data-id=\"_22831\" id=\"_22831\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_22831  col-sm-9 grid-target-0\" data-grid-width=\"9\" data-grid-num=\"0\"><div class=\"form_field all_fields email email preset_fields required has_prefix_icon\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_49872\" id=\"_49872\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let\"><label class=\"nf_title \" for=\"input__49872\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Email (must have to contact you &amp; future communications)<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix \" style=\"color: #000000;border-color: #000000\"><span class=\"fa fa-envelope\"><\/span><\/span><input type=\"text\" name=\"email_must_have_to_contact_you__future_communications\" class=\"error_message required email form-control the_input_element  aling_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid email address\" style=\"border-color: #000000\" id=\"input__49872\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_22831  col-sm-3 grid-target-1\" data-grid-width=\"3\" data-grid-num=\"1\"><div class=\"panel-default\"><div class=\"panel-body\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 nex_prev_steps bootstrap_field is_grid\" data-id=\"_32209\" id=\"_32209\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row grid_row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"grid_input_holder id-_32209  col-xs-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"form_field all_fields submit-button button_fields common_fields preset_fields special_fields selection_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px;z-index: 100\" data-id=\"_89499\" id=\"_89499\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12 input_container align_left\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <button class=\"svg_ready the_input_element btn btn-default prev-step\">Back<\/button>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"grid_input_holder id-_32209  col-xs-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"form_field all_fields submit-button button_fields common_fields preset_fields special_fields selection_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px;z-index: 100\" data-id=\"_43011\" id=\"_43011\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12 input_container align_right\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <button class=\"svg_ready the_input_element btn btn-default nex-step style_bold btn-lg text-center\" style=\"background-color: #62aef7;color: #ffffff\">Next<\/button>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div><div class=\"custom-fields step bootstrap_field nf_multi_step_2 is_grid\" data-step-name=\"Dental Services\" data-step-num=\"2\" style=\"display: none\" data-id=\"_72213\" id=\"_72213\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"form_field all_fields heading html_fields bootstrap_field\" data-id=\"_81210\" id=\"_81210\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_81210__math_result\"><h1 class=\"the_input_element align_center\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Dental Services<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider html_fields bootstrap_field\" data-id=\"_50108\" id=\"_50108\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><hr class=\"the_input_element\" style=\"border-width: 3px 0px\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field required for_rule__24681\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_80003\" id=\"_80003\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"label_container align_let align_center col-sm-12\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">*Please check ALL services you would like your child to receive \u2013 fees are for non-insured patients only<\/span><\/label><\/div><div class=\"input_container error_message the-radios col-sm-12\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-layout=\"1c\"><label class=\"radio-inline col-sm-12\" for=\"__60__80003_please_check_all_services_you_would_like_your_child_to_receive_\u2013_fees_are_for_non-insured_patients_only_I want Screening and Fluoride provided by the State Oral Health Program (SOHP)_i_want_screening_and_fluoride_provided_by_the_state_oral_health_program_sohp\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"please_check_all_services_you_would_like_your_child_to_receive_\u2013_fees_are_for_non-insured_patients_only\" id=\"__60__80003_please_check_all_services_you_would_like_your_child_to_receive_\u2013_fees_are_for_non-insured_patients_only_I want Screening and Fluoride provided by the State Oral Health Program (SOHP)_i_want_screening_and_fluoride_provided_by_the_state_oral_health_program_sohp\" value=\"I want Screening and Fluoride provided by the State Oral Health Program (SOHP)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">I want Screening and Fluoride provided by the State Oral Health Program (SOHP)<\/span><\/span><\/label><label class=\"radio-inline col-sm-12\" for=\"__60__80003_please_check_all_services_you_would_like_your_child_to_receive_\u2013_fees_are_for_non-insured_patients_only_I want ALL services my child needs that are covered by my insurance plan and services provided by the State Oral Health Program (SOHP). This includes Screening, Assessment, Oral Health Education, Full Cleaning, Fluoride and if needed Sealants, Temp Fillings, SDF, Referrals for restorative care, braces, extractions._i_want_all_services_my_child_needs_that_are_covered_by_my_insurance_plan_and_services_provided_by_the_state_oral_health_program_sohp_this_includes_screening_assessment_oral_health_education_full_cleaning_fluoride_and_if_needed_sealants_temp_fillings_sdf_referrals_for_restorative_care_braces_extractions\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"please_check_all_services_you_would_like_your_child_to_receive_\u2013_fees_are_for_non-insured_patients_only\" id=\"__60__80003_please_check_all_services_you_would_like_your_child_to_receive_\u2013_fees_are_for_non-insured_patients_only_I want ALL services my child needs that are covered by my insurance plan and services provided by the State Oral Health Program (SOHP). This includes Screening, Assessment, Oral Health Education, Full Cleaning, Fluoride and if needed Sealants, Temp Fillings, SDF, Referrals for restorative care, braces, extractions._i_want_all_services_my_child_needs_that_are_covered_by_my_insurance_plan_and_services_provided_by_the_state_oral_health_program_sohp_this_includes_screening_assessment_oral_health_education_full_cleaning_fluoride_and_if_needed_sealants_temp_fillings_sdf_referrals_for_restorative_care_braces_extractions\" value=\"I want ALL services my child needs that are covered by my insurance plan and services provided by the State Oral Health Program (SOHP). This includes Screening, Assessment, Oral Health Education, Full Cleaning, Fluoride and if needed Sealants, Temp Fillings, SDF, Referrals for restorative care, braces, extractions.\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">I want ALL services my child needs that are covered by my insurance plan and services provided by the State Oral Health Program (SOHP). This includes Screening, Assessment, Oral Health Education, Full Cleaning, Fluoride and if needed Sealants, Temp Fillings, SDF, Referrals for restorative care, braces, extractions.<\/span><\/span><\/label><label class=\"radio-inline col-sm-12\" for=\"__60__80003_please_check_all_services_you_would_like_your_child_to_receive_\u2013_fees_are_for_non-insured_patients_only_I want ONLY the services marked BELOW (check all services that you want your child to receive)_i_want_only_the_services_marked_below_check_all_services_that_you_want_your_child_to_receive\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"please_check_all_services_you_would_like_your_child_to_receive_\u2013_fees_are_for_non-insured_patients_only\" id=\"__60__80003_please_check_all_services_you_would_like_your_child_to_receive_\u2013_fees_are_for_non-insured_patients_only_I want ONLY the services marked BELOW (check all services that you want your child to receive)_i_want_only_the_services_marked_below_check_all_services_that_you_want_your_child_to_receive\" value=\"I want ONLY the services marked BELOW (check all services that you want your child to receive)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">I want ONLY the services marked BELOW (check all services that you want your child to receive)<\/span><\/span><\/label><label class=\"radio-inline col-sm-12\" for=\"__60__80003_please_check_all_services_you_would_like_your_child_to_receive_\u2013_fees_are_for_non-insured_patients_only_I DO NOT WANT any dental services. My child already receives regular dental cleanings 2 times a year._i_do_not_want_any_dental_services_my_child_already_receives_regular_dental_cleanings_2_times_a_year\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"please_check_all_services_you_would_like_your_child_to_receive_\u2013_fees_are_for_non-insured_patients_only\" id=\"__60__80003_please_check_all_services_you_would_like_your_child_to_receive_\u2013_fees_are_for_non-insured_patients_only_I DO NOT WANT any dental services. My child already receives regular dental cleanings 2 times a year._i_do_not_want_any_dental_services_my_child_already_receives_regular_dental_cleanings_2_times_a_year\" value=\"I DO NOT WANT any dental services. My child already receives regular dental cleanings 2 times a year.