{"id":328,"date":"2025-08-15T09:24:37","date_gmt":"2025-08-15T14:24:37","guid":{"rendered":"https:\/\/permissionform.toothprotectors.org\/?page_id=328"},"modified":"2025-08-15T10:09:41","modified_gmt":"2025-08-15T15:09:41","slug":"medical-permission-form","status":"publish","type":"page","link":"https:\/\/permissionform.toothprotectors.org\/index.php\/medical-permission-form\/","title":{"rendered":"Medical Office\/Community Site Dental Program Permission Form"},"content":{"rendered":"\n<style type=\"text\/css\">#nex-forms{display:none;}<\/style><div id=\"nf_form_66732\">\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.medical_permission_form_2025 .nf-loader-lds-spinner div:after {background: #40C4FF; }\r\n\t\t\t\t#nex-forms.medical_permission_form_2025 .nf-loader-lds-grid div {background: #40C4FF; }\r\n\t\t\t\t#nex-forms.medical_permission_form_2025 .nf-loader-lds-ellipsis div { background: #40C4FF;}\r\n\t\t\t\t#nex-forms.medical_permission_form_2025 .nf-loader-lds-default div {background: #40C4FF;}\r\n\t\t\t\t#nex-forms.medical_permission_form_2025 .nf-loader-lds-roller div:after {background: #40C4FF;}\r\n\t\t\t\t#nex-forms.medical_permission_form_2025 .nf-loader-lds-heart div,\r\n\t\t\t\t#nex-forms.medical_permission_form_2025 .nf-loader-lds-heart div:after,\r\n\t\t\t\t#nex-forms.medical_permission_form_2025 .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.medical_permission_form_2025 .nf-loader-lds-facebook div {background: #40C4FF;}\r\n\t\t\t\t#nex-forms.medical_permission_form_2025 .nf-loader-lds-circle > div {background: #40C4FF;}\r\n\t\t\t\t\r\n\t\t\t\t#nex-forms.medical_permission_form_2025 .nf-loader-lds-dual-ring:after {border: 6px solid #40C4FF;border-color: #40C4FF transparent #40C4FF transparent;}\r\n\t\t\t\t#nex-forms.medical_permission_form_2025 .nf-loader-lds-ring div {border: 8px solid #40C4FF;border-color: #40C4FF transparent transparent transparent;}\r\n\t\t\t\t#nex-forms.medical_permission_form_2025 .nf-loader-lds-hourglass:after {border: 32px solid #40C4FF;border-color: #40C4FF transparent #40C4FF transparent;}\r\n\t\t\t\t#nex-forms.medical_permission_form_2025 .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 medical_permission_form_2025  \"><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-57\"  ><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 current-next\"><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\"><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 current-prev\"><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\/328<\/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=\"57\" class=\"submit-nex-form nex-forms-57\" data-form-id=\"57\" 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=\"57\"><input type=\"hidden\" name=\"page\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/328\"><input type=\"hidden\" name=\"ip\" value=\"192.168.40.34\"><input type=\"hidden\" name=\"nf_page_id\" value=\"328\"><input type=\"hidden\" name=\"nf_page_title\" value=\"Medical Office\/Community Site Dental Program Permission Form\"><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 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-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-12 grid-target-0\" data-grid-width=\"12\" 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\">*Patient'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=\"patients_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><\/div><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field required\" style=\"position: relative;top: 0px\" data-id=\"_68260\" id=\"_68260\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\" style=\"padding-top: 10px;padding-bottom: 10px\"><div class=\"row\"><div class=\"label_container align_let align_center col-sm-5\"><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=\"input_container error_message the-radios col-sm-7 align_left\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-layout=\"2c\"><label class=\"radio-inline col-sm-6\" for=\"__57__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=\"__57__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\" style=\"color: #000000\">Female<\/span><\/span><\/label><label class=\"radio-inline col-sm-6\" for=\"__57__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=\"__57__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\" style=\"color: #000000\">Male<\/span><\/span><\/label><\/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><\/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=\"\" data-layout=\"1c\"><label class=\"radio-inline col-sm-12 display-block\" for=\"__57__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=\"__57__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 col-sm-12 display-block\" for=\"__57__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=\"__57__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\" data-step-description=\"\">\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 check-group bootstrap_field required radio-group\" style=\"position: relative;left: 0px;top: 0px\" 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\">*Must choose 1 service below<\/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=\"__57__52008_must_choose_1_service_below[]_Full dental cleaning (AGE 1-12) $55_full_dental_cleaning_age_1-12_55\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"must_choose_1_service_below[]\" id=\"__57__52008_must_choose_1_service_below[]_Full dental cleaning (AGE 1-12) $55_full_dental_cleaning_age_1-12_55\" value=\"Full dental cleaning (AGE 1-12) $55\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"color: #000000\">Full dental cleaning (AGE 1-12) $55<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__57__52008_must_choose_1_service_below[]_Full dental cleaning (AGE 13+) $65 _full_dental_cleaning_age_13_65_\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"must_choose_1_service_below[]\" id=\"__57__52008_must_choose_1_service_below[]_Full dental cleaning (AGE 13+) $65 _full_dental_cleaning_age_13_65_\" value=\"Full dental cleaning (AGE 13+) $65 \" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"color: #000000\">Full dental cleaning (AGE 13+) $65 <\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__57__52008_must_choose_1_service_below[]_Fluoride treatment $15_fluoride_treatment_15\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"must_choose_1_service_below[]\" id=\"__57__52008_must_choose_1_service_below[]_Fluoride treatment $15_fluoride_treatment_15\" value=\"Fluoride treatment $15\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"color: #000000\">Fluoride treatment $15<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__57__52008_must_choose_1_service_below[]_Sealants $20.00 PER TOOTH_sealants_2000_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=\"must_choose_1_service_below[]\" id=\"__57__52008_must_choose_1_service_below[]_Sealants $20.00 PER TOOTH_sealants_2000_per_tooth\" value=\"Sealants $20.00 PER TOOTH\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"color: #000000\">Sealants $20.00 PER TOOTH<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__57__52008_must_choose_1_service_below[]_Education Review ONLY $15_education_review_only_15\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"must_choose_1_service_below[]\" id=\"__57__52008_must_choose_1_service_below[]_Education Review ONLY $15_education_review_only_15\" value=\"Education Review ONLY $15\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"color: #000000\">Education Review ONLY $15<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph paragraph html_fields\" style=\"margin-bottom: 15px\" id=\"_60063\"><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=\"_60063__math_result\"><div class=\"the_input_element style_italic\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">NOTE: Educational review is covered by MaineCare but not by commercial insurance. If you do not have MaineCare there is a $15 fee.