{"id":337,"date":"2025-08-15T11:12:24","date_gmt":"2025-08-15T16:12:24","guid":{"rendered":"https:\/\/permissionform.toothprotectors.org\/?page_id=337"},"modified":"2025-08-15T11:12:24","modified_gmt":"2025-08-15T16:12:24","slug":"new-mainers-permission-form","status":"publish","type":"page","link":"https:\/\/permissionform.toothprotectors.org\/index.php\/new-mainers-permission-form\/","title":{"rendered":"New Mainers Dental Program Permission Form"},"content":{"rendered":"\n<style type=\"text\/css\">#nex-forms{display:none;}<\/style><div id=\"nf_form_13993\">\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.new_mainers_dental_program_permission_form_2025 .nf-loader-lds-spinner div:after {background: #40C4FF; }\r\n\t\t\t\t#nex-forms.new_mainers_dental_program_permission_form_2025 .nf-loader-lds-grid div {background: #40C4FF; }\r\n\t\t\t\t#nex-forms.new_mainers_dental_program_permission_form_2025 .nf-loader-lds-ellipsis div { background: #40C4FF;}\r\n\t\t\t\t#nex-forms.new_mainers_dental_program_permission_form_2025 .nf-loader-lds-default div {background: #40C4FF;}\r\n\t\t\t\t#nex-forms.new_mainers_dental_program_permission_form_2025 .nf-loader-lds-roller div:after {background: #40C4FF;}\r\n\t\t\t\t#nex-forms.new_mainers_dental_program_permission_form_2025 .nf-loader-lds-heart div,\r\n\t\t\t\t#nex-forms.new_mainers_dental_program_permission_form_2025 .nf-loader-lds-heart div:after,\r\n\t\t\t\t#nex-forms.new_mainers_dental_program_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.new_mainers_dental_program_permission_form_2025 .nf-loader-lds-facebook div {background: #40C4FF;}\r\n\t\t\t\t#nex-forms.new_mainers_dental_program_permission_form_2025 .nf-loader-lds-circle > div {background: #40C4FF;}\r\n\t\t\t\t\r\n\t\t\t\t#nex-forms.new_mainers_dental_program_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.new_mainers_dental_program_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.new_mainers_dental_program_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.new_mainers_dental_program_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 new_mainers_dental_program_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-59\"  ><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 Insurance Information<\/div><div class=\"step_description\"><\/div><\/a><div class=\"step_connecter\" style=\"display:none\"><\/div><\/div><\/li><li class=\"no-description no-icon\"><div class=\"crumb_container\"><div class=\"step_number_container\"><span class=\"the_step_num\">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\">Community Care Worker Contact Information<\/div><div class=\"step_description\"><\/div><\/a><div class=\"step_connecter\" style=\"display:none\"><\/div><\/div><\/li><li class=\"no-description no-icon\"><div class=\"crumb_container\"><div class=\"step_number_container\"><span class=\"the_step_num\">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\">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\">5<\/span><span class=\"the_step_icon \"><\/span><\/div><a href=\"#\" rel=\"nofollow\" data-show-step=\"5\"><div class=\"sreader\">5<\/div><div class=\"step_title\">Medical 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-prev\"><div class=\"crumb_container\"><div class=\"step_number_container\"><span class=\"the_step_num\">6<\/span><span class=\"the_step_icon \"><\/span><\/div><a href=\"#\" rel=\"nofollow\" data-show-step=\"6\"><div class=\"sreader\">6<\/div><div class=\"step_title\">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\/337<\/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=\"59\" class=\"submit-nex-form nex-forms-59\" data-form-id=\"59\" 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=\"59\"><input type=\"hidden\" name=\"page\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/337\"><input type=\"hidden\" name=\"ip\" value=\"192.168.40.34\"><input type=\"hidden\" name=\"nf_page_id\" value=\"337\"><input type=\"hidden\" name=\"nf_page_title\" value=\"New Mainers 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\" data-id=\"_60381\" 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 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=\"__59__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=\"__59__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=\"__59__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=\"__59__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 required\" 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 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__96651\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields bootstrap_field required\" 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 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__11695\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields numbers_only bootstrap_field required\" 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 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__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-9 grid-target-0\" data-grid-width=\"9\" 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\">*Best Contact Number<\/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=\"best_contact_number\" 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-3 grid-target-1\" data-grid-width=\"3\" data-grid-num=\"1\"><div class=\"form_field all_fields common_fields selection_fields radio-group bootstrap_field required\" style=\"position: relative;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=\"__59__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 required\" type=\"radio\" name=\"does_the_phone_take_texts__\" id=\"__59__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=\"__59__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 