{"id":1337,"date":"2023-02-23T21:31:33","date_gmt":"2023-02-24T05:31:33","guid":{"rendered":"https:\/\/pediatricdentistoregon.com\/?page_id=1337"},"modified":"2023-02-28T14:12:53","modified_gmt":"2023-02-28T22:12:53","slug":"new-patient-form","status":"publish","type":"page","link":"https:\/\/pediatricdentistoregon.com\/es\/new-patient-form\/","title":{"rendered":"New Patient Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1337\" class=\"elementor elementor-1337\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-section elementor-top-section elementor-element elementor-element-1961c752 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"1961c752\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-5d1ce738\" data-id=\"5d1ce738\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4fc8bf76 elementor-widget elementor-widget-text-editor\" data-id=\"4fc8bf76\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' ><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">New Patient Form<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/es\/wp-json\/wp\/v2\/pages\/1337#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_7\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Tell Us About Your Child<\/h3><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_1_1_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.8' id='input_1_1_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_1_8' class='gform-field-label gform-field-label--type-sub '>Nickname<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><div id=\"field_1_3\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-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_1_3'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_1_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_3_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_3' class='gform_hidden' value='https:\/\/pediatricdentistoregon.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_4'>\n\t\t\t<div class='gchoice gchoice_1_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Male'  id='choice_1_4_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_0' id='label_1_4_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Female'  id='choice_1_4_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_1' id='label_1_4_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_6\" class=\"gfield gfield--type-number gfield--width-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_1_6'>Weight<\/label><div class='ginput_container ginput_container_number'><input name='input_6' id='input_1_6' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Responsible Party Information:<\/h3><\/div><fieldset id=\"field_1_9\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mother\/Guardian<\/legend><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_1_9'>\n                            \n                            <span id='input_1_9_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.3' id='input_1_9_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_9_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_9_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.6' id='input_1_9_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_9_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_13\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-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_1_13'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_13' id='input_1_13' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_13_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_13_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_13' class='gform_hidden' value='https:\/\/pediatricdentistoregon.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-phone gfield--width-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_1_10'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_1_10' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Texting Ok?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_11'>\n\t\t\t<div class='gchoice gchoice_1_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_1_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_0' id='label_1_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_1_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_1' id='label_1_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_21\" class=\"gfield gfield--type-email 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_1_21'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_21' id='input_1_21' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_12\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_1_12_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_12_1' id='input_1_12_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_12_2_container' >\n                                        <input type='text' name='input_12.2' id='input_1_12_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_12_2' id='input_1_12_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_1_12_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_12_3' id='input_1_12_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_12_4_container' >\n                                        <input type='text' name='input_12.4' id='input_1_12_4' value=''      aria-required='false'    \/>\n                                        <label for='input_1_12_4' id='input_1_12_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_1_12_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_12_5' id='input_1_12_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_12_6_container' >\n                                        <select name='input_12.6' id='input_1_12_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_1_12_6' id='input_1_12_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_14\" class=\"gfield gfield--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_1_14'>Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_15\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Father\/Guardian<\/legend><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_1_15'>\n                            \n                            <span id='input_1_15_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_15.3' id='input_1_15_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_15_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_15_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_15.6' id='input_1_15_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_15_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_16\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-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_1_16'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_16' id='input_1_16' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_16_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_16_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_16' class='gform_hidden' value='https:\/\/pediatricdentistoregon.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-phone gfield--width-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_1_17'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_17' id='input_1_17' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Texting Ok?