<\/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=\"_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, Martins Point - 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\" for=\"__57__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=\"__57__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\" style=\"color: #000000\">MaineCare Insurance<\/span><\/span><\/label><label class=\"radio-inline col-sm-12\" for=\"__57__43591_please_select:_Dental Insurance_dental_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=\"__57__43591_please_select:_Dental Insurance_dental_insurance\" value=\"Dental Insurance\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Dental Insurance<\/span><\/span><\/label><label class=\"radio-inline col-sm-12\" for=\"__57__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=\"__57__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\" style=\"color: #000000\">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: #000000\">*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=\"__57__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=\"__57__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\" style=\"border-color: black\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Screening and Fluoride<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__57__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=\"__57__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\" style=\"border-color: black\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">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: #000000\">*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=\"__57__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=\"__57__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\" style=\"border-color: black\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Yes<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__57__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=\"__57__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\" style=\"border-color: black\" 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 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\">*Dental Insurance 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=\"dental_insurance_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 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 style_bold align_center\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\" style=\"font-size: 17px;color: #000000\">Please SEND A COPY OF YOUR INSURANCE CARD front &amp; back to: FAX: (207) 513-1197, EMAIL: Info@ToothProtectors.org, TEXT: (207) 402-8038<\/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-12 grid-target-0\" data-grid-width=\"12\" 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><\/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 paragraph html_fields hidden\" style=\"margin-bottom: 15px;display: none\" id=\"_22088\"><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=\"_22088__math_result\"><div class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Please write your child\u2019s Full Name in the Memo Line<\/div><div style=\"clear:both\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields select common_fields selection_fields required 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 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 check-group common_fields selection_fields required radio-group\" style=\"margin-bottom: 15px\" id=\"_82308\"><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\">*Please call our office prior to the clinic date<\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Minimum of {x} selections required\" title=\"\"><div class=\"input-inner\"><label class=\"checkbox-inline radio-inline\" for=\"__57__82308_please_call_our_office_prior_to_the_clinic_date[]_I agree_i_agree\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"please_call_our_office_prior_to_the_clinic_date[]\" id=\"__57__82308_please_call_our_office_prior_to_the_clinic_date[]_I agree_i_agree\" value=\"I agree\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"color: #000000\">I agree<\/span><\/span><\/label><\/div><\/div><\/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=\"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 you 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=\"__57__41809_does_you_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_you_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__57__41809_does_you_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\" style=\"undefined\">Hemophilia<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__57__41809_does_you_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_you_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__57__41809_does_you_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\" style=\"undefined\">Asthma<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__57__41809_does_you_have_any_of_the_following_select_all_that_apply:_[]_Diabetes_diabetes\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"does_you_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__57__41809_does_you_have_any_of_the_following_select_all_that_apply:_[]_Diabetes_diabetes\" value=\"Diabetes\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"undefined\">Diabetes<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__57__41809_does_you_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_you_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__57__41809_does_you_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\" style=\"undefined\">Autism<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__57__41809_does_you_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_you_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__57__41809_does_you_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\" style=\"undefined\">Cancer<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__57__41809_does_you_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_you_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__57__41809_does_you_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\" style=\"undefined\">Anxiety<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__57__41809_does_you_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_you_have_any_of_the_following_select_all_that_apply:_[]\" id=\"__57__41809_does_you_have_any_of_the_following_select_all_that_apply:_[]_Other_other\" value=\"Other\" style=\"display: none\"><a class=\"ui-state-default\" style=\"background: #ffffff33\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"undefined\">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\" data-id=\"_47845\" id=\"_61896\"><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\">Flouride Supplements<\/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=\"__57__61896_flouride_supplements_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=\"flouride_supplements\" id=\"__57__61896_flouride_supplements_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=\"__57__61896_flouride_supplements_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=\"flouride_supplements\" id=\"__57__61896_flouride_supplements_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=\"_21229\"><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\">Do you have a Dentist?