required\" type=\"radio\" name=\"does_the_phone_take_texts__\" id=\"__59__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 has_postfix_icon nf_multi_step_2 is_grid\" data-step-name=\"Dental Insurance Information\" data-step-num=\"2\" style=\"position: relative;top: 0px;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\">Dental Insurance Information<\/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 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=\"__59__43591_please_select:_MaineCare_mainecare\"><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=\"__59__43591_please_select:_MaineCare_mainecare\" value=\"MaineCare\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">MaineCare<\/span><\/span><\/label><label class=\"radio-inline col-sm-12\" for=\"__59__43591_please_select:_Other Insurance_other_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=\"__59__43591_please_select:_Other Insurance_other_insurance\" value=\"Other Insurance\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Other Insurance<\/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 #<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"mainecare_insurance-_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=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" placeholder=\"___ ___ ___ ___ ___ ___ ___ ___ A\" id=\"input__91029\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields bootstrap_field required hidden\" data-id=\"_11723\" id=\"_11723\" 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__11723\"><span class=\"the_label style_bold\" style=\"color: #000000\">*INSURANCE- ID #<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"insurance-_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=\"\" title=\"\" style=\"color: #444444;background: #ffffff;border-color: #000000\" placeholder=\"\" id=\"input__11723\"><\/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=\"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_3 is_grid\" data-step-name=\"Community Care Worker Contact Information\" data-step-num=\"3\" style=\"position: relative;top: 0px;display: none\" data-id=\"_26905\" data-step-description=\"\" id=\"_26905\">\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=\"_15183\" id=\"_15183\"><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=\"_15183__math_result\"><h1 class=\"the_input_element align_center\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Community Care Worker Contact Information<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider html_fields bootstrap_field\" data-id=\"_96091\" id=\"_96091\"><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 name preset_fields required has_prefix_icon\" style=\"margin-bottom: 15px\" data-id=\"_14349\" id=\"_14349\"><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__14349\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #000000\">*Name<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix\" style=\"color: #000000;background: white;border-color: #dddddd\"><span class=\"fa fas fa-user\" style=\"font-size: 17px\"><\/span><\/span><input type=\"text\" name=\"_name\" class=\"error_message required form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"\" data-text-transform=\"ucf\" style=\"font-size: 13px;color: #000000;background: white;border-color: #dddddd\" id=\"input__14349\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields phone_number phone_number preset_fields required has_prefix_icon\" style=\"margin-bottom: 15px\" data-id=\"_29739\" id=\"_29739\"><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__29739\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #000000\">*Contact Number<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix\" style=\"color: #000000;background: white;border-color: #dddddd\"><span class=\"fa fa fa-phone\" style=\"font-size: 17px\"><\/span><\/span><input type=\"text\" name=\"contact_number\" class=\"error_message required phone_number form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid phone number\" style=\"font-size: 13px;color: #000000;background: white;border-color: #dddddd\" id=\"input__29739\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields required\" style=\"margin-bottom: 15px\" data-id=\"_90255\" id=\"_90255\"><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\">*Are you responsible for changes to appointments and other concerns that we may need to speak with the patient about?<\/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=\"__59__90255_are_you_responsible_for_changes_to_appointments_and_other_concerns_that_we_may_need_to_speak_with_the_patient_about_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=\"are_you_responsible_for_changes_to_appointments_and_other_concerns_that_we_may_need_to_speak_with_the_patient_about\" id=\"__59__90255_are_you_responsible_for_changes_to_appointments_and_other_concerns_that_we_may_need_to_speak_with_the_patient_about_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=\"__59__90255_are_you_responsible_for_changes_to_appointments_and_other_concerns_that_we_may_need_to_speak_with_the_patient_about_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=\"are_you_responsible_for_changes_to_appointments_and_other_concerns_that_we_may_need_to_speak_with_the_patient_about\" id=\"__59__90255_are_you_responsible_for_changes_to_appointments_and_other_concerns_that_we_may_need_to_speak_with_the_patient_about_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 radio-group common_fields selection_fields required\" style=\"margin-bottom: 15px\" data-id=\"_85765\" id=\"_85765\"><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\">*Do we contact the patient directly for questions?