{"id":7922,"date":"2021-06-18T13:31:39","date_gmt":"2021-06-18T20:31:39","guid":{"rendered":"https:\/\/dev.sfveincenter.com\/registro-de-nuevos-pacientes\/"},"modified":"2021-06-18T13:31:44","modified_gmt":"2021-06-18T20:31:44","slug":"registro-de-nuevos-pacientes","status":"publish","type":"page","link":"https:\/\/dev.sfveincenter.com\/es\/registro-de-nuevos-pacientes\/","title":{"rendered":"Registro de nuevos pacientes"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_4' style='display:none'><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_4' id='gform_4'  action='\/es\/wp-json\/wp\/v2\/pages\/7922#gf_4' data-formid='4' novalidate>\n        <div id='gf_progressbar_wrapper_4' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>5<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_4_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_6\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_6'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_4_6' type='text' value='04\/09\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='1'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_4_6_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_6_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_6' class='gform_hidden' value='https:\/\/dev.sfveincenter.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">PATIENT DEMOGRAPHICS<\/h2><\/li><li id=\"field_4_9\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_9'>\n                            \n                            <span id='input_4_9_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.3' id='input_4_9_3' value='' tabindex='3'  aria-required='true'     \/>\n                                                    <label for='input_4_9_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_9_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.6' id='input_4_9_6' value='' tabindex='5'  aria-required='true'     \/>\n                                                    <label for='input_4_9_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_10\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_10' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_10_1_container' >\n                                        <input type='text' name='input_10.1' id='input_4_10_1' value='' tabindex='7'   aria-required='true'    \/>\n                                        <label for='input_4_10_1' id='input_4_10_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_4_10_2_container' >\n                                        <input type='text' name='input_10.2' id='input_4_10_2' value='' tabindex='8'    aria-required='false'   \/>\n                                        <label for='input_4_10_2' id='input_4_10_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_10_3_container' >\n                                    <input type='text' name='input_10.3' id='input_4_10_3' value='' tabindex='9'   aria-required='true'    \/>\n                                    <label for='input_4_10_3' id='input_4_10_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_10_4_container' >\n                                        <input type='text' name='input_10.4' id='input_4_10_4' value='' tabindex='11'     aria-required='true'    \/>\n                                        <label for='input_4_10_4' id='input_4_10_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_10_5_container' >\n                                    <input type='text' name='input_10.5' id='input_4_10_5' value='' tabindex='12'   aria-required='true'    \/>\n                                    <label for='input_4_10_5' id='input_4_10_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_10.6' id='input_4_10_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_11\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_11'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_11' id='input_4_11' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='13'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_4_11_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_11_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_11' class='gform_hidden' value='https:\/\/dev.sfveincenter.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_12\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_12'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_12' id='input_4_12' type='tel' value='' class='medium' tabindex='14'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_13\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_13'>Mobile Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_4_13' type='tel' value='' class='medium' tabindex='15'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_14\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_14'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_14' id='input_4_14' type='email' value='' class='medium' tabindex='16'    aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_4_75\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_15\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_15'>Emergency Contact (Next of Kin)<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_4_15' type='text' value='' class='medium'   tabindex='17'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_17\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_17'>Emergency Contact Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_17' id='input_4_17' type='tel' value='' class='medium' tabindex='18'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_18\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_18'>Relation to Emergency Contact<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_4_18' type='text' value='' class='medium'   tabindex='19'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_76\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_20\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_20'>Primary Physician<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_4_20' type='text' value='' class='medium'   tabindex='20'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_86\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_86'>Preferred Pharmacy and Address<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_4_86' type='text' value='' class='large'   tabindex='21'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >How did you hear about us?