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_18'>\n\t\t\t<div class='gchoice gchoice_1_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_1_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_0' id='label_1_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_1_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_22\" class=\"gfield gfield--type-email 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_1_22'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_1_22' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_19\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_19' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_19_1_container' >\n                                        <input type='text' name='input_19.1' id='input_1_19_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_19_1' id='input_1_19_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_19_2_container' >\n                                        <input type='text' name='input_19.2' id='input_1_19_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_19_2' id='input_1_19_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_19_3_container' >\n                                    <input type='text' name='input_19.3' id='input_1_19_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_19_3' id='input_1_19_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_19_4_container' >\n                                        <input type='text' name='input_19.4' id='input_1_19_4' value=''      aria-required='false'    \/>\n                                        <label for='input_1_19_4' id='input_1_19_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_19_5_container' >\n                                    <input type='text' name='input_19.5' id='input_1_19_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_19_5' id='input_1_19_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_19_6_container' >\n                                        <select name='input_19.6' id='input_1_19_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_1_19_6' id='input_1_19_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_20\" class=\"gfield gfield--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_1_20'>Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_23' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-23' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_24\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Primary Insurance Information<\/h3><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_25'>Insurance Company:<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_1_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>Insurance Co. Phone #:<\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_1_26' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_27\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_27'>Group #:<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>ID#:<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_1_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>Subscriber:<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>Subscriber\u2019s SS #:<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_34\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Secondary Insurance Information<\/h3><\/div><div id=\"field_1_35\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>Insurance Company:<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>Insurance Co. Phone #:<\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_1_36' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_37\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_37'>Group #:<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_1_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_38\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>ID#:<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_1_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_39\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_39'>Subscriber:<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_1_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_51'>Subscriber\u2019s SS #:<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_1_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_44' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_44' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-44' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_1_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Has your child ever Injured their teeth or jaws?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_43'>\n\t\t\t<div class='gchoice gchoice_1_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_1_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_43_0' id='label_1_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_1_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_43_1' id='label_1_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_45\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_45'>If Yes, when?<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_1_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_57\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"gformlabeljc\">Does your child have a history of the following:<\/div><\/div><fieldset id=\"field_1_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nursing\/Bottle Habits<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_53'><div class='gchoice gchoice_1_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Past'  id='choice_1_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_1' id='label_1_53_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='Present'  id='choice_1_53_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_2' id='label_1_53_2' class='gform-field-label gform-field-label--type-inline'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Thumb\/Finger Sucking<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_47'><div class='gchoice gchoice_1_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Past'  id='choice_1_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Present'  id='choice_1_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_2' id='label_1_47_2' class='gform-field-label gform-field-label--type-inline'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Pacifier<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_54'><div class='gchoice gchoice_1_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Past'  id='choice_1_54_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_54_1' id='label_1_54_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='Present'  id='choice_1_54_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_54_2' id='label_1_54_2' class='gform-field-label gform-field-label--type-inline'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_55\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Teeth grinding\/Clenching<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_55'><div class='gchoice gchoice_1_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='Past'  id='choice_1_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_55_1' id='label_1_55_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='Present'  id='choice_1_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_55_2' id='label_1_55_2' class='gform-field-label gform-field-label--type-inline'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_49\" class=\"gfield gfield--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_1_49'>Has your child ever had an unfavorable medical\/dental experience? Please Explain:<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_1_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_50\" class=\"gfield gfield--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_1_50'>How do you think your child will act at the dentist office?<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_1_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Medical History<\/h3><\/div><div id=\"field_1_61\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_61'>Child&#039;s Primary Care Physician<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_1_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_62\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_62'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_62' id='input_1_62' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your child currently under their care for a medical problem?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_63'>\n\t\t\t<div class='gchoice gchoice_1_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Yes'  id='choice_1_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_0' id='label_1_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='No'  id='choice_1_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_1' id='label_1_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_64\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_64'>If yes, please explain:<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_65\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Has your child had any of the following medical problems<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_65'><div class='gchoice gchoice_1_65_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.1' type='checkbox'  value='Is your child currently taking any prescription&lt;br&gt; or over-the-counter medications?'  