<\/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=\"__59__85765_do_we_contact_the_patient_directly_for_questions_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=\"do_we_contact_the_patient_directly_for_questions\" id=\"__59__85765_do_we_contact_the_patient_directly_for_questions_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=\"__59__85765_do_we_contact_the_patient_directly_for_questions_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=\"do_we_contact_the_patient_directly_for_questions\" id=\"__59__85765_do_we_contact_the_patient_directly_for_questions_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 radio-group common_fields selection_fields required\" style=\"margin-bottom: 15px\" data-id=\"_85765\" id=\"_15761\"><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\">*Does this patient require interpreter services?<\/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=\"__59__15761_does_this_patient_require_interpreter_services_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=\"does_this_patient_require_interpreter_services\" id=\"__59__15761_does_this_patient_require_interpreter_services_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=\"__59__15761_does_this_patient_require_interpreter_services_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=\"does_this_patient_require_interpreter_services\" id=\"__59__15761_does_this_patient_require_interpreter_services_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\" style=\"margin-bottom: 15px\" id=\"_2862\"><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__2862\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #000000\">Language Spoken<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"language_spoken\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #000000;background: white;border-color: #dddddd\" id=\"input__2862\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 nex_prev_steps bootstrap_field is_grid\" data-id=\"_31135\" id=\"_31135\">\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-_31135 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=\"_74948\" id=\"_74948\">\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-_31135 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=\"_68367\" id=\"_68367\">\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 nf_multi_step_4 is_grid\" data-step-name=\"Dental Services\" data-step-num=\"4\" style=\"display: none\" data-id=\"_72213\" data-step-description=\"\" id=\"_72213\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"form_field all_fields heading html_fields bootstrap_field\" data-id=\"_81210\" id=\"_81210\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" id=\"_81210__math_result\"><h1 class=\"the_input_element align_center\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Dental Services<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider html_fields bootstrap_field\" data-id=\"_50108\" id=\"_50108\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><hr class=\"the_input_element\" style=\"border-width: 3px 0px\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph paragraph html_fields\" style=\"margin-bottom: 15px\" id=\"_46173\"><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=\"_46173__math_result\"><div class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Services covered by insurance will be completed.<br><br>Any non-covered services charges will be discussed before performing services<\/div><div style=\"clear:both\"><\/div><\/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=\"__59__52008_must_choose_1_service_below[]_Full dental cleaning_full_dental_cleaning\"><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=\"__59__52008_must_choose_1_service_below[]_Full dental cleaning_full_dental_cleaning\" value=\"Full dental cleaning\" 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<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__59__52008_must_choose_1_service_below[]_Fluoride treatment_fluoride_treatment\"><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=\"__59__52008_must_choose_1_service_below[]_Fluoride treatment_fluoride_treatment\" value=\"Fluoride treatment\" 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<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__59__52008_must_choose_1_service_below[]_Preventative Tooth Sealants_preventative_tooth_sealants\"><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=\"__59__52008_must_choose_1_service_below[]_Preventative Tooth Sealants_preventative_tooth_sealants\" value=\"Preventative Tooth Sealants\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"color: #000000\">Preventative Tooth Sealants<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__59__52008_must_choose_1_service_below[]_Education &amp; Screening Only_education__screening_only\"><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=\"__59__52008_must_choose_1_service_below[]_Education &amp; Screening Only_education__screening_only\" value=\"Education &amp; Screening Only\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"color: #000000\">Education &amp; Screening Only<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__59__52008_must_choose_1_service_below[]_SDF (Cavity Medication-contains fluoride)_sdf_cavity_medication-contains_fluoride\"><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=\"__59__52008_must_choose_1_service_below[]_SDF (Cavity Medication-contains fluoride)_sdf_cavity_medication-contains_fluoride\" value=\"SDF (Cavity Medication-contains fluoride)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"color: #000000\">SDF (Cavity Medication-contains fluoride)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__59__52008_must_choose_1_service_below[]_Temporary Fillings (contains fluoride)_temporary_fillings_contains_fluoride\"><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=\"__59__52008_must_choose_1_service_below[]_Temporary