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_21'>\n\t\t\t<li class='gchoice gchoice_4_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Web Search \/ Google \/ www.sfveincenter.com'  id='choice_4_21_0' tabindex='22'   \/>\n\t\t\t\t<label for='choice_4_21_0' id='label_4_21_0' class='gform-field-label gform-field-label--type-inline'>Web Search \/ Google \/ www.sfveincenter.com<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='Yelp'  id='choice_4_21_1' tabindex='23'   \/>\n\t\t\t\t<label for='choice_4_21_1' id='label_4_21_1' class='gform-field-label gform-field-label--type-inline'>Yelp<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_21_2'>\n\t\t\t\t<input name='input_21' type='radio' value='I came from a doctor or a hospital'  id='choice_4_21_2' tabindex='24'   \/>\n\t\t\t\t<label for='choice_4_21_2' id='label_4_21_2' class='gform-field-label gform-field-label--type-inline'>I came from a doctor or a hospital<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_22\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_22'>Referring doctor or hospital<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_4_22' type='text' value='' class='medium'   tabindex='25'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_85\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_4_85'>Insurance Card<\/label><div class='gfield_description' id='gfield_description_4_85'>This link will allow you to use your mobile phone to capture the front and back of your insurance card\/s. Desktop computers will require you to upload an existing image.<BR><BR>\n\nIf you have trouble uploading, you may skip this step but be sure to bring your insurance card\/s to your appointment.<BR><BR>\n\nBe sure to capture the front and back of the card\/s.<\/div><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_4_85' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_4_85&quot;,&quot;container&quot;:&quot;gform_multifile_upload_4_85&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_4_85&quot;,&quot;filelist&quot;:&quot;gform_preview_4_85&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/dev.sfveincenter.com\\\/?gf_page=49143f4a138f037&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/dev.sfveincenter.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/dev.sfveincenter.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Archivos permitidos&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;67108864b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:4,&quot;field_id&quot;:85,&quot;_gform_file_upload_nonce_4_85&quot;:&quot;8bb2d5a176&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;6&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_4_85&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_4_85' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelta archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_4_85' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_4_85 gfield_description_4_85\" tabindex='26' >Selecciona archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_85'>Tama\u00f1o m\u00e1ximo de archivo: 64 MB, N\u00famero m\u00e1ximo de archivos: 6.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_4_85'><\/ul> <div id='gform_preview_4_85' class='ginput_preview_list'><\/div><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_4_25' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='27' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_2' class='gform_page' data-js='page-field-id-25' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_23\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">PATIENT MEDICAL HISTORY<\/h2><\/li><li id=\"field_4_24\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_24'>Reason for visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_4_24' class='textarea small' tabindex='28'    aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_26\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_26'>Please list any medical conditions you have. For example: high blood pressure, diabetes, varicose veins, etc.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_26' id='input_4_26' class='textarea medium' tabindex='29'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_29\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_29'>Please list any hospitalizations or surgeries you have had in the past. Please include approximate date and hospital<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_4_29' class='textarea medium' tabindex='30'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you take any medications?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_87'>\n\t\t\t<li class='gchoice gchoice_4_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='No'  id='choice_4_87_0' tabindex='31'   \/>\n\t\t\t\t<label for='choice_4_87_0' id='label_4_87_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='Yes - I will bring a list of my medications to the office.'  id='choice_4_87_1' tabindex='32'   \/>\n\t\t\t\t<label for='choice_4_87_1' id='label_4_87_1' class='gform-field-label gform-field-label--type-inline'>Yes - I will bring a list of my medications to the office.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_87_2'>\n\t\t\t\t<input name='input_87' type='radio' value='Yes - I can enter my medications now'  id='choice_4_87_2' tabindex='33'   \/>\n\t\t\t\t<label for='choice_4_87_2' id='label_4_87_2' class='gform-field-label gform-field-label--type-inline'>Yes - I can enter my medications now<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_30\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_30'>Please list medications you take. (Name, Quantity, Frequency). If you have too many to write, please be sure to bring us an accurate list at the office.