id='choice_1_65_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_1' id='label_1_65_1' class='gform-field-label gform-field-label--type-inline'>Is your child currently taking any prescription<br> or over-the-counter medications?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_65_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.2' type='checkbox'  value='Has your child ever been hospitalized or had surgery?'  id='choice_1_65_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_2' id='label_1_65_2' class='gform-field-label gform-field-label--type-inline'>Has your child ever been hospitalized or had surgery?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_65_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.3' type='checkbox'  value='Is your child allergic\/sensitive to latex, acrylics or metals?'  id='choice_1_65_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_3' id='label_1_65_3' class='gform-field-label gform-field-label--type-inline'>Is your child allergic\/sensitive to latex, acrylics or metals?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_65_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.4' type='checkbox'  value='Is your child allergic to any medications\/foods?'  id='choice_1_65_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_4' id='label_1_65_4' class='gform-field-label gform-field-label--type-inline'>Is your child allergic to any medications\/foods?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_65_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.5' type='checkbox'  value='Has anyone in your family had a negative reaction to any local or general anesthetic?'  id='choice_1_65_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_5' id='label_1_65_5' class='gform-field-label gform-field-label--type-inline'>Has anyone in your family had a negative reaction to any local or general anesthetic?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_65_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.6' type='checkbox'  value='Are you interested in orthodontics if your child would benefit from braces?'  id='choice_1_65_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_6' id='label_1_65_6' class='gform-field-label gform-field-label--type-inline'>Are you interested in orthodontics if your child would benefit from braces?<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_66\" class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_66'>If yes, please explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_66' id='input_1_66' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Has your child had any of the following medical problems<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_42'><div class='gchoice gchoice_1_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='Anemia'  id='choice_1_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_1' id='label_1_42_1' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.2' type='checkbox'  value='Arthritis'  id='choice_1_42_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_2' id='label_1_42_2' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.3' type='checkbox'  value='Asthma'  id='choice_1_42_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_3' id='label_1_42_3' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.4' type='checkbox'  value='Autism\/Sensory Disorder'  id='choice_1_42_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_4' id='label_1_42_4' class='gform-field-label gform-field-label--type-inline'>Autism\/Sensory Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.5' type='checkbox'  value='Blood Disease'  id='choice_1_42_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_5' id='label_1_42_5' class='gform-field-label gform-field-label--type-inline'>Blood Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.6' type='checkbox'  value='Bone\/Joint Problems'  id='choice_1_42_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_6' id='label_1_42_6' class='gform-field-label gform-field-label--type-inline'>Bone\/Joint Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.7' type='checkbox'  value='Bruise Easily'  id='choice_1_42_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_7' id='label_1_42_7' class='gform-field-label gform-field-label--type-inline'>Bruise Easily<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.8' type='checkbox'  value='Cancer, Malignancy, Chemotherapy or Radiation'  id='choice_1_42_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_8' id='label_1_42_8' class='gform-field-label gform-field-label--type-inline'>Cancer, Malignancy, Chemotherapy or Radiation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.9' type='checkbox'  value='Cerebral Palsy'  id='choice_1_42_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_9' id='label_1_42_9' class='gform-field-label gform-field-label--type-inline'>Cerebral Palsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.11' type='checkbox'  value='Chronic Adenoid\/Tonsil Issues'  id='choice_1_42_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_11' id='label_1_42_11' class='gform-field-label gform-field-label--type-inline'>Chronic Adenoid\/Tonsil Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.12' type='checkbox'  value='Chronic Ear Infections'  id='choice_1_42_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_12' id='label_1_42_12' class='gform-field-label gform-field-label--type-inline'>Chronic Ear Infections<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.13' type='checkbox'  value='Cleft Lip\/Palate'  id='choice_1_42_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_13' id='label_1_42_13' class='gform-field-label gform-field-label--type-inline'>Cleft Lip\/Palate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.14' type='checkbox'  value='Congenital Heart Defect'  id='choice_1_42_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_14' id='label_1_42_14' class='gform-field-label gform-field-label--type-inline'>Congenital Heart Defect<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.15' type='checkbox'  value='Developmentally Delayed'  id='choice_1_42_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_15' id='label_1_42_15' class='gform-field-label gform-field-label--type-inline'>Developmentally Delayed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.16' type='checkbox'  value='Diabetes'  id='choice_1_42_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_16' id='label_1_42_16' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.17' type='checkbox'  value='Epilepsy\/Seizures'  id='choice_1_42_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_17' id='label_1_42_17' class='gform-field-label gform-field-label--type-inline'>Epilepsy\/Seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.18' type='checkbox'  value='Fainting\/Dizziness'  id='choice_1_42_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_18' id='label_1_42_18' class='gform-field-label gform-field-label--type-inline'>Fainting\/Dizziness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.19' type='checkbox'  value='Growth\/Development Problems'  id='choice_1_42_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_19' id='label_1_42_19' class='gform-field-label gform-field-label--type-inline'>Growth\/Development Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.21' type='checkbox'  value='Heart Surgery\/Murmur\/Defects'  id='choice_1_42_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_21' id='label_1_42_21' class='gform-field-label gform-field-label--type-inline'>Heart Surgery\/Murmur\/Defects<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.22' type='checkbox'  value='Hearing\/Speech Problems'  id='choice_1_42_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_22' id='label_1_42_22' class='gform-field-label gform-field-label--type-inline'>Hearing\/Speech Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.23' type='checkbox'  value='Hemophilia'  id='choice_1_42_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_23' id='label_1_42_23' class='gform-field-label