Fillings (contains fluoride)_temporary_fillings_contains_fluoride\" value=\"Temporary Fillings (contains fluoride)\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"color: #000000\">Temporary Fillings (contains fluoride)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-6 radio-inline\" for=\"__59__52008_must_choose_1_service_below[]_Referral for Treatment_referral_for_treatment\"><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=\"__59__52008_must_choose_1_service_below[]_Referral for Treatment_referral_for_treatment\" value=\"Referral for Treatment\" style=\"display: none\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\" style=\"color: #000000\">Referral for Treatment<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 nex_prev_steps bootstrap_field is_grid\" data-id=\"_79129\" id=\"_79129\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row grid_row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"grid_input_holder id-_79129 col-xs-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"form_field all_fields submit-button button_fields common_fields preset_fields special_fields selection_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px;z-index: 100\" data-id=\"_17901\" id=\"_17901\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12 input_container align_left\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <button class=\"svg_ready the_input_element btn btn-default prev-step style_bold\" style=\"color: #ffffff;background-color: #62aef7\">Back<\/button>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"grid_input_holder id-_79129 col-xs-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"form_field all_fields submit-button button_fields common_fields preset_fields special_fields selection_fields bootstrap_field\" style=\"position: relative;top: 0px;left: 0px;z-index: 100\" data-id=\"_73342\" id=\"_73342\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <div class=\"row\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"col-sm-12 input_container align_right\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <button class=\"svg_ready the_input_element btn btn-default nex-step style_bold\" style=\"background-color: #62aef7;color: #ffffff\">Next<\/button>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div><div class=\"custom-fields step bootstrap_field nf_multi_step_5 is_grid\" data-step-name=\"Medical Information\" data-step-num=\"5\" style=\"display: none\" data-id=\"_72213\" data-step-description=\"\" id=\"_48105\">\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=\"_213\"><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=\"_213__math_result\"><h1 class=\"the_input_element align_center\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Medical Information<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider html_fields bootstrap_field\" data-id=\"_50108\" id=\"_13596\"><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 radio-group common_fields selection_fields required\" style=\"margin-bottom: 15px\" id=\"_2713\"><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\">*Does this patient require a pre-med prior to service? (Heart conditions, Joint Replacements)<\/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=\"__59__2713_does_this_patient_require_a_pre-med_prior_to_service_heart_conditions_joint_replacements_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=\"does_this_patient_require_a_pre-med_prior_to_service_heart_conditions_joint_replacements\" id=\"__59__2713_does_this_patient_require_a_pre-med_prior_to_service_heart_conditions_joint_replacements_Yes_yes\" value=\"Yes\" style=\"display: none\"><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=\"__59__2713_does_this_patient_require_a_pre-med_prior_to_service_heart_conditions_joint_replacements_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=\"does_this_patient_require_a_pre-med_prior_to_service_heart_conditions_joint_replacements\" id=\"__59__2713_does_this_patient_require_a_pre-med_prior_to_service_heart_conditions_joint_replacements_No_no\" value=\"No\" style=\"display: none\"><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 textarea common_fields\" style=\"margin-bottom: 15px\" id=\"_24721\"><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__24721\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #000000\">If yes, what is the condition or when was the replacement done?<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"if_yes_what_is_the_condition_or_when_was_the_replacement_done\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #000000;background: white;border-color: #dddddd\" id=\"input__24721\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields required\" style=\"margin-bottom: 15px;position: relative;top: 0px\" id=\"_53882\"><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\">*Has this patient had a stroke within the last year?<\/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=\"__59__53882_has_this_patient_had_a_stroke_within_the_last_year_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=\"has_this_patient_had_a_stroke_within_the_last_year\" id=\"__59__53882_has_this_patient_had_a_stroke_within_the_last_year_Yes_yes\" value=\"Yes\" style=\"display: none\"><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=\"__59__53882_has_this_patient_had_a_stroke_within_the_last_year_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=\"has_this_patient_had_a_stroke_within_the_last_year\" id=\"__59__53882_has_this_patient_had_a_stroke_within_the_last_year_No_no\" value=\"No\" style=\"display: none\"><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 textarea common_fields\" style=\"margin-bottom: 15px;position: relative;top: 0px\" id=\"_98970\"><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__98970\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #000000\">If yes, when?