{"id":610,"date":"2025-10-25T22:31:12","date_gmt":"2025-10-26T02:31:12","guid":{"rendered":"https:\/\/rmtandrac.com\/therapist\/?page_id=610"},"modified":"2025-11-16T11:56:23","modified_gmt":"2025-11-16T16:56:23","slug":"update-health-record","status":"publish","type":"page","link":"https:\/\/rmtandrac.com\/therapist\/update-health-record\/","title":{"rendered":"Update Intake Form"},"content":{"rendered":"<style id=\"wpforms-css-vars-592-block-c934a2e0-da10-4b26-8b29-6a6b5fcbf5d7\">\n\t\t\t\t#wpforms-592.wpforms-block-c934a2e0-da10-4b26-8b29-6a6b5fcbf5d7 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-c934a2e0-da10-4b26-8b29-6a6b5fcbf5d7 wpf-accordion-form wpforms-render-modern\" id=\"wpforms-592\"><form id=\"wpforms-form-592\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"592\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/therapist\/wp-json\/wp\/v2\/pages\/610\" data-token=\"e6752dac09192c2a9880573ffcba5cbe\" data-token-time=\"1776621826\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-592-field_2-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"2\"><fieldset><legend class=\"wpforms-field-label\">Full Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-592-field_2\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][2][first]\" placeholder=\"e.g., Michael \" aria-errormessage=\"wpforms-592-field_2-error\" required><label for=\"wpforms-592-field_2\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-592-field_2-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][2][last]\" placeholder=\"Johnson\" aria-errormessage=\"wpforms-592-field_2-last-error\" required><label for=\"wpforms-592-field_2-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-592-field_3-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"3\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><\/div><\/div><\/div><div id=\"wpforms-592-field_154-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"154\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-592-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_5\">Gender<\/label><input type=\"text\" id=\"wpforms-592-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\" placeholder=\"e.g., Male\" aria-errormessage=\"wpforms-592-field_5-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-592-field_78-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_78\">Occupation<\/label><input type=\"text\" id=\"wpforms-592-field_78\" class=\"wpforms-field-medium\" name=\"wpforms[fields][78]\" aria-errormessage=\"wpforms-592-field_78-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-592-field_156-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"156\"><div id=\"wpforms-592-field_156\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-592-field_156-error\"><h4><span style=\"color:#0000ff\">CONTACT INFO<\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-592-field_77-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"77\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_6-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_6\">Email Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-592-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" placeholder=\"e.g., michaeljohnson@email.com\" spellcheck=\"false\" aria-errormessage=\"wpforms-592-field_6-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_7-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_7\">Mobile Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-592-field_7\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][7]\" aria-label=\"Mobile Phone\" aria-errormessage=\"wpforms-592-field_7-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_79-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_79\">Home Phone<\/label><input type=\"tel\" id=\"wpforms-592-field_79\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][79]\" aria-label=\"Home Phone\" aria-errormessage=\"wpforms-592-field_79-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_80-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_80\">Work Phone<\/label><input type=\"tel\" id=\"wpforms-592-field_80\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][80]\" aria-label=\"Work Phone\" aria-errormessage=\"wpforms-592-field_80-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-592-field_98-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"98\"><fieldset><legend class=\"wpforms-field-label\">Address<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-592-field_98\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][98][address1]\" aria-errormessage=\"wpforms-592-field_98-error\" ><label for=\"wpforms-592-field_98\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-592-field_98-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][98][address2]\" aria-errormessage=\"wpforms-592-field_98-address2-error\" ><label for=\"wpforms-592-field_98-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-592-field_98-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][98][city]\" aria-errormessage=\"wpforms-592-field_98-city-error\" ><label for=\"wpforms-592-field_98-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-592-field_98-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][98][state]\" aria-errormessage=\"wpforms-592-field_98-state-error\" ><label for=\"wpforms-592-field_98-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-592-field_98-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][98][postal]\" aria-errormessage=\"wpforms-592-field_98-postal-error\" ><label for=\"wpforms-592-field_98-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-592-field_98-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][98][country]\" aria-errormessage=\"wpforms-592-field_98-country-error\" ><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select country &#8212;<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-592-field_98-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-592-field_88-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"88\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-592-field_89-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"89\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_89\">Emergency Contact<\/label><input type=\"text\" id=\"wpforms-592-field_89\" class=\"wpforms-field-medium\" name=\"wpforms[fields][89]\" aria-errormessage=\"wpforms-592-field_89-error\" aria-describedby=\"wpforms-592-field_89-description\" ><div