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_4_30' class='textarea medium' tabindex='34'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_31\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_31'>Please list any medical conditions that run in your family.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_4_31' class='textarea medium' tabindex='35'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_32\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_32'>Please list any allergies you have if any<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_4_32' class='textarea medium' tabindex='36'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever smoked?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_41'>\n\t\t\t<li class='gchoice gchoice_4_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='Yes'  id='choice_4_41_0' tabindex='37'   \/>\n\t\t\t\t<label for='choice_4_41_0' id='label_4_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='No'  id='choice_4_41_1' tabindex='38'   \/>\n\t\t\t\t<label for='choice_4_41_1' id='label_4_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_34\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_34'>How many packs per day?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_34' id='input_4_34' type='number' step='any'   value='' class='medium' tabindex='39'    aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_35\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_35'>How many years did you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_35' id='input_4_35' type='number' step='any'   value='' class='medium' tabindex='40'    aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you stopped?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_42'>\n\t\t\t<li class='gchoice gchoice_4_42_0'>\n\t\t\t\t<input name='input_42' type='radio' value='Yes'  id='choice_4_42_0' tabindex='41'   \/>\n\t\t\t\t<label for='choice_4_42_0' id='label_4_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_42_1'>\n\t\t\t\t<input name='input_42' type='radio' value='No'  id='choice_4_42_1' tabindex='42'   \/>\n\t\t\t\t<label for='choice_4_42_1' id='label_4_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_37'>When did you stop<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_4_37' type='text' value='' class='medium'   tabindex='43'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_48\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_48'>How many alcoholic drinks do you have per day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_48' id='input_4_48' class='medium gfield_select' tabindex='44'   aria-required=\"true\" aria-invalid=\"false\" ><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/div><\/li><li id=\"field_4_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had a problem with alcohol<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_43'>\n\t\t\t<li class='gchoice gchoice_4_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='Yes'  id='choice_4_43_0' tabindex='45'   \/>\n\t\t\t\t<label for='choice_4_43_0' id='label_4_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='No'  id='choice_4_43_1' tabindex='46'   \/>\n\t\t\t\t<label for='choice_4_43_1' id='label_4_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_40\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_40'>What do you do for work?<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_4_40' type='text' value='' class='medium'   tabindex='47'   aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_44' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='48' \/> <input type='button' id='gform_next_button_4_44' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='49' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_3' class='gform_page' data-js='page-field-id-44' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_45\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Patient Medical History - Review of Systems<\/h2><div class='gsection_description' id='gfield_description_4_45'>Please check any that apply<\/div><\/li><li id=\"field_4_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >General \/ Endocrine<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_47'><li class='gchoice gchoice_4_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Weight change'  id='choice_4_47_1' tabindex='50'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_47_1' id='label_4_47_1' class='gform-field-label gform-field-label--type-inline'>Weight change<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Chills'  id='choice_4_47_2' tabindex='51'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_47_2' id='label_4_47_2' class='gform-field-label gform-field-label--type-inline'>Chills<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='Difficulty sleeping'  id='choice_4_47_3' tabindex='52'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_47_3' id='label_4_47_3' class='gform-field-label gform-field-label--type-inline'>Difficulty sleeping<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_47_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.4' type='checkbox'  value='Fevers'  id='choice_4_47_4' tabindex='53'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_47_4' id='label_4_47_4' class='gform-field-label gform-field-label--type-inline'>Fevers<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_47_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.5' type='checkbox'  value='Sweats'  id='choice_4_47_5' tabindex='54'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_47_5' id='label_4_47_5' class='gform-field-label gform-field-label--type-inline'>Sweats<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_47_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.6' type='checkbox'  value='Dizzyness'  