gform-field-label--type-inline'>Hemophilia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.24' type='checkbox'  value='Hyperactivity\/ADD'  id='choice_1_42_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_24' id='label_1_42_24' class='gform-field-label gform-field-label--type-inline'>Hyperactivity\/ADD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.25' type='checkbox'  value='Neurological Disorder'  id='choice_1_42_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_25' id='label_1_42_25' class='gform-field-label gform-field-label--type-inline'>Neurological Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.26' type='checkbox'  value='Rheumatic Fever'  id='choice_1_42_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_26' id='label_1_42_26' class='gform-field-label gform-field-label--type-inline'>Rheumatic Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.27' type='checkbox'  value='Seasonal Allergies'  id='choice_1_42_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_27' id='label_1_42_27' class='gform-field-label gform-field-label--type-inline'>Seasonal Allergies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.28' type='checkbox'  value='Tuberculosis'  id='choice_1_42_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_28' id='label_1_42_28' class='gform-field-label gform-field-label--type-inline'>Tuberculosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_67\" class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_67'>If yes, please explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_67' id='input_1_67' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_68\" class=\"gfield gfield--type-textarea 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_1_68'>Is there anything else that we should know about your child?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_68' id='input_1_68' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_70\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Authorization &amp; Release<\/legend><div class='ginput_container ginput_container_consent'><input name='input_70.1' id='input_1_70_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_70\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_70_1' >I agree to the Authorization & Release policy.<\/label><input type='hidden' name='input_70.2' value='I agree to the Authorization &amp; Release policy.' class='gform_hidden' \/><input type='hidden' name='input_70.3' value='15' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_70' tabindex='0'>I authorize Pediatric Dental Associates of Albany to administer necessary medications and perform such diagnostic, photographic, preventive,<br \/>\ntherapeutic, and restorative procedures a may be necessary for proper dental health and care. I understand that no treatment will be started<br \/>\nuntil such recommended treatment, time involved, and financial investment has been discussed with me by either one of the Doctors or one of<br \/>\ntheir staff members. The information on this page and the dental\/medical history is correct to the best of my knowledge. I grant Pediatric Dental<br \/>\nAssociates of Albany the right to release my child's dental\/medical histories and other information about my child's dental treatment to third<br \/>\nparty payers and\/or other health professionals I attest that I have answered this dental\/medical history to the best of my knowledge and have<br \/>\ndisclosed my child's complete health history on this document.<\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_71' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_71' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-71' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_1_72\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Privacy Practices Consent Policy<\/legend><div class='ginput_container ginput_container_consent'><input name='input_72.1' id='input_1_72_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_72\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_72_1' >I agree to the Privacy Practices Policy<\/label><input type='hidden' name='input_72.2' value='I agree to the Privacy Practices Policy' class='gform_hidden' \/><input type='hidden' name='input_72.3' value='15' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_72' tabindex='0'>I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability ad Accountability Act of 1996 (HIPPA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:<br \/>\n*Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment).<br \/>\n*Obtaining payment from third party payers (e.g. my insurance company).<br \/>\n*The day-to-day healthcare operation of your practice.<br \/>\n<br \/>\n I have also been informed of, and given the rights to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPPA. I understand that you reserve the right to change the terms of this notice from time to time and I may contact you at any time to obtain the most current copy of this notice.<br \/>\n<br \/>\nI understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.<br \/>\n<br \/>\nI understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred to prior to the date I revoke this consent is not affected.<br \/>\n<\/div><\/fieldset><fieldset id=\"field_1_73\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Payment Options<\/legend><div class='ginput_container ginput_container_consent'><input name='input_73.1' id='input_1_73_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_73\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_73_1' >I agree to Pediatric Dental Associates Payment Options<\/label><input type='hidden' name='input_73.2' value='I agree to Pediatric Dental Associates Payment Options' class='gform_hidden' \/><input type='hidden' name='input_73.3' value='15' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_73' tabindex='0'>Payment Options<br \/>\nIn order to make payment for services as convenient as possible, while at the same time maintaining operations of our office in the highest standard of comprehensive care, we offer three different payment options (see below). We will do our best to give you an accurate estimate of your total fees at the onset of your child's treatment, however in some cases the required treatment will be more or less expensive than was originally quoted. All estimates are based on insurance information provided by the parent\/guardian, and estimated coverage is not a guarantee of payment from your insurance provider.<br \/>\n<strong>Payment Options<\/strong><br \/>\n<ol><li>Payment in Full: Payment of your estimated patient share is expected at the time of service. We accept Cash, Check, Visa, Master Card, Discover, American Express, and Care Credit. A 10% discount will be credited for any accounts who do not have dental insurance.<\/li><br \/>\n<li>Installments\/Payment Plan: Our office understands that the cost of dental treatment can sometimes be unexpected. In order to help ease any financial burden, we offer in-house payment plans. Each plan is customized based on the cost of your child's treatment and the amount of months you would like to pay. There is no interest and no early termination fee if you wish to pay your account off early. You will be required to keep a debit or credit card on file for automatic monthly payments. If the account becomes delinquent due to three (3) missed payments, our office reserves the right to turn the account over to an outside collections agency. For additional information regarding this payment option, please ask a front office staff member.<\/li><br \/>\n<li>Insurance Assignments: We will gladly file insurance claims and accept assignment of benefits in place of payment at the time of service. You will still be responsible for any non-covered services, co-insurances, or co-payments at the time services are rendered. Insurance payments are determined by your insurance company at the time they receive the dental claim based on their \"usual and customary\" fee schedule. Your insurance company's fee schedule may not align with our offices charges. You may be responsible for the difference in these amounts. You are financially responsible for any charges not covered by your insurance.