id=\"wpforms-592-field_89-description\" class=\"wpforms-field-description\">Name<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-592-field_90-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"90\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_90\">Emergency Phone<\/label><input type=\"text\" id=\"wpforms-592-field_90\" class=\"wpforms-field-medium\" name=\"wpforms[fields][90]\" aria-errormessage=\"wpforms-592-field_90-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-592-field_92-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"92\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_92\">Relationship<\/label><input type=\"text\" id=\"wpforms-592-field_92\" class=\"wpforms-field-medium\" name=\"wpforms[fields][92]\" aria-errormessage=\"wpforms-592-field_92-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-592-field_164-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"164\"><div id=\"wpforms-592-field_164\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-592-field_164-error\"><h4><span style=\"color:#0000ff\"><strong>Family Doctor<\/strong><\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-592-field_94-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"94\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_95-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"95\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_95\">Family Doctor&#039;Name<\/label><input type=\"text\" id=\"wpforms-592-field_95\" class=\"wpforms-field-medium\" name=\"wpforms[fields][95]\" aria-errormessage=\"wpforms-592-field_95-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_96-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"96\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_96\">Family Doctor&#039;s Phone<\/label><input type=\"tel\" id=\"wpforms-592-field_96\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][96]\" aria-label=\"Family Doctor&#039;s Phone\" aria-errormessage=\"wpforms-592-field_96-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_97-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"97\"><fieldset><legend class=\"wpforms-field-label\">Family Doctor&#039;s Address<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-592-field_97\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][97][address1]\" aria-errormessage=\"wpforms-592-field_97-error\" ><label for=\"wpforms-592-field_97\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-592-field_97-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][97][address2]\" aria-errormessage=\"wpforms-592-field_97-address2-error\" ><label for=\"wpforms-592-field_97-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-592-field_97-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][97][city]\" aria-errormessage=\"wpforms-592-field_97-city-error\" ><label for=\"wpforms-592-field_97-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-592-field_97-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][97][state]\" aria-errormessage=\"wpforms-592-field_97-state-error\" ><label for=\"wpforms-592-field_97-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-592-field_97-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][97][postal]\" aria-errormessage=\"wpforms-592-field_97-postal-error\" ><label for=\"wpforms-592-field_97-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-592-field_97-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][97][country]\" aria-errormessage=\"wpforms-592-field_97-country-error\" ><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select country &#8212;<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-592-field_97-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-592-field_157-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"157\"><div id=\"wpforms-592-field_157\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-592-field_157-error\"><h4><span style=\"color:#0000ff\">Please update any profile information, and provide us with any health changes you have had over the past year.<\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-592-field_158-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"158\"><div id=\"wpforms-592-field_158\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-592-field_158-error\"><h4><span style=\"color:#0000ff\">Health Update<\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-592-field_101-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"101\"><fieldset><legend class=\"wpforms-field-label\">Have you had any changes to your health over the past year?<\/legend><ul id=\"wpforms-592-field_101\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-592-field_101_1\" name=\"wpforms[fields][101]\" value=\"Yes\" aria-errormessage=\"wpforms-592-field_101_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-592-field_101_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-592-field_101_2\" name=\"wpforms[fields][101]\" value=\"No\" aria-errormessage=\"wpforms-592-field_101_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-592-field_101_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-592-field_103-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"103\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_103\">If Yes, please explain:<\/label><textarea id=\"wpforms-592-field_103\" class=\"wpforms-field-medium\" name=\"wpforms[fields][103]\" aria-errormessage=\"wpforms-592-field_103-error\" ><\/textarea><\/div><div id=\"wpforms-592-field_105-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"105\"><fieldset><legend class=\"wpforms-field-label\"> Do you have any other information you might want to provide us at this time?<\/legend><ul id=\"wpforms-592-field_105\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-592-field_105_1\" name=\"wpforms[fields][105]\" value=\"Yes\" aria-errormessage=\"wpforms-592-field_105_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-592-field_105_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-592-field_105_2\" name=\"wpforms[fields][105]\" value=\"No\" aria-errormessage=\"wpforms-592-field_105_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-592-field_105_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-592-field_106-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"106\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_106\">If Yes, please explain:<\/label><textarea id=\"wpforms-592-field_106\" class=\"wpforms-field-medium\" name=\"wpforms[fields][106]\" aria-errormessage=\"wpforms-592-field_106-error\" ><\/textarea><\/div><div id=\"wpforms-592-field_159-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"159\"><div id=\"wpforms-592-field_159\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-592-field_159-error\"><h4><span style=\"color:#0000ff\"><strong>Medications<\/strong><\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-592-field_108-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-trigger\" data-field-id=\"108\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_108\">How many medications do you have now?