id='choice_4_47_6' tabindex='55'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_47_6' id='label_4_47_6' class='gform-field-label gform-field-label--type-inline'>Dizzyness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_47_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.7' type='checkbox'  value='Fatigue'  id='choice_4_47_7' tabindex='56'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_47_7' id='label_4_47_7' class='gform-field-label gform-field-label--type-inline'>Fatigue<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_47_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.8' type='checkbox'  value='Loud snoring'  id='choice_4_47_8' tabindex='57'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_47_8' id='label_4_47_8' class='gform-field-label gform-field-label--type-inline'>Loud snoring<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_49\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Head, Eyes, Ears, Nose, Throat<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_49'><li class='gchoice gchoice_4_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Loss of eyesight'  id='choice_4_49_1' tabindex='58'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_1' id='label_4_49_1' class='gform-field-label gform-field-label--type-inline'>Loss of eyesight<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='Hearing loss'  id='choice_4_49_2' tabindex='59'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_2' id='label_4_49_2' class='gform-field-label gform-field-label--type-inline'>Hearing loss<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_49_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.3' type='checkbox'  value='Sinus infection'  id='choice_4_49_3' tabindex='60'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_3' id='label_4_49_3' class='gform-field-label gform-field-label--type-inline'>Sinus infection<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_49_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.4' type='checkbox'  value='Neck stiffness'  id='choice_4_49_4' tabindex='61'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_4' id='label_4_49_4' class='gform-field-label gform-field-label--type-inline'>Neck stiffness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_49_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.5' type='checkbox'  value='Headaches'  id='choice_4_49_5' tabindex='62'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_5' id='label_4_49_5' class='gform-field-label gform-field-label--type-inline'>Headaches<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_49_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.6' type='checkbox'  value='Nose bleeds'  id='choice_4_49_6' tabindex='63'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_6' id='label_4_49_6' class='gform-field-label gform-field-label--type-inline'>Nose bleeds<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_49_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.7' type='checkbox'  value='Ear infections'  id='choice_4_49_7' tabindex='64'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_7' id='label_4_49_7' class='gform-field-label gform-field-label--type-inline'>Ear infections<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_49_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.8' type='checkbox'  value='Difficulty swallowing'  id='choice_4_49_8' tabindex='65'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_8' id='label_4_49_8' class='gform-field-label gform-field-label--type-inline'>Difficulty swallowing<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Gastrointestinal<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_51'><li class='gchoice gchoice_4_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Stomach pain'  id='choice_4_51_1' tabindex='66'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_1' id='label_4_51_1' class='gform-field-label gform-field-label--type-inline'>Stomach pain<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='Nausea'  id='choice_4_51_2' tabindex='67'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_2' id='label_4_51_2' class='gform-field-label gform-field-label--type-inline'>Nausea<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.3' type='checkbox'  value='Ulcers'  id='choice_4_51_3' tabindex='68'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_3' id='label_4_51_3' class='gform-field-label gform-field-label--type-inline'>Ulcers<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.4' type='checkbox'  value='Diarrhea'  id='choice_4_51_4' tabindex='69'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_4' id='label_4_51_4' class='gform-field-label gform-field-label--type-inline'>Diarrhea<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.5' type='checkbox'  value='Bloody stools'  id='choice_4_51_5' tabindex='70'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_5' id='label_4_51_5' class='gform-field-label gform-field-label--type-inline'>Bloody stools<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.6' type='checkbox'  value='Black stools'  id='choice_4_51_6' tabindex='71'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_6' id='label_4_51_6' class='gform-field-label gform-field-label--type-inline'>Black stools<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.7' type='checkbox'  value='Heartburn'  id='choice_4_51_7' tabindex='72'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_7' id='label_4_51_7' class='gform-field-label gform-field-label--type-inline'>Heartburn<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.8' type='checkbox'  value='Constipation'  id='choice_4_51_8' tabindex='73'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_8' id='label_4_51_8' class='gform-field-label gform-field-label--type-inline'>Constipation<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_52\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Urologic<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_52'><li class='gchoice