<\/li><\/ol><br \/>\n<br \/>\n<strong>Additional Payment Policies\/Information<\/strong><br \/>\n<ol><li><strong>Missed Appointments:<\/strong> To best serve our patients, we kindly ask for your appointments to be kept, or to be notified 24 hours in advance of the cancellation of an appointment. We do understand emergencies happen, and calling before missing an appointment is not always possible. If two (2) appointments are missed within a six (6) month period, you will be responsible for a $30.00 missed appointment fee (per missed appointment).<\/li><br \/>\n <li><strong>Military\/Emergency Response Personnel Discount:<\/strong> To honor those who serve, a 15% discount will be applied to any out of pocket cost that is incurred in our office. 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class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_3' class='gform_hidden' value='https:\/\/pediatricdentistoregon.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_4'>\n\t\t\t<div class='gchoice gchoice_1_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Male'  id='choice_1_4_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_0' id='label_1_4_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Female'  id='choice_1_4_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_1' id='label_1_4_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_6\" class=\"gfield gfield--type-number gfield--width-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_1_6'>Weight<\/label><div class='ginput_container ginput_container_number'><input name='input_6' id='input_1_6' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Responsible Party Information:<\/h3><\/div><fieldset id=\"field_1_9\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mother\/Guardian<\/legend><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_1_9'>\n                            \n                            <span id='input_1_9_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.3' id='input_1_9_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_9_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_9_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.6' id='input_1_9_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_9_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_13\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-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_1_13'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_13' id='input_1_13' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_13_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_13_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_13' class='gform_hidden' value='https:\/\/pediatricdentistoregon.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-phone gfield--width-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_1_10'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_1_10' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Texting Ok?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_11'>\n\t\t\t<div class='gchoice gchoice_1_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_1_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_0' id='label_1_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_1_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_1' id='label_1_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_21\" class=\"gfield gfield--type-email 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_1_21'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_21' id='input_1_21' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_12\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_1_12_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_12_1' id='input_1_12_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_12_2_container' >\n                                        <input type='text' name='input_12.2' id='input_1_12_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_12_2' id='input_1_12_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_1_12_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_12_3' id='input_1_12_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_12_4_container' >\n                                        <input type='text' name='input_12.4' id='input_1_12_4' value=''      aria-required='false'    \/>\n                                        <label for='input_1_12_4' id='input_1_12_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_1_12_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_12_5' id='input_1_12_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_12_6_container' >\n                                        <select name='input_12.6' id='input_1_12_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_1_12_6' id='input_1_12_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_14\" class=\"gfield gfield--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_1_14'>Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_15\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Father\/Guardian<\/legend><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_1_15'>\n                            \n                            <span id='input_1_15_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_15.3' id='input_1_15_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_15_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_15_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_15.6' id='input_1_15_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_15_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_16\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-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_1_16'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_16' id='input_1_16' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_16_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_16_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_16' class='gform_hidden' value='https:\/\/pediatricdentistoregon.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-phone gfield--width-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_1_17'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_17' id='input_1_17' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Texting Ok?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_18'>\n\t\t\t<div class='gchoice gchoice_1_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_1_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_0' id='label_1_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_1_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_22\" class=\"gfield gfield--type-email 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_1_22'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_1_22' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_19\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_19' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_19_1_container' >\n                                        <input type='text' name='input_19.1' id='input_1_19_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_19_1' id='input_1_19_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_19_2_container' >\n                                        <input type='text' name='input_19.2' id='input_1_19_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_19_2' id='input_1_19_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_19_3_container' >\n                                    <input type='text' name='input_19.3' id='input_1_19_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_19_3' id='input_1_19_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_19_4_container' >\n                                        <input type='text' name='input_19.4' id='input_1_19_4' value=''      aria-required='false'    \/>\n                                        <label for='input_1_19_4' id='input_1_19_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_19_5_container' >\n                                    <input type='text' name='input_19.5' id='input_1_19_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_19_5' id='input_1_19_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_19_6_container' >\n                                        <select name='input_19.6' id='input_1_19_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_1_19_6' id='input_1_19_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_20\" class=\"gfield gfield--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_1_20'>Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_23' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-23' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_24\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Primary Insurance Information<\/h3><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_25'>Insurance Company:<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_1_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>Insurance Co. Phone #:<\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_1_26' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_27\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_27'>Group #:<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>ID#:<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_1_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>Subscriber:<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>Subscriber\u2019s SS #:<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_34\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Secondary Insurance Information<\/h3><\/div><div id=\"field_1_35\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>Insurance Company:<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>Insurance Co. Phone #:<\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_1_36' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_37\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_37'>Group #:<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_1_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_38\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>ID#:<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_1_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_39\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_39'>Subscriber:<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_1_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_51'>Subscriber\u2019s SS #:<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_1_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_44' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_44' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-44' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_1_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Has your child ever Injured their teeth or jaws?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_43'>\n\t\t\t<div class='gchoice gchoice_1_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_1_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_43_0' id='label_1_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_1_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_43_1' id='label_1_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_45\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_45'>If Yes, when?<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_1_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_57\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"gformlabeljc\">Does your child have a history of the following:<\/div><\/div><fieldset id=\"field_1_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nursing\/Bottle Habits<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_53'><div class='gchoice gchoice_1_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Past'  id='choice_1_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_1' id='label_1_53_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='Present'  id='choice_1_53_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_2' id='label_1_53_2' class='gform-field-label gform-field-label--type-inline'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Thumb\/Finger Sucking<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_47'><div class='gchoice gchoice_1_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Past'  id='choice_1_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Present'  id='choice_1_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_2' id='label_1_47_2' class='gform-field-label gform-field-label--type-inline'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Pacifier<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_54'><div class='gchoice gchoice_1_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Past'  id='choice_1_54_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_54_1' id='label_1_54_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='Present'  id='choice_1_54_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_54_2' id='label_1_54_2' class='gform-field-label gform-field-label--type-inline'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_55\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Teeth grinding\/Clenching<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_55'><div class='gchoice gchoice_1_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='Past'  id='choice_1_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_55_1' id='label_1_55_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='Present'  id='choice_1_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_55_2' id='label_1_55_2' class='gform-field-label gform-field-label--type-inline'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_49\" class=\"gfield gfield--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_1_49'>Has your child ever had an unfavorable medical\/dental experience? Please Explain:<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_1_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_50\" class=\"gfield gfield--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_1_50'>How do you think your child will act at the dentist office?<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_1_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Medical History<\/h3><\/div><div id=\"field_1_61\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_61'>Child&#039;s Primary Care Physician<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_1_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_62\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_62'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_62' id='input_1_62' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your child currently under their care for a medical problem?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_63'>\n\t\t\t<div class='gchoice gchoice_1_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Yes'  id='choice_1_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_0' id='label_1_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='No'  id='choice_1_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_1' id='label_1_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_64\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_64'>If yes, please explain:<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_65\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Has your child had any of the following medical problems<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_65'><div class='gchoice gchoice_1_65_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.1' type='checkbox'  value='Is your child currently taking any prescription&lt;br&gt; or over-the-counter medications?'  id='choice_1_65_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_1' id='label_1_65_1' class='gform-field-label gform-field-label--type-inline'>Is your child currently taking any prescription<br> or over-the-counter medications?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_65_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.2' type='checkbox'  value='Has your child ever been hospitalized or had surgery?'  id='choice_1_65_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_2' id='label_1_65_2' class='gform-field-label gform-field-label--type-inline'>Has your child ever been hospitalized or had surgery?