<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-592-field_108\" class=\"wpforms-field-medium\" name=\"wpforms[fields][108]\" value=\"0\" aria-errormessage=\"wpforms-592-field_108-error\"\t\tmin=\"0\"\n\tmax=\"5\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-592-field_16-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"16\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-592-field_9-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"9\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_9\">Medication<\/label><input type=\"text\" id=\"wpforms-592-field_9\" class=\"wpforms-field-large\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-592-field_9-error\" ><\/div><div id=\"wpforms-592-field_11-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"11\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_11\">Medication<\/label><input type=\"text\" id=\"wpforms-592-field_11\" class=\"wpforms-field-large\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-592-field_11-error\" ><\/div><div id=\"wpforms-592-field_13-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"13\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_13\">Medication<\/label><input type=\"text\" id=\"wpforms-592-field_13\" class=\"wpforms-field-large\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-592-field_13-error\" ><\/div><div id=\"wpforms-592-field_109-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"109\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_109\">Medication<\/label><input type=\"text\" id=\"wpforms-592-field_109\" class=\"wpforms-field-medium\" name=\"wpforms[fields][109]\" aria-errormessage=\"wpforms-592-field_109-error\" ><\/div><div id=\"wpforms-592-field_111-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"111\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_111\">Medication<\/label><input type=\"text\" id=\"wpforms-592-field_111\" class=\"wpforms-field-medium\" name=\"wpforms[fields][111]\" aria-errormessage=\"wpforms-592-field_111-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-592-field_10-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"10\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_10\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_10\" class=\"wpforms-field-large\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-592-field_10-error\" ><\/div><div id=\"wpforms-592-field_12-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"12\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_12\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_12\" class=\"wpforms-field-large\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-592-field_12-error\" ><\/div><div id=\"wpforms-592-field_14-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"14\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_14\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_14\" class=\"wpforms-field-large\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-592-field_14-error\" ><\/div><div id=\"wpforms-592-field_110-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"110\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_110\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_110\" class=\"wpforms-field-medium\" name=\"wpforms[fields][110]\" aria-errormessage=\"wpforms-592-field_110-error\" ><\/div><div id=\"wpforms-592-field_112-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"112\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_112\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_112\" class=\"wpforms-field-medium\" name=\"wpforms[fields][112]\" aria-errormessage=\"wpforms-592-field_112-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-592-field_160-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"160\"><div id=\"wpforms-592-field_160\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-592-field_160-error\"><h4><span style=\"color:#0000ff\"><strong>Injuries<\/strong><\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-592-field_114-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-trigger\" data-field-id=\"114\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_114\">How many new injuries?<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-592-field_114\" class=\"wpforms-field-medium\" name=\"wpforms[fields][114]\" value=\"0\" aria-errormessage=\"wpforms-592-field_114-error\"\t\tmin=\"0\"\n\tmax=\"5\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-592-field_115-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"115\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_116-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"116\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_116\">Injury<\/label><input type=\"text\" id=\"wpforms-592-field_116\" class=\"wpforms-field-medium\" name=\"wpforms[fields][116]\" aria-errormessage=\"wpforms-592-field_116-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_117-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"117\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_117\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_117\" class=\"wpforms-field-medium\" name=\"wpforms[fields][117]\" aria-errormessage=\"wpforms-592-field_117-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_118-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"118\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_118\">Injury<\/label><input type=\"text\" id=\"wpforms-592-field_118\" class=\"wpforms-field-medium\" name=\"wpforms[fields][118]\" aria-errormessage=\"wpforms-592-field_118-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_119-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"119\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_119\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_119\" class=\"wpforms-field-medium\" name=\"wpforms[fields][119]\" aria-errormessage=\"wpforms-592-field_119-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_120-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"120\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_120\">Injury<\/label><input