gchoice_4_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Blood in urine'  id='choice_4_52_1' tabindex='74'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_52_1' id='label_4_52_1' class='gform-field-label gform-field-label--type-inline'>Blood in urine<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='Nightly urination'  id='choice_4_52_2' tabindex='75'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_52_2' id='label_4_52_2' class='gform-field-label gform-field-label--type-inline'>Nightly urination<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_52_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.3' type='checkbox'  value='Impotence'  id='choice_4_52_3' tabindex='76'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_52_3' id='label_4_52_3' class='gform-field-label gform-field-label--type-inline'>Impotence<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_52_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.4' type='checkbox'  value='Kidney stones'  id='choice_4_52_4' tabindex='77'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_52_4' id='label_4_52_4' class='gform-field-label gform-field-label--type-inline'>Kidney stones<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Musculoskeletal<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_53'><li class='gchoice gchoice_4_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Weakness'  id='choice_4_53_1' tabindex='78'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_53_1' id='label_4_53_1' class='gform-field-label gform-field-label--type-inline'>Weakness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='Joint pain'  id='choice_4_53_2' tabindex='79'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_53_2' id='label_4_53_2' class='gform-field-label gform-field-label--type-inline'>Joint pain<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_53_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.3' type='checkbox'  value='Muscle aches'  id='choice_4_53_3' tabindex='80'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_53_3' id='label_4_53_3' class='gform-field-label gform-field-label--type-inline'>Muscle aches<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_53_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.4' type='checkbox'  value='Back pain'  id='choice_4_53_4' tabindex='81'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_53_4' id='label_4_53_4' class='gform-field-label gform-field-label--type-inline'>Back pain<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Neurological<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_54'><li class='gchoice gchoice_4_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Tremors'  id='choice_4_54_1' tabindex='82'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_54_1' id='label_4_54_1' class='gform-field-label gform-field-label--type-inline'>Tremors<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='Difficulty speaking'  id='choice_4_54_2' tabindex='83'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_54_2' id='label_4_54_2' class='gform-field-label gform-field-label--type-inline'>Difficulty speaking<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_54_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.3' type='checkbox'  value='Numbness'  id='choice_4_54_3' tabindex='84'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_54_3' id='label_4_54_3' class='gform-field-label gform-field-label--type-inline'>Numbness<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_55\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Respiratory<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_55'><li class='gchoice gchoice_4_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='Cough'  id='choice_4_55_1' tabindex='85'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_55_1' id='label_4_55_1' class='gform-field-label gform-field-label--type-inline'>Cough<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='Wheezing'  id='choice_4_55_2' tabindex='86'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_55_2' id='label_4_55_2' class='gform-field-label gform-field-label--type-inline'>Wheezing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_55_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.3' type='checkbox'  value='Coughing blood'  id='choice_4_55_3' tabindex='87'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_55_3' id='label_4_55_3' class='gform-field-label gform-field-label--type-inline'>Coughing blood<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_56\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Cardiac<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_56'><li class='gchoice gchoice_4_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='Chest pain'  id='choice_4_56_1' tabindex='88'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_56_1' id='label_4_56_1' class='gform-field-label gform-field-label--type-inline'>Chest pain<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_56_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.2' type='checkbox'  value='Heart palpitations'  id='choice_4_56_2' tabindex='89'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_56_2' id='label_4_56_2' class='gform-field-label gform-field-label--type-inline'>Heart palpitations<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_56_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.3' type='checkbox'  value='Heart attack'  id='choice_4_56_3' tabindex='90'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_56_3' id='label_4_56_3' class='gform-field-label gform-field-label--type-inline'>Heart attack<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Hematologic<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_57'><li class='gchoice gchoice_4_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Bleeding tendencies'  id='choice_4_57_1' tabindex='91'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_57_1' id='label_4_57_1' class='gform-field-label