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_65_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.3' type='checkbox'  value='Is your child allergic\/sensitive to latex, acrylics or metals?'  id='choice_1_65_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_3' id='label_1_65_3' class='gform-field-label gform-field-label--type-inline'>Is your child allergic\/sensitive to latex, acrylics or metals?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_65_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.4' type='checkbox'  value='Is your child allergic to any medications\/foods?'  id='choice_1_65_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_4' id='label_1_65_4' class='gform-field-label gform-field-label--type-inline'>Is your child allergic to any medications\/foods?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_65_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.5' type='checkbox'  value='Has anyone in your family had a negative reaction to any local or general anesthetic?'  id='choice_1_65_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_5' id='label_1_65_5' class='gform-field-label gform-field-label--type-inline'>Has anyone in your family had a negative reaction to any local or general anesthetic?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_65_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.6' type='checkbox'  value='Are you interested in orthodontics if your child would benefit from braces?'  id='choice_1_65_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_6' id='label_1_65_6' class='gform-field-label gform-field-label--type-inline'>Are you interested in orthodontics if your child would benefit from braces?<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_66\" class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_66'>If yes, please explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_66' id='input_1_66' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Has your child had any of the following medical problems<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_42'><div class='gchoice gchoice_1_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='Anemia'  id='choice_1_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_1' id='label_1_42_1' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.2' type='checkbox'  value='Arthritis'  id='choice_1_42_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_2' id='label_1_42_2' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.3' type='checkbox'  value='Asthma'  id='choice_1_42_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_3' id='label_1_42_3' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.4' type='checkbox'  value='Autism\/Sensory Disorder'  id='choice_1_42_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_4' id='label_1_42_4' class='gform-field-label gform-field-label--type-inline'>Autism\/Sensory Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.5' type='checkbox'  value='Blood Disease'  id='choice_1_42_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_5' id='label_1_42_5' class='gform-field-label gform-field-label--type-inline'>Blood Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.6' type='checkbox'  value='Bone\/Joint Problems'  id='choice_1_42_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_6' id='label_1_42_6' class='gform-field-label gform-field-label--type-inline'>Bone\/Joint Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.7' type='checkbox'  value='Bruise Easily'  id='choice_1_42_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_7' id='label_1_42_7' class='gform-field-label gform-field-label--type-inline'>Bruise Easily<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.8' type='checkbox'  value='Cancer, Malignancy, Chemotherapy or Radiation'  id='choice_1_42_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_8' id='label_1_42_8' class='gform-field-label gform-field-label--type-inline'>Cancer, Malignancy, Chemotherapy or Radiation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.9' type='checkbox'  value='Cerebral Palsy'  id='choice_1_42_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_9' id='label_1_42_9' class='gform-field-label gform-field-label--type-inline'>Cerebral Palsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.11' type='checkbox'  value='Chronic Adenoid\/Tonsil Issues'  id='choice_1_42_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_11' id='label_1_42_11' class='gform-field-label gform-field-label--type-inline'>Chronic Adenoid\/Tonsil Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.12' type='checkbox'  value='Chronic Ear Infections'  id='choice_1_42_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_12' id='label_1_42_12' class='gform-field-label gform-field-label--type-inline'>Chronic Ear Infections<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.13' type='checkbox'  value='Cleft Lip\/Palate'  id='choice_1_42_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_13' id='label_1_42_13' class='gform-field-label gform-field-label--type-inline'>Cleft Lip\/Palate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.14' type='checkbox'  value='Congenital Heart Defect'  id='choice_1_42_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_14' id='label_1_42_14' class='gform-field-label gform-field-label--type-inline'>Congenital Heart Defect<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.15' type='checkbox'  value='Developmentally Delayed'  id='choice_1_42_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_15' id='label_1_42_15' class='gform-field-label gform-field-label--type-inline'>Developmentally Delayed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.16' type='checkbox'  value='Diabetes'  id='choice_1_42_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_16' id='label_1_42_16' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.17' type='checkbox'  value='Epilepsy\/Seizures'  id='choice_1_42_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_17' id='label_1_42_17' class='gform-field-label gform-field-label--type-inline'>Epilepsy\/Seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.18' type='checkbox'  value='Fainting\/Dizziness'  id='choice_1_42_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_18' id='label_1_42_18' class='gform-field-label gform-field-label--type-inline'>Fainting\/Dizziness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.19' type='checkbox'  value='Growth\/Development Problems'  id='choice_1_42_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_19' id='label_1_42_19' class='gform-field-label gform-field-label--type-inline'>Growth\/Development Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.21' type='checkbox'  value='Heart Surgery\/Murmur\/Defects'  id='choice_1_42_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_21' id='label_1_42_21' class='gform-field-label gform-field-label--type-inline'>Heart Surgery\/Murmur\/Defects<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.22' type='checkbox'  value='Hearing\/Speech Problems'  id='choice_1_42_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_22' id='label_1_42_22' class='gform-field-label gform-field-label--type-inline'>Hearing\/Speech Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.23' type='checkbox'  value='Hemophilia'  id='choice_1_42_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_23' id='label_1_42_23' class='gform-field-label gform-field-label--type-inline'>Hemophilia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.24' type='checkbox'  value='Hyperactivity\/ADD'  id='choice_1_42_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_24' id='label_1_42_24' class='gform-field-label gform-field-label--type-inline'>Hyperactivity\/ADD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.25' type='checkbox'  value='Neurological Disorder'  id='choice_1_42_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_25' id='label_1_42_25' class='gform-field-label gform-field-label--type-inline'>Neurological Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.26' type='checkbox'  value='Rheumatic Fever'  id='choice_1_42_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_26' id='label_1_42_26' class='gform-field-label gform-field-label--type-inline'>Rheumatic Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.27' type='checkbox'  value='Seasonal Allergies'  id='choice_1_42_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_27' id='label_1_42_27' class='gform-field-label gform-field-label--type-inline'>Seasonal Allergies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.28' type='checkbox'  value='Tuberculosis'  id='choice_1_42_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_28' id='label_1_42_28' class='gform-field-label gform-field-label--type-inline'>Tuberculosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_67\" class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_67'>If yes, please explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_67' id='input_1_67' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_68\" class=\"gfield gfield--type-textarea 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_1_68'>Is there anything else that we should know about your child?