type=\"text\" id=\"wpforms-592-field_120\" class=\"wpforms-field-medium\" name=\"wpforms[fields][120]\" aria-errormessage=\"wpforms-592-field_120-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_121-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"121\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_121\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_121\" class=\"wpforms-field-medium\" name=\"wpforms[fields][121]\" aria-errormessage=\"wpforms-592-field_121-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_122-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"122\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_122\">Injury<\/label><input type=\"text\" id=\"wpforms-592-field_122\" class=\"wpforms-field-medium\" name=\"wpforms[fields][122]\" aria-errormessage=\"wpforms-592-field_122-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_123-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"123\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_123\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_123\" class=\"wpforms-field-medium\" name=\"wpforms[fields][123]\" aria-errormessage=\"wpforms-592-field_123-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_124-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"124\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_124\">Injury<\/label><input type=\"text\" id=\"wpforms-592-field_124\" class=\"wpforms-field-medium\" name=\"wpforms[fields][124]\" aria-errormessage=\"wpforms-592-field_124-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_125-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"125\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_125\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_125\" class=\"wpforms-field-medium\" name=\"wpforms[fields][125]\" aria-errormessage=\"wpforms-592-field_125-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-592-field_161-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"161\"><div id=\"wpforms-592-field_161\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-592-field_161-error\"><h4><span style=\"color:#0000ff\"><strong>Surgeries<\/strong><\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-592-field_127-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-trigger\" data-field-id=\"127\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_127\">How many new surgeries?<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-592-field_127\" class=\"wpforms-field-medium\" name=\"wpforms[fields][127]\" value=\"0\" aria-errormessage=\"wpforms-592-field_127-error\"\t\tmin=\"0\"\n\tmax=\"5\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-592-field_128-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"128\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_129-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"129\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_129\">Surgery<\/label><input type=\"text\" id=\"wpforms-592-field_129\" class=\"wpforms-field-medium\" name=\"wpforms[fields][129]\" aria-errormessage=\"wpforms-592-field_129-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_134-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"134\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_134\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_134\" class=\"wpforms-field-medium\" name=\"wpforms[fields][134]\" aria-errormessage=\"wpforms-592-field_134-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_130-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"130\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_130\">Surgery<\/label><input type=\"text\" id=\"wpforms-592-field_130\" class=\"wpforms-field-medium\" name=\"wpforms[fields][130]\" aria-errormessage=\"wpforms-592-field_130-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_135-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"135\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_135\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_135\" class=\"wpforms-field-medium\" name=\"wpforms[fields][135]\" aria-errormessage=\"wpforms-592-field_135-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_131-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"131\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_131\">Surgery<\/label><input type=\"text\" id=\"wpforms-592-field_131\" class=\"wpforms-field-medium\" name=\"wpforms[fields][131]\" aria-errormessage=\"wpforms-592-field_131-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_136-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"136\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_136\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_136\" class=\"wpforms-field-medium\" name=\"wpforms[fields][136]\" aria-errormessage=\"wpforms-592-field_136-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_132-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"132\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_132\">Surgery<\/label><input type=\"text\" id=\"wpforms-592-field_132\" class=\"wpforms-field-medium\" name=\"wpforms[fields][132]\" aria-errormessage=\"wpforms-592-field_132-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_137-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"137\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_137\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_137\" class=\"wpforms-field-medium\" name=\"wpforms[fields][137]\" aria-errormessage=\"wpforms-592-field_137-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_133-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"133\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_133\">Surgery<\/label><input type=\"text\" id=\"wpforms-592-field_133\" class=\"wpforms-field-medium\" name=\"wpforms[fields][133]\" aria-errormessage=\"wpforms-592-field_133-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-592-field_138-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"138\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_138\">Comment<\/label><input type=\"text\" id=\"wpforms-592-field_138\" class=\"wpforms-field-medium\" name=\"wpforms[fields][138]\" aria-errormessage=\"wpforms-592-field_138-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-592-field_162-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"162\"><div