\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">I DO NOT WANT any dental services. My child already receives regular dental cleanings 2 times a year.<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading html_fields hidden\" style=\"margin-bottom: 15px;display: none\" id=\"_33067\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_33067__math_result\"><h1 class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Warning: You do not need to fill out this form. Only fill out if you WANT your child seen!<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields common_fields selection_fields check-group bootstrap_field required radio-group hidden\" style=\"position: relative;left: 0px;top: 0px;display: none\" data-id=\"_52008\" id=\"_52008\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">*Please Select<\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 input_container error_message the-radios\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-layout=\"2c\"><div class=\"input-inner\"><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__52008_please_select[]_Dental Cleaning (AGE 1-12= $75, AGE 13 and over $85)_dental_cleaning_age_1-12_75_age_13_and_over_85\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"please_select[]\" id=\"__60__52008_please_select[]_Dental Cleaning (AGE 1-12= $75, AGE 13 and over $85)_dental_cleaning_age_1-12_75_age_13_and_over_85\" value=\"Dental Cleaning (AGE 1-12= $75, AGE 13 and over $85)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"undefined\">Dental Cleaning (AGE 1-12= $75, AGE 13 and over $85)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__52008_please_select[]_Oral Hygiene Instruction ($30)_oral_hygiene_instruction_30\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"please_select[]\" id=\"__60__52008_please_select[]_Oral Hygiene Instruction ($30)_oral_hygiene_instruction_30\" value=\"Oral Hygiene Instruction ($30)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"undefined\">Oral Hygiene Instruction ($30)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__52008_please_select[]_Nutritional Counseling ($30)_nutritional_counseling_30\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"please_select[]\" id=\"__60__52008_please_select[]_Nutritional Counseling ($30)_nutritional_counseling_30\" value=\"Nutritional Counseling ($30)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"undefined\">Nutritional Counseling ($30)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__52008_please_select[]_Fluoride ($35)_fluoride_35\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"please_select[]\" id=\"__60__52008_please_select[]_Fluoride ($35)_fluoride_35\" value=\"Fluoride ($35)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"undefined\">Fluoride ($35)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__52008_please_select[]_Preventative Tooth Sealants ($40 PER TOOTH)_preventative_tooth_sealants_40_per_tooth\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"please_select[]\" id=\"__60__52008_please_select[]_Preventative Tooth Sealants ($40 PER TOOTH)_preventative_tooth_sealants_40_per_tooth\" value=\"Preventative Tooth Sealants ($40 PER TOOTH)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"undefined\">Preventative Tooth Sealants ($40 PER TOOTH)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__52008_please_select[]_Temporary Filling ($70)_temporary_filling_70\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"please_select[]\" id=\"__60__52008_please_select[]_Temporary Filling ($70)_temporary_filling_70\" value=\"Temporary Filling ($70)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"undefined\">Temporary Filling ($70)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__52008_please_select[]_SDF ($20)_sdf_20\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"please_select[]\" id=\"__60__52008_please_select[]_SDF ($20)_sdf_20\" value=\"SDF ($20)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"undefined\">SDF ($20)<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 nex_prev_steps bootstrap_field is_grid\" data-id=\"_79129\" id=\"_79129\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row grid_row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"grid_input_holder id-_79129  col-xs-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"form_field all_fields submit-button button_fields common_fields preset_fields special_fields selection_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px;z-index: 100\" data-id=\"_17901\" id=\"_17901\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12 input_container align_left\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <button class=\"svg_ready the_input_element btn btn-default prev-step style_bold\" style=\"color: #ffffff;background-color: #62aef7\">Back<\/button>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"grid_input_holder id-_79129  col-xs-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"form_field all_fields submit-button button_fields common_fields preset_fields special_fields selection_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px;z-index: 100\" data-id=\"_73342\" id=\"_73342\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12 input_container align_right\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <button class=\"svg_ready the_input_element btn btn-default nex-step style_bold\" style=\"background-color: #62aef7;color: #ffffff\">Next<\/button>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div><div class=\"custom-fields step bootstrap_field has_prefix_icon has_postfix_icon nf_multi_step_3 is_grid\" data-step-name=\"Insurance Coverage\" data-step-num=\"3\" style=\"display: none\" data-id=\"_47213\" id=\"_47213\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"form_field all_fields heading html_fields bootstrap_field\" data-id=\"_17282\" id=\"_17282\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_17282__math_result\"><h1 class=\"the_input_element align_center\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Insurance Coverage<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider html_fields bootstrap_field\" data-id=\"_35816\" id=\"_35816\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><hr class=\"the_input_element\" style=\"border-width: 3px 0px\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph html_fields bootstrap_field\" data-id=\"_49033\" id=\"_49033\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_49033__math_result\"><div class=\"the_input_element style_bold\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">We currently DO NOT accept:  Humana, Harvard Pilgrim, BCBS Federal - Accepted insurance is subject to change without notice<\/div><div style=\"clear:both\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field required\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_43591\" id=\"_43591\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold align_center\" style=\"color: #000000\">*Please Select:<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 input_container error_message the-radios\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-layout=\"1c\"><label class=\"radio-inline col-sm-12 display-block\" for=\"__60__43591_please_select:_MaineCare Insurance_mainecare_insurance\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"please_select:\" id=\"__60__43591_please_select:_MaineCare Insurance_mainecare_insurance\" value=\"MaineCare Insurance\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">MaineCare Insurance<\/span><\/span><\/label><label class=\"radio-inline col-sm-12 display-block\" for=\"__60__43591_please_select:_NO Dental Insurance- All services paid for by the State Oral Health Program (SOHP)_no_dental_insurance-_all_services_paid_for_by_the_state_oral_health_program_sohp\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"please_select:\" id=\"__60__43591_please_select:_NO Dental Insurance- All services paid for by the State Oral Health Program (SOHP)_no_dental_insurance-_all_services_paid_for_by_the_state_oral_health_program_sohp\" value=\"NO Dental Insurance- All services paid for by the State Oral Health Program (SOHP)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">NO Dental Insurance- All services paid for by the State Oral Health Program (SOHP)<\/span><\/span><\/label><label class=\"radio-inline col-sm-12 display-block\" for=\"__60__43591_please_select:_Other Dental Insurance \u2013 Delta, Cigna, United, Aetna, etc._other_dental_insurance_\u2013_delta_cigna_united_aetna_etc\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"please_select:\" id=\"__60__43591_please_select:_Other Dental Insurance \u2013 Delta, Cigna, United, Aetna, etc._other_dental_insurance_\u2013_delta_cigna_united_aetna_etc\" value=\"Other Dental Insurance \u2013 Delta, Cigna, United, Aetna, etc.