<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"if_yes_when\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #000000;background: white;border-color: #dddddd\" id=\"input__98970\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px\" id=\"_82762\"><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__82762\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #000000\">Please list any allergies<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"please_list_any_allergies\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #000000;background: white;border-color: #dddddd\" id=\"input__82762\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px\" id=\"_10231\"><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__10231\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #000000\">Please list any medications<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"please_list_any_medications\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #000000;background: white;border-color: #dddddd\" id=\"input__10231\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px\" id=\"_66788\"><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__66788\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #000000\">Please list any other medical conditions<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"please_list_any_other_medical_conditions\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #000000;background: white;border-color: #dddddd\" id=\"input__66788\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 nex_prev_steps bootstrap_field is_grid\" data-id=\"_79129\" id=\"_23805\">\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-_23805 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=\"_43102\">\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-_23805 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=\"_30393\">\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_6 is_grid\" data-step-name=\"Dental History\" data-step-num=\"6\" 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\">Dental History<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider html_fields bootstrap_field\" data-id=\"_82500\" style=\"position: relative;top: 0px\" id=\"_82500\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><hr class=\"the_input_element\" style=\"border-width: 3px 0px\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields required\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_19718\" id=\"_19718\"><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\">*Last Dental Visit<\/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=\"__59__19718_last_dental_visit_6 Months_6_months\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"last_dental_visit\" id=\"__59__19718_last_dental_visit_6 Months_6_months\" value=\"6 Months\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;border-color: black\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">6 Months<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__59__19718_last_dental_visit_1 Year_1_year\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"last_dental_visit\" id=\"__59__19718_last_dental_visit_1 Year_1_year\" value=\"1 Year\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;border-color: black\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">1 Year<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__59__19718_last_dental_visit_3 Years_3_years\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"last_dental_visit\" id=\"__59__19718_last_dental_visit_3 Years_3_years\" value=\"3 Years\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;border-color: black\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">3 Years<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__59__19718_last_dental_visit_5 Years or More_5_years_or_more\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"last_dental_visit\" id=\"__59__19718_last_dental_visit_5 Years or More_5_years_or_more\" value=\"5 Years or More\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;border-color: black\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">5 Years or More<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__59__19718_last_dental_visit_Never_never\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"last_dental_visit\" id=\"__59__19718_last_dental_visit_Never_never\" value=\"Never\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;border-color: black\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Never<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields multi-select selection_fields\" style=\"margin-bottom: 15px;position: relative;top: 0px;z-index: 10000;left: 0px\" data-id=\"_18030\" id=\"_18030\"><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__18030\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #000000\">What was the visit for?<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><select name=\"what_was_the_visit_for[]\" multiple=\"\" class=\"the_input_element error_message text pre-format form-control aling_left align_left\" data-content=\"Required\" data-secondary-message=\"Minimum of {x} selections required\" style=\"font-size: 13px;color: #000000;background: white;border-color: #dddddd\" data-default-selected-value=\"0\" data-selected=\"0\" id=\"input__18030\"><option value=\"0\" selected=\"selected\">--- Select ---<\/option><option value=\"Cleaning\">Cleaning<\/option><option value=\"X Ray\">X Ray<\/option><option value=\"Extraction\">Extraction<\/option><option value=\"Fillings\/Etc.\">Fillings\/Etc.