id=\"wpforms-592-field_162\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-592-field_162-error\"><h4><span style=\"color:#0000ff\"><strong>Insurance<\/strong><\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-592-field_140-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"140\"><fieldset><legend class=\"wpforms-field-label\">Insurance<\/legend><ul id=\"wpforms-592-field_140\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-592-field_140_1\" name=\"wpforms[fields][140][]\" value=\"I have insurance\" aria-errormessage=\"wpforms-592-field_140_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-592-field_140_1\">I have insurance<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-592-field_141-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"141\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-592-field_142-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"142\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_142\">Insurer<\/label><select id=\"wpforms-592-field_142\" class=\"wpforms-field-medium\" name=\"wpforms[fields][142]\"><option value=\"Blue Cross\"  class=\"choice-1 depth-1\"  >Blue Cross<\/option><option value=\"Canada Life\"  class=\"choice-2 depth-1\"  >Canada Life<\/option><option value=\"Chambers of Commerce\"  class=\"choice-3 depth-1\"  >Chambers of Commerce<\/option><option value=\"Desjardins\"  class=\"choice-9 depth-1\"  >Desjardins<\/option><option value=\"Equitable\"  class=\"choice-8 depth-1\"  >Equitable<\/option><option value=\"Green Shield Insurance (GSC)\"  class=\"choice-7 depth-1\"  >Green Shield Insurance (GSC)<\/option><option value=\"Industrial Alliance (IA)\"  class=\"choice-6 depth-1\"  >Industrial Alliance (IA)<\/option><option value=\"Manulife Financial\"  class=\"choice-5 depth-1\"  >Manulife Financial<\/option><option value=\"People Corporation\"  class=\"choice-4 depth-1\"  >People Corporation<\/option><option value=\"RBC\"  class=\"choice-10 depth-1\"  >RBC<\/option><option value=\"The co-operators\"  class=\"choice-11 depth-1\"  >The co-operators<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-592-field_144-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"144\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_144\">Policy Name<\/label><input type=\"text\" id=\"wpforms-592-field_144\" class=\"wpforms-field-medium\" name=\"wpforms[fields][144]\" aria-errormessage=\"wpforms-592-field_144-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-592-field_145-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"145\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_145\">Policy \/ Group \/ Plan #<\/label><input type=\"text\" id=\"wpforms-592-field_145\" class=\"wpforms-field-medium\" name=\"wpforms[fields][145]\" aria-errormessage=\"wpforms-592-field_145-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-592-field_146-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"146\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_146\">Member ID \/ Certificate #<\/label><input type=\"text\" id=\"wpforms-592-field_146\" class=\"wpforms-field-medium\" name=\"wpforms[fields][146]\" aria-errormessage=\"wpforms-592-field_146-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-592-field_155-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"155\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_155\">Other Insurer not list above<\/label><input type=\"text\" id=\"wpforms-592-field_155\" class=\"wpforms-field-medium\" name=\"wpforms[fields][155]\" aria-errormessage=\"wpforms-592-field_155-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><\/div><\/div><\/div><div id=\"wpforms-592-field_147-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"147\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Policy Holder<\/legend><ul id=\"wpforms-592-field_147\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-592-field_147_1\" name=\"wpforms[fields][147]\" value=\"I am not the policy holder\" aria-errormessage=\"wpforms-592-field_147_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-592-field_147_1\">I am not the policy holder<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-592-field_148-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"148\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-592-field_149-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"149\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Policy Holder&#039;s Name<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-592-field_149\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][149][first]\" aria-errormessage=\"wpforms-592-field_149-error\" ><label for=\"wpforms-592-field_149\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-592-field_149-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][149][last]\" aria-errormessage=\"wpforms-592-field_149-last-error\" ><label for=\"wpforms-592-field_149-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-592-field_150-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"150\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_150\">Policy Holder&#039;s Birthday<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-592-field_150\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][150][date]\" aria-errormessage=\"wpforms-592-field_150-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-592-field_151-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"151\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_151\">Relationship To Patient<\/label><select id=\"wpforms-592-field_151\" class=\"wpforms-field-medium\" name=\"wpforms[fields][151]\"><option value=\"Child\"  class=\"choice-1 depth-1\"  >Child<\/option><option value=\"Parent\"  class=\"choice-2 depth-1\"  >Parent<\/option><option value=\"Spouse\"  class=\"choice-3 depth-1\"  >Spouse<\/option><option value=\"Common Law Spouse\"  class=\"choice-4 depth-1\"  >Common Law Spouse<\/option><option value=\"Other\"  class=\"choice-5 depth-1\"  >Other<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-592-field_152-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"152\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_152\">Policy Holder&#039;s Phone<\/label><input type=\"tel\" id=\"wpforms-592-field_152\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][152]\" aria-label=\"Policy Holder&#039;s