\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Other Dental Insurance \u2013 Delta, Cigna, United, Aetna, etc.<\/span><\/span><\/label><label class=\"radio-inline col-sm-12 display-block\" for=\"__60__43591_please_select:_Self Pay out of Pocket_self_pay_out_of_pocket\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"please_select:\" id=\"__60__43591_please_select:_Self Pay out of Pocket_self_pay_out_of_pocket\" value=\"Self Pay out of Pocket\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Self Pay out of Pocket<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields required hidden\" style=\"margin-bottom: 15px;display: none\" id=\"_66122\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">*Services covered by SOHP at no charge for Uninsured\/Under Insured<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"__60__66122_services_covered_by_sohp_at_no_charge_for_uninsuredunder_insured_Screening and Fluoride_screening_and_fluoride\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"services_covered_by_sohp_at_no_charge_for_uninsuredunder_insured\" id=\"__60__66122_services_covered_by_sohp_at_no_charge_for_uninsuredunder_insured_Screening and Fluoride_screening_and_fluoride\" value=\"Screening and Fluoride\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Screening and Fluoride<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__60__66122_services_covered_by_sohp_at_no_charge_for_uninsuredunder_insured_Screening Only (no fluoride)_screening_only_no_fluoride\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"services_covered_by_sohp_at_no_charge_for_uninsuredunder_insured\" id=\"__60__66122_services_covered_by_sohp_at_no_charge_for_uninsuredunder_insured_Screening Only (no fluoride)_screening_only_no_fluoride\" value=\"Screening Only (no fluoride)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Screening Only (no fluoride)<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields required hidden\" style=\"margin-bottom: 15px;display: none\" id=\"_88871\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">*Would you like to pay for services NOT covered by the Maine State SOHP if your child should need them?<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"__60__88871_would_you_like_to_pay_for_services_not_covered_by_the_maine_state_sohp_if_your_child_should_need_them_Yes_yes\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"would_you_like_to_pay_for_services_not_covered_by_the_maine_state_sohp_if_your_child_should_need_them\" id=\"__60__88871_would_you_like_to_pay_for_services_not_covered_by_the_maine_state_sohp_if_your_child_should_need_them_Yes_yes\" value=\"Yes\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Yes<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__60__88871_would_you_like_to_pay_for_services_not_covered_by_the_maine_state_sohp_if_your_child_should_need_them_No_no\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"would_you_like_to_pay_for_services_not_covered_by_the_maine_state_sohp_if_your_child_should_need_them\" id=\"__60__88871_would_you_like_to_pay_for_services_not_covered_by_the_maine_state_sohp_if_your_child_should_need_them_No_no\" value=\"No\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">No<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields bootstrap_field is_focused required hidden\" data-id=\"_91029\" id=\"_91029\" style=\"display: none\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__91029\"><span class=\"the_label style_bold\" style=\"color: #000000\">*MAINECARE INSURANCE- ID # for Child: <\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"mainecare_insurance-_id__for_child:_\" class=\"form-control error_message the_input_element aling_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" placeholder=\"___ ___ ___ ___ ___ ___ ___ ___ A\" id=\"input__91029\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 bootstrap_field has_prefix_icon is_grid\" data-id=\"_63480\" id=\"_63480\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_63480  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields bootstrap_field required hidden\" style=\"position: relative;left: 0px;top: 0px;display: none\" data-id=\"_29944\" id=\"_29944\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__29944\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Insurance Company Name:<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"insurance_company_name:\" class=\"form-control error_message the_input_element aling_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__29944\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_63480  col-sm-5 grid-target-1\" data-grid-width=\"5\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields bootstrap_field required hidden\" style=\"position: relative;top: 0px;left: 0px;display: none\" data-id=\"_33097\" id=\"_33097\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__33097\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Policy Holders Full Name:<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"policy_holders_full_name:\" class=\"form-control error_message the_input_element aling_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__33097\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_63480  col-sm-3 grid-target-2\" data-grid-width=\"3\" data-grid-num=\"2\"><div class=\"form_field all_fields special_fields bootstrap_field date required has_prefix_icon hidden\" style=\"position: relative;left: 0px;top: 0px;display: none\" data-id=\"_35642\" id=\"_35642\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__35642\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Date of Birth<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"MM\/DD\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #000000;border-color: #000000\"><span class=\"fa fa-calendar-o\"><\/span><\/span><input type=\"text\" name=\"date_of_birth\" class=\"error_message form-control the_input_element  aling_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-dtp=\"dtp_j46bM\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__35642\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-4 bootstrap_field is_grid\" data-id=\"_71321\" id=\"_71321\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_71321  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields numbers_only bootstrap_field required hidden\" style=\"position: relative;top: 0px;left: 0px;display: none\" data-id=\"_25754\" id=\"_25754\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__25754\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Group #<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"group_\" class=\"form-control error_message the_input_element aling_left numbers_only required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Only numbers are allowed\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__25754\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_71321  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields bootstrap_field required hidden\" style=\"position: relative;top: 0px;left: 0px;display: none\" data-id=\"_27553\" id=\"_27553\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__27553\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Policy\/Subscriber ID or Social Security #<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"policysubscriber_id_or_social_security_\" class=\"form-control