<\/option><option value=\"Other\">Other<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields required\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_61680\" id=\"_61680\"><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\">*How often do you brush?<\/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=\"__59__61680_how_often_do_you_brush_Once a day_once_a_day\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"how_often_do_you_brush\" id=\"__59__61680_how_often_do_you_brush_Once a day_once_a_day\" value=\"Once a day\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;border-color: black\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Once a day<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__59__61680_how_often_do_you_brush_Twice a day_twice_a_day\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"how_often_do_you_brush\" id=\"__59__61680_how_often_do_you_brush_Twice a day_twice_a_day\" value=\"Twice a day\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;border-color: black\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">Twice a day<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__59__61680_how_often_do_you_brush_None_none\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element required\" type=\"radio\" name=\"how_often_do_you_brush\" id=\"__59__61680_how_often_do_you_brush_None_none\" value=\"None\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;border-color: black\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\" style=\"color: #000000\">None<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields required\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_33531\" id=\"_33531\"><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\">*Do you floss?<\/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=\"__59__33531_do_you_floss_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=\"do_you_floss\" id=\"__59__33531_do_you_floss_Yes_yes\" value=\"Yes\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;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=\"__59__33531_do_you_floss_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=\"do_you_floss\" id=\"__59__33531_do_you_floss_No_no\" value=\"No\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;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 radio-group common_fields selection_fields required\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_94946\" id=\"_94946\"><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\">*Mouth rinse?<\/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=\"__59__94946_mouth_rinse_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=\"mouth_rinse\" id=\"__59__94946_mouth_rinse_Yes_yes\" value=\"Yes\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;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=\"__59__94946_mouth_rinse_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=\"mouth_rinse\" id=\"__59__94946_mouth_rinse_No_no\" value=\"No\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;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 radio-group common_fields selection_fields required\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_4203\" id=\"_4203\"><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\">*Do you have any pain?<\/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=\"__59__4203_do_you_have_any_pain_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=\"do_you_have_any_pain\" id=\"__59__4203_do_you_have_any_pain_Yes_yes\" value=\"Yes\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;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=\"__59__4203_do_you_have_any_pain_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=\"do_you_have_any_pain\" id=\"__59__4203_do_you_have_any_pain_No_no\" value=\"No\" style=\"display: none\"><a class=\"fa ui-state-default\" style=\"background: #ffffff33;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 textarea common_fields\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_32731\" id=\"_32731\"><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__32731\"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #000000\">If yes, please describe<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"if_yes_please_describe\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #000000;background: white;border-color: #dddddd\" id=\"input__32731\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph paragraph html_fields\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_7340\" id=\"_7340\"><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=\"_7340__math_result\"><div class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\" style=\"color: #000000\">I give permission for myself or my child to receive dental services provided by licensed registered dental hygienist with Public Health Status (PHS) or IPDH. Tooth Protectors Inc. (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 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 an I 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 another dental provider within 6 months and I did not divulged this above, than I assume all responsibility for payment of services received and understand that I will receive a bill from Tooth Protectors<\/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\n\n\n<p><\/p>\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-337","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/pages\/337","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=337"}],"version-history":[{"count":1,"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/pages\/337\/revisions"}],"predecessor-version":[{"id":338,"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/pages\/337\/revisions\/338"}],"wp:attachment":[{"href":"https:\/\/permissionform.toothprotectors.org\/index.php\/wp-json\/wp\/v2\/media?parent=337"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}