gform-field-label--type-inline'>Bleeding tendencies<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Blood clots in legs'  id='choice_4_57_2' tabindex='92'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_57_2' id='label_4_57_2' class='gform-field-label gform-field-label--type-inline'>Blood clots in legs<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='Blood clots in lungs'  id='choice_4_57_3' tabindex='93'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_57_3' id='label_4_57_3' class='gform-field-label gform-field-label--type-inline'>Blood clots in lungs<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Skin<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_59'><li class='gchoice gchoice_4_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Rashes'  id='choice_4_59_1' tabindex='94'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_59_1' id='label_4_59_1' class='gform-field-label gform-field-label--type-inline'>Rashes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='Itching'  id='choice_4_59_2' tabindex='95'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_59_2' id='label_4_59_2' class='gform-field-label gform-field-label--type-inline'>Itching<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_59_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.3' type='checkbox'  value='Change in skin'  id='choice_4_59_3' tabindex='96'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_59_3' id='label_4_59_3' class='gform-field-label gform-field-label--type-inline'>Change in skin<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Psychiatric<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_60'><li class='gchoice gchoice_4_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Depression'  id='choice_4_60_1' tabindex='97'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_60_1' id='label_4_60_1' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='Panic attacks'  id='choice_4_60_2' tabindex='98'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_60_2' id='label_4_60_2' class='gform-field-label gform-field-label--type-inline'>Panic attacks<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_60_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.3' type='checkbox'  value='Anxiety'  id='choice_4_60_3' tabindex='99'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_60_3' id='label_4_60_3' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_61\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Pulmonary<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_61'><li class='gchoice gchoice_4_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Asthma'  id='choice_4_61_1' tabindex='100'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_61_1' id='label_4_61_1' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='Allergies'  id='choice_4_61_2' tabindex='101'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_61_2' id='label_4_61_2' class='gform-field-label gform-field-label--type-inline'>Allergies<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_61_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.3' type='checkbox'  value='Cough'  id='choice_4_61_3' tabindex='102'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_61_3' id='label_4_61_3' class='gform-field-label gform-field-label--type-inline'>Cough<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_62' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='103' \/> <input type='button' id='gform_next_button_4_62' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='104' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_4' class='gform_page' data-js='page-field-id-62' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_64\" class=\"gfield gfield--type-html gfield--input-type-html pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 style=\"text-align: center\">Patient Financial Responsibility Agreement<\/h2>\n<p><strong>Cancellation policy<\/strong><\/p>\n<p>While we understand there may be times when you miss an appointment due to emergencies or obligations, we enforce the following cancellation policy:<\/p>\n<ul>\n<li>We require at least a 48 hour (<u>2 business days<\/u>) notice to cancel an office appointment. A $75 fee will be charged for cancellations made less than 48 hours (<u>2 business days<\/u>) from the appointment time or missed appointments<\/li>\n<li>We require at least a 72 hour notice (3 business days) to cancel a procedure. A $250 fee will be charged for cancellations made less than 48 hours from the procedure time or if the procedure is missed. Procedures require special preparation of equipment and a procedure room which is reserved.<\/li>\n<\/ul>\n<p><strong>General responsibilities<\/strong><\/p>\n<p>You (or patient&rsquo;s guardian) are responsible for the payment of your treatment and care.<\/p>\n<p><strong>Insurance<\/strong><\/p>\n<ul>\n<li>Your insurance policy is a contract between you and your insurance provider. <u>You are responsible for understanding and paying your insurance copays, deductibles, and coinsurance.<\/u>&nbsp; Our staff is happy to explain what these are if you need help.<\/li>\n<li>As a curtesy, we bill your insurance company for you and charge you copays, deductibles, and\/or coinsurance as instructed by your insurance company.<\/li>\n<li>As a curtesy, we try to verify coverage and eligibility. However, it is your responsibility to determine if the doctor is in-network prior to being seen.<\/li>\n<li>You are responsible for providing us with the most correct and updated information about your insurance.<\/li>\n<li>You are responsible for any amounts not covered by insurance.<\/li>\n<\/ul>\n<p>We are committed to providing you with the best possible care.&nbsp; Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions.&nbsp; We are pleased to discuss our financial policy with you at any time.