error_message the_input_element aling_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Only numbers are allowed\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__27553\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_71321  col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"form_field all_fields text common_fields bootstrap_field required hidden\" style=\"position: relative;top: 0px;left: 0px;display: none\" data-id=\"_91551\" id=\"_91551\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__91551\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Payer ID<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"payer_id\" class=\"form-control error_message the_input_element aling_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Only numbers are allowed\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__91551\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields phone_number phone_number preset_fields bootstrap_field has_prefix_icon required hidden\" style=\"position: relative;top: 0px;display: none\" data-id=\"_99984\" id=\"_99984\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__99984\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Provider Phone # (located on the back of insurance card)<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix\" style=\"color: #000000;border-color: #000000\"><span class=\"fa fa-phone\"><\/span><\/span><input type=\"text\" name=\"provider_phone__located_on_the_back_of_insurance_card\" class=\"error_message phone_number form-control the_input_element aling_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid phone number\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__99984\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields required hidden\" style=\"margin-bottom: 15px;position: relative;top: 0px;display: none\" data-id=\"_86010\" id=\"_86010\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #000000\">*How is patient related to Policy Holder?<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"__60__86010_how_is_patient_related_to_policy_holder_Child (18 &amp; under)_child_18__under\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"how_is_patient_related_to_policy_holder\" id=\"__60__86010_how_is_patient_related_to_policy_holder_Child (18 &amp; under)_child_18__under\" value=\"Child (18 &amp; under)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Child (18 &amp; under)<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__60__86010_how_is_patient_related_to_policy_holder_Dependent (19 &amp; over)_dependent_19__over\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"how_is_patient_related_to_policy_holder\" id=\"__60__86010_how_is_patient_related_to_policy_holder_Dependent (19 &amp; over)_dependent_19__over\" value=\"Dependent (19 &amp; over)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Dependent (19 &amp; over)<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__60__86010_how_is_patient_related_to_policy_holder_Self_self\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"how_is_patient_related_to_policy_holder\" id=\"__60__86010_how_is_patient_related_to_policy_holder_Self_self\" value=\"Self\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Self<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__60__86010_how_is_patient_related_to_policy_holder_Spouse_spouse\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"how_is_patient_related_to_policy_holder\" id=\"__60__86010_how_is_patient_related_to_policy_holder_Spouse_spouse\" value=\"Spouse\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Spouse<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__60__86010_how_is_patient_related_to_policy_holder_Significant Other_significant_other\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"how_is_patient_related_to_policy_holder\" id=\"__60__86010_how_is_patient_related_to_policy_holder_Significant Other_significant_other\" value=\"Significant Other\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Significant Other<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__60__86010_how_is_patient_related_to_policy_holder_Life Partner_life_partner\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"how_is_patient_related_to_policy_holder\" id=\"__60__86010_how_is_patient_related_to_policy_holder_Life Partner_life_partner\" value=\"Life Partner\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Life Partner<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__60__86010_how_is_patient_related_to_policy_holder_Other_other\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"how_is_patient_related_to_policy_holder\" id=\"__60__86010_how_is_patient_related_to_policy_holder_Other_other\" value=\"Other\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Other<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields hidden\" style=\"margin-bottom: 15px;position: relative;top: 0px;display: none\" data-id=\"_19859\" id=\"_19859\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_left\"><label class=\"nf_title \" for=\"input__19859\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">If Other, please enter<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"if_other_please_enter\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white none repeat scroll 0% 0%;border-color: #dddddd\" id=\"input__19859\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph html_fields bootstrap_field hidden\" data-id=\"_84718\" id=\"_84718\" style=\"display: none\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_84718__math_result\"><div class=\"the_input_element align_left style_bold\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\" style=\"font-size: 17px\">Please SEND A COPY OF YOUR INSURANCE CARD front &amp; back to <br>TEXT: (207) 588-1798<\/div><div style=\"clear:both\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 bootstrap_field has_postfix_icon is_grid\" data-id=\"_15768\" id=\"_15768\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_15768  col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields upload-multi upload_fields bootstrap_field has_postfix_icon hidden\" style=\"position: relative;left: 0px;top: 0px;display: none\" data-id=\"_10489\" id=\"_10489\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_let col-sm-12 align_center\"><label class=\"nf_title \" for=\"input__10489\"><span class=\"the_label style_bold\" style=\"color: #000000\">Or Upload Here<\/span><\/label><\/div><div class=\"input_container col-sm-12\"><div class=\"fileinput fileinput-new\" data-provides=\"fileinput\"><input type=\"hidden\" value=\"\" id=\"_10489__undefined\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"input-group\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"the_input_element form-control  aling_left uneditable-input span3 error_message\" data-content=\"Required\" data-secondary-message=\"Invalid file extension\" data-max-per-file-message=\"Maximum File Size of {x}MB Exceeded\" data-max-all-file-message=\"Maximum Size for all files can not exceed {x}MB \" data-file-upload-limit-message=\"Only a maximum of {x} files can be uploaded\" data-max-size-pf=\"0\" data-max-size-overall=\"0\" data-max-files=\"0\" data-placement=\"bottom\" data-trigger=\"fileinput\" name=\"or_upload_here[]\"><i class=\"glyphicon glyphicon-file fileinput-exists\"><\/i> <span class=\"fileinput-filename\"><\/span><\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"input-group-addon btn-default btn-file postfix\" style=\"color: #000000;border-color: #000000\"><span class=\"fa fa-cloud-upload\"><\/span><input type=\"file\" name=\"or_upload_here[]\" multiple=\"\" class=\"the_input_element\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"_10489__or_upload_here[]\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" class=\"input-group-addon btn btn-default fileinput-exists\" data-dismiss=\"fileinput\"><span class=\"fu-text\">X<\/span><\/a>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"get_file_ext\" style=\"display:none\">mpg\nmpeg\npdf\njpg\njpeg\npng\npsd\ntif\ntiff<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_15768  col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"panel-default\"><div class=\"panel-body\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph html_fields hidden\" style=\"margin-bottom: 15px;display: none\" id=\"_5143\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_5143__math_result\"><div class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">There