Phone\" aria-errormessage=\"wpforms-592-field_152-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-592-field_153-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"153\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Address<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-592-field_153\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][153][address1]\" aria-errormessage=\"wpforms-592-field_153-error\" ><label for=\"wpforms-592-field_153\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-592-field_153-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][153][address2]\" aria-errormessage=\"wpforms-592-field_153-address2-error\" ><label for=\"wpforms-592-field_153-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-592-field_153-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][153][city]\" aria-errormessage=\"wpforms-592-field_153-city-error\" ><label for=\"wpforms-592-field_153-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-592-field_153-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][153][state]\" aria-errormessage=\"wpforms-592-field_153-state-error\" ><label for=\"wpforms-592-field_153-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-592-field_153-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][153][postal]\" aria-errormessage=\"wpforms-592-field_153-postal-error\" ><label for=\"wpforms-592-field_153-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-592-field_153-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][153][country]\" aria-errormessage=\"wpforms-592-field_153-country-error\" ><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select country &#8212;<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-592-field_153-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><\/div><\/div><\/div>\t\t<div id=\"wpforms-592-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-592-field_1\" >Do your Plan<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-592-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-592-field_163-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"163\"><div id=\"wpforms-592-field_163\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-592-field_163-error\"><h4><span style=\"color:#0000ff\">Consent and Agreement<\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-592-field_25-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"25\"><fieldset><legend class=\"wpforms-field-label\">Terms &amp; Conditions <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-592-field_25\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-592-field_25_1\" name=\"wpforms[fields][25][]\" value=\"I hereby agree to the following terms and conditions:\" aria-errormessage=\"wpforms-592-field_25_1-error\" aria-describedby=\"wpforms-592-field_25-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-592-field_25_1\">I hereby agree to the following terms and conditions:<\/label><\/li><\/ul><div id=\"wpforms-592-field_25-description\" class=\"wpforms-field-description wpforms-disclaimer-description\">Welcome to Wellnesssteps. Because the Terms and Conditions contain legal obligations, please read them carefully.<br \/>\n<br \/>\n1. YOUR MASSAGE AGREEMENT<br \/>\n<br \/>\nBy agreeing to this, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use click agree.<br \/>\n<br \/>\n    PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.<br \/>\n<br \/>\n2 YOUR Traditional Chinese Medicine or Acupuncturist AGREEMENT<br \/>\n<br \/>\nI understand that some of the techniques used under the scope of Traditional Chinese Medicine include the use of sterile, single-use needles to penetrate the skin. Additional treatment methods can include, but are not limited to: acupuncture, acupressure, the electrical stimulation of needles, cupping or moxibustion, gua sha, and tuina. Before any of these procedures are performed, my practitioner will discuss my treatment options and only processed if my consent is given.<br \/>\n<br \/>\nMy practitioner has informed me the risks and symptoms of treatments, which can include, but are not limited to: slight pain, light-headedness or nausea, soreness, bruising, bleeding or discoloration of the skin, and the possibility of other unforeseen risks. I freely accept the risks involved with my procedure.<br \/>\n<br \/>\nI will inform my practitioner if I currently have or develop any major health issues, if I suffer from any type of major bleeding disorder, or if I use a pacemaker.<br \/>\n<br \/>\nI understand that I must let my practitioner know I am carrying, or believe to have any infectious agents, including but at not limited to HIV, TB and Hepatitis. In some cases where cross-infection is high, my practitioner may withhold treatment.<br \/>\n<br \/>\nI understand that there are no guarantees for the results of my treatment. Traditional Chinese Medicine does not often provide an instant cure. The length of my treatment depends on the severity of my condition. In some cases my symptoms may temporarily worsen before they begin to improve.<br \/>\n<br \/>\nI understand that the fees charged for my treatment are not covered under OHIP and must be covered in full by myself or through third party insurance. I am responsible for the full and prompt payment after services have been rendered.<br \/>\n<br \/>\nI discuss the content of this form with my practitioner. I acknowledge that I can ask any questions I may have and receive answers I understand. By signing this form, I give my informed consent for Traditional Chinese Medicine treatments.<br \/>\n<br \/>\n3. PRIVACY <br \/>\n<br \/>\nYour information will be logged in our system and will not be shared with 3rd parties.<\/div><\/fieldset><\/div><div id=\"wpforms-592-field_26-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_26\">Signature of Patient <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-592-field_26\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][26]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-592-field_26-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-592-field_26-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-592-field_27-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-592-field_27\">Date of Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-592-field_27\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][27][date]\" placeholder=\"MM\/DD\/YY\" aria-errormessage=\"wpforms-592-field_27-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-592-field_1-container { position: absolute !important; 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