<\/p>\n<p>I have read, understand and agree to the provisions of this Patient Financial Responsibility Form. In the event of nonpayment or default, I am responsible for all costs and reasonable collection and\/or attorney fees.<\/p><\/li><li id=\"field_4_65\" class=\"gfield gfield--type-signature gfield--input-type-signature gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_65'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_65' id='input_4_65_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_4_65_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_4_65' width='300' height='180' style='border-style: solid; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/dev.sfveincenter.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_4_65_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_4_65_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_4_65_data' name='input_4_65_data' value=''><\/div><\/li><li id=\"field_4_78\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_78'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_4_78' type='text' value='' class='medium'   tabindex='105'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_79\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_79'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_79' id='input_4_79' type='text' value='04\/09\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='106'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_4_79_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_79_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_79' class='gform_hidden' value='https:\/\/dev.sfveincenter.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_66' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='107' \/> <input type='button' id='gform_next_button_4_66' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='108' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_5' class='gform_page pagebreak' data-js='page-field-id-66' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_68\" class=\"gfield gfield--type-html gfield--input-type-html pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 style=\"text-align: center\">Patient Health Information Authorization Agreement and Consent<\/h2>\n<p>We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we require you to read and sign this form stating that you understand and agree with how your health information will be used, your authorization to use that information, and your rights regarding that information.<\/p>\n<p><strong>Notice of Privacy Practices<\/strong><\/p>\n<p>I acknowledge that I have been provided with this office's Notice of Privacy Practices.&nbsp; I understand that it provides a complete description of the uses and disclosures of my health information. I understand that a copy of the Notice of Privacy Practices is also available at the front desk as well as <a href=\"https:\/\/dev.sfveincenter.com\">https:\/\/dev.sfveincenter.com<\/a>.&nbsp;<\/p>\n<p><strong>Authorization for the Disclosure of PHI for Treatment, Payment, or Healthcare Operations<\/strong><\/p>\n<p>I understand that as part of my healthcare this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:<\/p>\n<ul>\n<li>a basis for planning my care and treatment.<\/li>\n<li>a means of communication among the health professionals who may contribute to my healthcare.<\/li>\n<li>a source of information for applying my diagnosis and surgical information to my bill.<\/li>\n<li>a means by which a third-party payer can verify that services billed were actually provided.<\/li>\n<li>a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.<\/li>\n<\/ul>\n<p>I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I authorize the disclosure of my Protected Health Information as specified above.<\/p>\n<p><strong>Consent to the Use and Disclosure of PHI for Treatment, Payment, or Healthcare Operations<\/strong><\/p>\n<p>I understand that:<\/p>\n<ul>\n<li>I have the right to review this facility's Notice of Information practices prior to signing this consent.<\/li>\n<li>This facility, reserves the right to change the notice and practices.<\/li>\n<li>I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested.<\/li>\n<li>I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon.<\/li>\n<li>It is this facility's procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.<\/li>\n<\/ul>\n<p><strong>Open Payments Database<\/strong><\/p>\n<p>The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https:\/\/openpaymentsdata.cms.gov.<\/p><\/li><li id=\"field_4_69\" class=\"gfield gfield--type-signature gfield--input-type-signature gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_69'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_69' id='input_4_69_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_4_69_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_4_69' width='300' height='180' style='border-style: solid; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/dev.sfveincenter.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_4_69_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_4_69_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_4_69_data' name='input_4_69_data' value=''><\/div><\/li><li id=\"field_4_82\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_82'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_4_82' type='text' value='' class='medium'   tabindex='109'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_81\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_81'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_81' id='input_4_81' type='text' value='04\/09\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='110'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_4_81_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_81_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_81' class='gform_hidden' value='https:\/\/dev.sfveincenter.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_88\" class=\"gfield gfield--type-radio gfield--type-choice 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