will be a $25.00 fee for INSUFFICIENT FUNDS<\/div><div style=\"clear:both\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields select common_fields selection_fields required is_arrow for_rule__33943 hidden\" style=\"margin-bottom: 15px;display: none\" id=\"_23973\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__23973\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">*Self Pay Methods<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><select name=\"self_pay_methods\" class=\"the_input_element error_message text pre-format form-control aling_left align_left required\" data-content=\"Required\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\" data-default-selected-value=\"\" data-required=\"true\" id=\"input__23973\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Check\">Check<\/option><option value=\"Money Order\">Money Order<\/option><option value=\"Cash\">Cash<\/option><option value=\"Credit Card\">Credit Card<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph html_fields hidden\" style=\"margin-bottom: 15px;display: none\" id=\"_87521\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_87521__math_result\"><div class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Attach to this COMPLETED permission form and return form &amp; payment to your child\u2019s School. <br> <br> Check needs to be sent to the school \/ nurse Prior to the dental clinic date.<\/div><div style=\"clear:both\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph html_fields is_target for_rule__33943 hidden\" style=\"margin-bottom: 15px;display: none\" id=\"_33943\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_33943__math_result\"><div class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Attach to this COMPLETED permission form and return form &amp; payment to your child\u2019s School. <br> <br> Money Order needs to be sent to the school \/ nurse Prior to the dental clinic date.<\/div><div style=\"clear:both\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields required hidden\" style=\"margin-bottom: 15px;display: none\" id=\"_57258\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_center\"><label class=\"nf_title \" for=\"input__57258\"><span class=\"the_label style_bold align_center\" style=\"font-size: 13px;color: #000000\">*Check Number<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"check_number\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\" id=\"input__57258\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields is_focused required hidden\" style=\"margin-bottom: 15px;display: none\" id=\"_16340\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_let align_center\"><label class=\"nf_title \" for=\"input__16340\"><span class=\"the_label style_bold align_center\" style=\"font-size: 13px;color: #000000\">*Please total services requested<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"please_total_services_requested\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\" placeholder=\"TOTAL: $\" id=\"input__16340\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph html_fields hidden\" style=\"margin-bottom: 15px;display: none\" id=\"_91555\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_91555__math_result\"><div class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Former or No Dental MaineCare insured patients please read fully: \u201cI understand, that my child no longer has active MaineCare coverage. I understand that I will be paying out of pocket and by signing this permission form, I understand that I am responsible for payment of services rendered\u201d<\/div><div style=\"clear:both\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 nex_prev_steps bootstrap_field is_grid\" data-id=\"_92335\" id=\"_92335\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row grid_row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"grid_input_holder id-_92335  col-xs-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"form_field all_fields submit-button button_fields common_fields preset_fields special_fields selection_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px;z-index: 100\" data-id=\"_98862\" id=\"_98862\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12 input_container align_left\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <button class=\"svg_ready the_input_element btn btn-default prev-step style_bold\" style=\"color: #ffffff;background-color: #62aef7\">Back<\/button>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"grid_input_holder id-_92335  col-xs-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"form_field all_fields submit-button button_fields common_fields preset_fields special_fields selection_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px;z-index: 100\" data-id=\"_87070\" id=\"_87070\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12 input_container align_right\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <button class=\"svg_ready the_input_element btn btn-default nex-step style_bold\" style=\"background-color: #62aef7;color: #ffffff\">Next<\/button>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div><div class=\"custom-fields step bootstrap_field has_prefix_icon nf_multi_step_4 is_grid\" data-step-name=\"Medical \/ Dental History\" data-step-num=\"4\" style=\"position: relative;left: 0px;top: 0px;display: none\" data-id=\"_15207\" id=\"_15207\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"form_field all_fields heading html_fields bootstrap_field\" data-id=\"_50025\" id=\"_50025\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_50025__math_result\"><h1 class=\"the_input_element align_center\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Medical \/ Dental History<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider html_fields bootstrap_field\" data-id=\"_82500\" id=\"_82500\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><hr class=\"the_input_element\" style=\"border-width: 3px 0px\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field required\" data-id=\"_44207\" id=\"_44207\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">*Has your child ever needed Antibiotics for dental treatment?  If yes, please take the same precautions prior to treatment <\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 input_container error_message the-radios\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline  \" for=\"__60__44207_has_your_child_ever_needed_antibiotics_for_dental_treatment__if_yes_please_take_the_same_precautions_prior_to_treatment__Yes_yes\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control required\" type=\"radio\" name=\"has_your_child_ever_needed_antibiotics_for_dental_treatment__if_yes_please_take_the_same_precautions_prior_to_treatment_\" id=\"__60__44207_has_your_child_ever_needed_antibiotics_for_dental_treatment__if_yes_please_take_the_same_precautions_prior_to_treatment__Yes_yes\" value=\"Yes\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Yes<\/span><\/span><\/label><label class=\"radio-inline  \" for=\"__60__44207_has_your_child_ever_needed_antibiotics_for_dental_treatment__if_yes_please_take_the_same_precautions_prior_to_treatment__No_no\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control required\" type=\"radio\" name=\"has_your_child_ever_needed_antibiotics_for_dental_treatment__if_yes_please_take_the_same_precautions_prior_to_treatment_\" id=\"__60__44207_has_your_child_ever_needed_antibiotics_for_dental_treatment__if_yes_please_take_the_same_precautions_prior_to_treatment__No_no\" value=\"No\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">No<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 bootstrap_field is_grid\" data-id=\"_88694\" id=\"_88694\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_88694  col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields bootstrap_field\" style=\"position: relative;left: 0px;top: 0px\" data-id=\"_64680\" id=\"_64680\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__64680\"><span class=\"the_label style_bold\" style=\"color: #000000\">Please list dental concerns you may have<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"please_list_dental_concerns_you_may_have\" class=\"form-control error_message the_input_element  aling_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__64680\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_88694  col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_36032\" id=\"_36032\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__36032\"><span