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_68' id='input_1_68' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_70\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Authorization &amp; Release<\/legend><div class='ginput_container ginput_container_consent'><input name='input_70.1' id='input_1_70_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_70\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_70_1' >I agree to the Authorization & Release policy.<\/label><input type='hidden' name='input_70.2' value='I agree to the Authorization &amp; Release policy.' class='gform_hidden' \/><input type='hidden' name='input_70.3' value='15' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_70' tabindex='0'>I authorize Pediatric Dental Associates of Albany to administer necessary medications and perform such diagnostic, photographic, preventive,<br \/>\ntherapeutic, and restorative procedures a may be necessary for proper dental health and care. I understand that no treatment will be started<br \/>\nuntil such recommended treatment, time involved, and financial investment has been discussed with me by either one of the Doctors or one of<br \/>\ntheir staff members. The information on this page and the dental\/medical history is correct to the best of my knowledge. I grant Pediatric Dental<br \/>\nAssociates of Albany the right to release my child's dental\/medical histories and other information about my child's dental treatment to third<br \/>\nparty payers and\/or other health professionals I attest that I have answered this dental\/medical history to the best of my knowledge and have<br \/>\ndisclosed my child's complete health history on this document.<\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_71' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_71' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-71' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_1_72\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Privacy Practices Consent Policy<\/legend><div class='ginput_container ginput_container_consent'><input name='input_72.1' id='input_1_72_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_72\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_72_1' >I agree to the Privacy Practices Policy<\/label><input type='hidden' name='input_72.2' value='I agree to the Privacy Practices Policy' class='gform_hidden' \/><input type='hidden' name='input_72.3' value='15' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_72' tabindex='0'>I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability ad Accountability Act of 1996 (HIPPA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:<br \/>\n*Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment).<br \/>\n*Obtaining payment from third party payers (e.g. my insurance company).<br \/>\n*The day-to-day healthcare operation of your practice.<br \/>\n<br \/>\n I have also been informed of, and given the rights to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPPA. I understand that you reserve the right to change the terms of this notice from time to time and I may contact you at any time to obtain the most current copy of this notice.<br \/>\n<br \/>\nI understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.<br \/>\n<br \/>\nI understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred to prior to the date I revoke this consent is not affected.<br \/>\n<\/div><\/fieldset><fieldset id=\"field_1_73\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Payment Options<\/legend><div class='ginput_container ginput_container_consent'><input name='input_73.1' id='input_1_73_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_73\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_73_1' >I agree to Pediatric Dental Associates Payment Options<\/label><input type='hidden' name='input_73.2' value='I agree to Pediatric Dental Associates Payment Options' class='gform_hidden' \/><input type='hidden' name='input_73.3' value='15' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_73' tabindex='0'>Payment Options<br \/>\nIn order to make payment for services as convenient as possible, while at the same time maintaining operations of our office in the highest standard of comprehensive care, we offer three different payment options (see below). We will do our best to give you an accurate estimate of your total fees at the onset of your child's treatment, however in some cases the required treatment will be more or less expensive than was originally quoted. All estimates are based on insurance information provided by the parent\/guardian, and estimated coverage is not a guarantee of payment from your insurance provider.<br \/>\n<strong>Payment Options<\/strong><br \/>\n<ol><li>Payment in Full: Payment of your estimated patient share is expected at the time of service. We accept Cash, Check, Visa, Master Card, Discover, American Express, and Care Credit. A 10% discount will be credited for any accounts who do not have dental insurance.<\/li><br \/>\n<li>Installments\/Payment Plan: Our office understands that the cost of dental treatment can sometimes be unexpected. In order to help ease any financial burden, we offer in-house payment plans. Each plan is customized based on the cost of your child's treatment and the amount of months you would like to pay. There is no interest and no early termination fee if you wish to pay your account off early. You will be required to keep a debit or credit card on file for automatic monthly payments. If the account becomes delinquent due to three (3) missed payments, our office reserves the right to turn the account over to an outside collections agency. For additional information regarding this payment option, please ask a front office staff member.<\/li><br \/>\n<li>Insurance Assignments: We will gladly file insurance claims and accept assignment of benefits in place of payment at the time of service. You will still be responsible for any non-covered services, co-insurances, or co-payments at the time services are rendered. Insurance payments are determined by your insurance company at the time they receive the dental claim based on their \"usual and customary\" fee schedule. Your insurance company's fee schedule may not align with our offices charges. You may be responsible for the difference in these amounts. You are financially responsible for any charges not covered by your insurance.<\/li><\/ol><br \/>\n<br \/>\n<strong>Additional Payment Policies\/Information<\/strong><br \/>\n<ol><li><strong>Missed Appointments:<\/strong> To best serve our patients, we kindly ask for your appointments to be kept, or to be notified 24 hours in advance of the cancellation of an appointment. We do understand emergencies happen, and calling before missing an appointment is not always possible. If two (2) appointments are missed within a six (6) month period, you will be responsible for a $30.00 missed appointment fee (per missed appointment).<\/li><br \/>\n <li><strong>Military\/Emergency Response Personnel Discount:<\/strong> To honor those who serve, a 15% discount will be applied to any out of pocket cost that is incurred in our office. 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