<\/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=\"\"><label class=\"radio-inline  \" for=\"__57__21229_do_you_have_a_dentist_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=\"do_you_have_a_dentist\" id=\"__57__21229_do_you_have_a_dentist_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=\"__57__21229_do_you_have_a_dentist_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=\"do_you_have_a_dentist\" id=\"__57__21229_do_you_have_a_dentist_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 align_center\" 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=\"__57__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=\"__57__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=\"__57__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=\"__57__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=\"__57__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=\"__57__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\" style=\"color: #000000\">Cleaning<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__57__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=\"__57__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\" style=\"color: #000000\">Fluoride<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__57__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=\"__57__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\" style=\"color: #000000\">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=\"__57__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=\"__57__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\" style=\"color: #000000\">Fillings<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__57__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=\"__57__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\" style=\"color: #000000\">Exam<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__57__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=\"__57__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\" style=\"color: #000000\">X-Ray<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__57__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=\"__57__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\" style=\"color: #000000\">Extraction (tooth pulled)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__57__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=\"__57__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\" style=\"color: #000000\">Braces (orthodontic appointment where braces are installed, removed, or adjusted)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-4 radio-inline\" for=\"__57__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=\"__57__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\" style=\"color: #000000\">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 you 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=\"\" data-layout=\"1c\"><label class=\"radio-inline col-sm-12 display-block\" for=\"__57__82937_does_you_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_you_have_a_history_of_cavities\" id=\"__57__82937_does_you_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 col-sm-12 display-block\" for=\"__57__82937_does_you_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_you_have_a_history_of_cavities\" id=\"__57__82937_does_you_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 you 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=\"\" data-layout=\"1c\"><label class=\"radio-inline col-sm-12 display-block\" for=\"__57__84390_does_you_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_you_brushfloss_at_least_2_times_daily____\" id=\"__57__84390_does_you_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 col-sm-12 display-block\" for=\"__57__84390_does_you_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_you_brushfloss_at_least_2_times_daily____\" id=\"__57__84390_does_you_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 you 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=\"\" data-layout=\"1c\"><label class=\"radio-inline col-sm-12 display-block\" for=\"__57__21930_does_you_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_you_consume_sugary_products_regularly\" id=\"__57__21930_does_you_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 col-sm-12 display-block\" for=\"__57__21930_does_you_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_you_consume_sugary_products_regularly\" id=\"__57__21930_does_you_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 you 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=\"\" data-layout=\"1c\"><label class=\"radio-inline col-sm-12 display-block\" for=\"__57__29424_does_you_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_you_use_a_fluoride_rinse___\" id=\"__57__29424_does_you_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 col-sm-12 display-block\" for=\"__57__29424_does_you_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_you_use_a_fluoride_rinse___\" id=\"__57__29424_does_you_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 myself or my child to receive dental services provided by licensed registered dental hygienist with Public Health Status (PHS). Tooth Protectors Inc.<br>(TPI) may release basic information confirming myself or my child\u2019s services, for school screenings, dental offices, and others for the benefit of myself or child. I<br>understand that the services provided do not take the place of an exam by a dentist. I understand that TPI is HIPAA compliant and all records are kept confidential and<br>that claims to my insurance will go directly through TPI per electronic transfer. I also understand that all information that I have entered onto this permission form is accurate<br>and truthful and understand that it is my responsibility to report\/remember the patients dates of dental service and report dates when needed for current\/future dental treatment and<br>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<br>understand that if I have listed insurance information for the patient &amp; he\/she does NOT have dental coverage at the time services are provided, and\/or received the same services by<br>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<br>from Tooth Protectors.<\/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\">*Parent\/Guardian Signature<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"parentguardian_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 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":5,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-no-title","meta":{"footnotes":""},"class_list":["post-328","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/pages\/328","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\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/comments?post=328"}],"version-history":[{"count":4,"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/pages\/328\/revisions"}],"predecessor-version":[{"id":332,"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/pages\/328\/revisions\/332"}],"wp:attachment":[{"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/media?parent=328"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}