class=\"the_label style_bold\" style=\"color: #000000\">List any Allergies your child has<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"list_any_allergies_your_child_has\" class=\"form-control error_message the_input_element  aling_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__36032\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 bootstrap_field is_grid\" data-id=\"_89223\" id=\"_89223\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_89223  col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields common_fields selection_fields check-group bootstrap_field radio-group\" style=\"position: relative;left: 0px;top: 0px\" data-id=\"_41809\" id=\"_41809\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">Does your child have any of the following (select all that apply): <\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 input_container error_message the-radios\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-layout=\"2c\"><div class=\"input-inner\"><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Special Need_special_need\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"does_your_child_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Special Need_special_need\" value=\"Special Need\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Special Need<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Hemophilia_hemophilia\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"does_your_child_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Hemophilia_hemophilia\" value=\"Hemophilia\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Hemophilia<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Asthma_asthma\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"does_your_child_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Asthma_asthma\" value=\"Asthma\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Asthma<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_ADHD_adhd\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"does_your_child_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_ADHD_adhd\" value=\"ADHD\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">ADHD<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Autism_autism\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"does_your_child_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Autism_autism\" value=\"Autism\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Autism<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Cancer_cancer\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"does_your_child_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Cancer_cancer\" value=\"Cancer\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Cancer<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Anxiety_anxiety\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"does_your_child_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Anxiety_anxiety\" value=\"Anxiety\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Anxiety<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Other_other\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"does_your_child_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__60__41809_does_your_child_have_any_of_the_following_select_all_that_apply:_[]_Other_other\" value=\"Other\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Other<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_89223  col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields bootstrap_field\" style=\"position: relative;left: 0px;top: 0px\" data-id=\"_68837\" id=\"_68837\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__68837\"><span class=\"the_label style_bold\" style=\"color: #000000\">Other<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"other\" class=\"form-control error_message the_input_element  aling_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__68837\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 bootstrap_field is_grid\" data-id=\"_28338\" id=\"_28338\" style=\"position: relative;top: 0px\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_28338  col-sm-12 grid-target-0\" data-grid-width=\"12\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_83463\" id=\"_83463\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__83463\"><span class=\"the_label style_bold\" style=\"color: #000000\">List ALL Medications<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"list_all_medications\" class=\"form-control error_message the_input_element  aling_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__83463\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field\" style=\"position: relative;top: 0px;z-index: 1000;left: 0px\" data-id=\"_9542\" id=\"_9542\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">Does your child receive regular dental cleanings twice per year?<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 input_container error_message the-radios\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline  \" for=\"__60__9542_does_your_child_receive_regular_dental_cleanings_twice_per_year_Yes_yes\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"does_your_child_receive_regular_dental_cleanings_twice_per_year\" id=\"__60__9542_does_your_child_receive_regular_dental_cleanings_twice_per_year_Yes_yes\" value=\"Yes\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Yes<\/span><\/span><\/label><label class=\"radio-inline  \" for=\"__60__9542_does_your_child_receive_regular_dental_cleanings_twice_per_year_No_no\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"does_your_child_receive_regular_dental_cleanings_twice_per_year\" id=\"__60__9542_does_your_child_receive_regular_dental_cleanings_twice_per_year_No_no\" value=\"No\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">No<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field\" style=\"position: relative;top: 0px\" data-id=\"_47845\" id=\"_47845\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">Had a cleaning in the past 6 months?   <\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 input_container error_message the-radios\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline  \" for=\"__60__47845_had_a_cleaning_in_the_past_6_months____Yes_yes\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"had_a_cleaning_in_the_past_6_months___\" id=\"__60__47845_had_a_cleaning_in_the_past_6_months____Yes_yes\" value=\"Yes\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Yes<\/span><\/span><\/label><label class=\"radio-inline  \" for=\"__60__47845_had_a_cleaning_in_the_past_6_months____No_no\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"had_a_cleaning_in_the_past_6_months___\" id=\"__60__47845_had_a_cleaning_in_the_past_6_months____No_no\" value=\"No\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">No<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 bootstrap_field is_grid\" data-id=\"_69620\" id=\"_69620\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_69620  col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_15441\" id=\"_15441\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__15441\"><span class=\"the_label style_bold\" style=\"color: #000000\">Patient was last seen (month &amp; year):<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"patient_was_last_seen_month__year:\" class=\"form-control error_message the_input_element  aling_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__15441\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_69620  col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_83795\" id=\"_83795\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__83795\"><span class=\"the_label style_bold\" style=\"color: #000000\">Patient last seen by:  <\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"patient_last_seen_by:__\" class=\"form-control error_message the_input_element  aling_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__83795\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields common_fields selection_fields check-group bootstrap_field radio-group\" data-id=\"_85605\" id=\"_85605\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">Services received during Last Visit (Extractions &amp; a cleaning are never done at the same appointment)<\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 input_container error_message the-radios\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-layout=\"3c\"><div class=\"input-inner\"><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Cleaning_cleaning\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]\" id=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Cleaning_cleaning\" value=\"Cleaning\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Cleaning<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Fluoride_fluoride\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]\" id=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Fluoride_fluoride\" value=\"Fluoride\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Fluoride<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Sealant (protective coating on the biting surface of the tooth to prevent cavities)_sealant_protective_coating_on_the_biting_surface_of_the_tooth_to_prevent_cavities\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]\" id=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Sealant (protective coating on the biting surface of the tooth to prevent cavities)_sealant_protective_coating_on_the_biting_surface_of_the_tooth_to_prevent_cavities\" value=\"Sealant (protective coating on the biting surface of the tooth to prevent cavities)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Sealant (protective coating on the biting surface of the tooth to prevent cavities)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Fillings_fillings\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]\" id=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Fillings_fillings\" value=\"Fillings\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Fillings<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Exam_exam\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]\" id=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Exam_exam\" value=\"Exam\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Exam<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_X-Ray_x-ray\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]\" id=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_X-Ray_x-ray\" value=\"X-Ray\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">X-Ray<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Extraction (tooth pulled)_extraction_tooth_pulled\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]\" id=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Extraction (tooth pulled)_extraction_tooth_pulled\" value=\"Extraction (tooth pulled)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Extraction (tooth pulled)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Braces (orthodontic appointment where braces are installed, removed, or adjusted)_braces_orthodontic_appointment_where_braces_are_installed_removed_or_adjusted\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]\" id=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Braces (orthodontic appointment where braces are installed, removed, or adjusted)_braces_orthodontic_appointment_where_braces_are_installed_removed_or_adjusted\" value=\"Braces (orthodontic appointment where braces are installed, removed, or adjusted)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Braces (orthodontic appointment where braces are installed, removed, or adjusted)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Space Maintainer_space_maintainer\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]\" id=\"__60__85605_services_received_during_last_visit_extractions__a_cleaning_are_never_done_at_the_same_appointment[]_Space Maintainer_space_maintainer\" value=\"Space Maintainer\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Space Maintainer<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-4 bootstrap_field is_grid\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_9459\" id=\"_9459\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_9459  col-sm-3 grid-target-0\" data-grid-width=\"3\" data-grid-num=\"0\"><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_82937\" id=\"_82937\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">Does your child have a history of cavities?<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 input_container error_message the-radios\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline  \" for=\"__60__82937_does_your_child_have_a_history_of_cavities_Yes_yes\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"does_your_child_have_a_history_of_cavities\" id=\"__60__82937_does_your_child_have_a_history_of_cavities_Yes_yes\" value=\"Yes\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Yes<\/span><\/span><\/label><label class=\"radio-inline  \" for=\"__60__82937_does_your_child_have_a_history_of_cavities_No_no\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"does_your_child_have_a_history_of_cavities\" id=\"__60__82937_does_your_child_have_a_history_of_cavities_No_no\" value=\"No\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">No<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_9459  col-sm-3 grid-target-1\" data-grid-width=\"3\" data-grid-num=\"1\"><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_84390\" id=\"_84390\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">Does your child Brush\/floss at least 2 times Daily?    <\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 input_container error_message the-radios\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline  \" for=\"__60__84390_does_your_child_brushfloss_at_least_2_times_daily_____Yes_yes\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"does_your_child_brushfloss_at_least_2_times_daily____\" id=\"__60__84390_does_your_child_brushfloss_at_least_2_times_daily_____Yes_yes\" value=\"Yes\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Yes<\/span><\/span><\/label><label class=\"radio-inline  \" for=\"__60__84390_does_your_child_brushfloss_at_least_2_times_daily_____No_no\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"does_your_child_brushfloss_at_least_2_times_daily____\" id=\"__60__84390_does_your_child_brushfloss_at_least_2_times_daily_____No_no\" value=\"No\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">No<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_9459  col-sm-3 grid-target-2\" data-grid-width=\"3\" data-grid-num=\"2\"><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_21930\" id=\"_21930\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">Does your child consume sugary products regularly?<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 input_container error_message the-radios\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline  \" for=\"__60__21930_does_your_child_consume_sugary_products_regularly_Yes_yes\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"does_your_child_consume_sugary_products_regularly\" id=\"__60__21930_does_your_child_consume_sugary_products_regularly_Yes_yes\" value=\"Yes\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Yes<\/span><\/span><\/label><label class=\"radio-inline  \" for=\"__60__21930_does_your_child_consume_sugary_products_regularly_No_no\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"does_your_child_consume_sugary_products_regularly\" id=\"__60__21930_does_your_child_consume_sugary_products_regularly_No_no\" value=\"No\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">No<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_9459  col-sm-3 grid-target-3\" data-grid-width=\"3\" data-grid-num=\"3\"><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_29424\" id=\"_29424\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"color: #000000\">Does your child use a fluoride Rinse?   <\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 input_container error_message the-radios\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline  \" for=\"__60__29424_does_your_child_use_a_fluoride_rinse____Yes_yes\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"does_your_child_use_a_fluoride_rinse___\" id=\"__60__29424_does_your_child_use_a_fluoride_rinse____Yes_yes\" value=\"Yes\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Yes<\/span><\/span><\/label><label class=\"radio-inline  \" for=\"__60__29424_does_your_child_use_a_fluoride_rinse____No_no\" style=\"color: #000000\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element form-control\" type=\"radio\" name=\"does_your_child_use_a_fluoride_rinse___\" id=\"__60__29424_does_your_child_use_a_fluoride_rinse____No_no\" value=\"No\" style=\"display: none;color: #444444;background: #ffffff;border-color: #000000\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">No<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph html_fields bootstrap_field\" data-id=\"_89673\" id=\"_89673\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_89673__math_result\"><div class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">I give permission for my child to receive dental hygiene services TWO (2) TIMES DURING THIS SCHOOL YEAR. (if my child's school can offer it two times this school year.) I understand that I will receive a reminder of the 2nd dental clinic date from the school and\/or TPI and that my child will be automatically added to the dental clinic list to be seen. It is my responsibility to notify either TPI (207) 513-1111 or my child's school prior to the 2nd dental clinic spring date to make any changes regarding my child\u2019s medical\/dental history or removing them from the spring dental clinic list. I understand that the services provided today do not take the place of a complete dental exam by a dentist. However, dental services are being provided by a registered, licensed dental hygienist with Public Health Status (PHS) associated with Tooth Protectors Inc. (TPI), at school, during school hours. I have entered my child\u2019s information on this permission\/consent form accurately and truthfully and understand that it is my responsibility to report\/remember my child\u2019s date of dental service. I am also responsible to report this date when needed for current\/future dental treatment and cannot hold TPI responsible if the information is not accurate\/truthful on this form regarding current and\/or previous treatment\/appointments with other dental office locations. I agree to notify my child\u2019s school and\/or TPI at (207) 513-1111 of ANY changes to my child's medical\/dental history or of a dental home. I give permission for TPI to release patient and dental service information to benefit my child. I understand that services provided do not take the place of a complete exam by a dentist. I understand that TPI is HIPAA compliant and all records are kept confidential and that claims to insurance (if applies to your child) will go through TPI per electronic transfer or mail. Services not paid for by my insurance are my responsibility. I understand that if I have listed insurance information for my child &amp; he\/she does NOT have dental coverage at the time services are provided, and\/or received the same services by another dental provider within 6 months and I did not divulged this above, than I assume all responsibility for payment of services received and understand that I will receive a bill from Tooth Protectors Inc.\n\nI understand that the coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I understand that COVID-19 is extremely contagious and is believed to spread by person -to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that Tooth Protectors Inc &amp; all staff are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of Covid-19 However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with receiving dental treatment. I hereby acknowledge and assume the risk of myself \/child becoming infected with COVID-19 through this elective dental care. I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with dental care for myself\/child.<\/div><div style=\"clear:both\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 bootstrap_field has_prefix_icon is_grid\" style=\"position: relative;top: 0px;left: 0px\" data-id=\"_35458\" id=\"_35458\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_35458  col-sm-12 grid-target-0\" data-grid-width=\"12\" data-grid-num=\"0\"><div class=\"form_field all_fields digital-signature special_fields required\" style=\"position: relative;top: 0px\" data-id=\"_14028\" id=\"_14028\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\" style=\"padding-right: 15px\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let\"><label class=\"nf_title \" for=\"input__14028\"><span class=\"the_label style_bold\" style=\"font-size: 14px\">*Signature<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"signature\" class=\"the_input_element digital-signature-data error_message required\" data-content=\"Required\" id=\"input__14028\"><\/textarea><div class=\"js-signature\" data-width=\"800\" data-height=\"\"><div class=\"clear_digital_siganture\"><span class=\"fa fa-eraser\"><\/span><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields name preset_fields bootstrap_field has_prefix_icon required\" style=\"position: relative;top: 0px\" data-id=\"_89446\" id=\"_89446\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__89446\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Parent\/Guardian PRINTED NAME<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix\" style=\"color: #000000;border-color: #000000\"><span class=\"fa fa-user\"><\/span><\/span><input type=\"text\" name=\"parentguardian_printed_name\" class=\"error_message  form-control the_input_element  aling_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__89446\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields required\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_88347\" id=\"_88347\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_left\"><label class=\"nf_title \" for=\"input__88347\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">*Relationship to child\/patient<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"relationship_to_childpatient\" class=\"form-control error_message the_input_element  aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: #ffffff;border-color: #dddddd\" id=\"input__88347\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields special_fields required bootstrap_field date has_prefix_icon\" style=\"position: relative;top: 0px\" data-id=\"_58991\" id=\"_58991\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12  label_container align_let align_center\"><label class=\"nf_title \" for=\"input__58991\"><span class=\"the_label style_bold\" style=\"color: #000000\">*Date<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"MM\/DD\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #000000;border-color: #000000\"><span class=\"fa fa-calendar-o\"><\/span><\/span><input type=\"text\" name=\"date\" class=\"error_message form-control the_input_element  aling_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-dtp=\"dtp_33JJ0\" style=\"color: #444444;background: #ffffff;border-color: #000000\" id=\"input__58991\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 nex_prev_steps bootstrap_field is_grid\" data-id=\"_34328\" id=\"_34328\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row grid_row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"grid_input_holder id-_34328  col-xs-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"form_field all_fields submit-button button_fields common_fields preset_fields special_fields selection_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px;z-index: 100\" data-id=\"_14020\" id=\"_14020\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12 input_container align_left\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <button class=\"svg_ready the_input_element btn btn-default prev-step style_bold\" style=\"background-color: #62aef7;color: #ffffff\">Back<\/button>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"grid_input_holder id-_34328  col-xs-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"form_field all_fields submit-button the_submit button_fields common_fields preset_fields special_fields selection_fields bootstrap_field\" style=\"position: relative;left: 0px;top: 0px\" data-id=\"_19197\" id=\"_19197\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container align_right\"><button class=\"nex-submit svg_ready the_input_element btn btn-default text-right style_bold\" style=\"color: #ffffff;background-color: #62aef7\">Submit<\/button><\/div><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div><\/form><\/div><\/div><\/div><\/div><\/div><style type=\"text\/css\" class=\"nex-forms-custom-css\"><\/style>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-no-title","meta":{"footnotes":""},"class_list":["post-13","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/pages\/13","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/comments?post=13"}],"version-history":[{"count":10,"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/pages\/13\/revisions"}],"predecessor-version":[{"id":383,"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/pages\/13\/revisions\/383"}],"wp:attachment":[{"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/media?parent=13"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}