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name=\"q45_patientName[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_45 sublabel_45_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_45\" id=\"sublabel_45_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_45\" name=\"q45_patientName[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_45 sublabel_45_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_45\" id=\"sublabel_45_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_birthdate\" id=\"id_46\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_46\" for=\"input_46\">\n          Patient Birth Date\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_46\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <select name=\"q46_patientBirth[month]\" id=\"input_46_month\" class=\"form-dropdown validate[required]\" data-component=\"birthdate-month\">\n                <option>  <\/option>\n                <option value=\"January\"> January <\/option>\n                <option value=\"February\"> February <\/option>\n                <option value=\"March\"> March <\/option>\n                <option value=\"April\"> April <\/option>\n                <option value=\"May\"> May <\/option>\n                <option value=\"June\"> June <\/option>\n                <option value=\"July\"> July <\/option>\n                <option value=\"August\"> August <\/option>\n                <option value=\"September\"> September <\/option>\n                <option value=\"October\"> October <\/option>\n                <option value=\"November\"> November <\/option>\n                <option value=\"December\"> December <\/option>\n              <\/select>\n              <label class=\"form-sub-label\" for=\"input_46_month\" id=\"sublabel_46_month\" style=\"min-height:13px\"> Month <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <select name=\"q46_patientBirth[day]\" id=\"input_46_day\" class=\"form-dropdown validate[required]\" data-component=\"birthdate-day\">\n                <option>  <\/option>\n                <option value=\"1\"> 1 <\/option>\n                <option value=\"2\"> 2 <\/option>\n                <option value=\"3\"> 3 <\/option>\n                <option value=\"4\"> 4 <\/option>\n                <option value=\"5\"> 5 <\/option>\n                <option value=\"6\"> 6 <\/option>\n                <option value=\"7\"> 7 <\/option>\n                <option value=\"8\"> 8 <\/option>\n                <option value=\"9\"> 9 <\/option>\n                <option value=\"10\"> 10 <\/option>\n                <option value=\"11\"> 11 <\/option>\n                <option value=\"12\"> 12 <\/option>\n                <option value=\"13\"> 13 <\/option>\n                <option value=\"14\"> 14 <\/option>\n                <option value=\"15\"> 15 <\/option>\n                <option value=\"16\"> 16 <\/option>\n                <option value=\"17\"> 17 <\/option>\n                <option value=\"18\"> 18 <\/option>\n                <option value=\"19\"> 19 <\/option>\n                <option value=\"20\"> 20 <\/option>\n                <option value=\"21\"> 21 <\/option>\n                <option value=\"22\"> 22 <\/option>\n                <option value=\"23\"> 23 <\/option>\n                <option value=\"24\"> 24 <\/option>\n                <option value=\"25\"> 25 <\/option>\n                <option value=\"26\"> 26 <\/option>\n                <option value=\"27\"> 27 <\/option>\n                <option value=\"28\"> 28 <\/option>\n                <option value=\"29\"> 29 <\/option>\n                <option value=\"30\"> 30 <\/option>\n                <option value=\"31\"> 31 <\/option>\n              <\/select>\n              <label class=\"form-sub-label\" for=\"input_46_day\" id=\"sublabel_46_day\" style=\"min-height:13px\"> Day <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <select name=\"q46_patientBirth[year]\" id=\"input_46_year\" class=\"form-dropdown validate[required]\" data-component=\"birthdate-year\">\n                <option>  <\/option>\n                <option value=\"2019\"> 2019 <\/option>\n                <option value=\"2018\"> 2018 <\/option>\n                <option value=\"2017\"> 2017 <\/option>\n                <option value=\"2016\"> 2016 <\/option>\n                <option value=\"2015\"> 2015 <\/option>\n                <option value=\"2014\"> 2014 <\/option>\n                <option value=\"2013\"> 2013 <\/option>\n                <option value=\"2012\"> 2012 <\/option>\n                <option value=\"2011\"> 2011 <\/option>\n                <option value=\"2010\"> 2010 <\/option>\n                <option value=\"2009\"> 2009 <\/option>\n                <option value=\"2008\"> 2008 <\/option>\n                <option value=\"2007\"> 2007 <\/option>\n                <option value=\"2006\"> 2006 <\/option>\n                <option value=\"2005\"> 2005 <\/option>\n                <option value=\"2004\"> 2004 <\/option>\n                <option value=\"2003\"> 2003 <\/option>\n                <option value=\"2002\"> 2002 <\/option>\n                <option value=\"2001\"> 2001 <\/option>\n                <option value=\"2000\"> 2000 <\/option>\n                <option value=\"1999\"> 1999 <\/option>\n                <option value=\"1998\"> 1998 <\/option>\n                <option value=\"1997\"> 1997 <\/option>\n                <option value=\"1996\"> 1996 <\/option>\n                <option value=\"1995\"> 1995 <\/option>\n                <option value=\"1994\"> 1994 <\/option>\n                <option value=\"1993\"> 1993 <\/option>\n                <option value=\"1992\"> 1992 <\/option>\n                <option value=\"1991\"> 1991 <\/option>\n                <option value=\"1990\"> 1990 <\/option>\n                <option value=\"1989\"> 1989 <\/option>\n                <option value=\"1988\"> 1988 <\/option>\n                <option value=\"1987\"> 1987 <\/option>\n                <option value=\"1986\"> 1986 <\/option>\n                <option value=\"1985\"> 1985 <\/option>\n                <option value=\"1984\"> 1984 <\/option>\n                <option value=\"1983\"> 1983 <\/option>\n                <option value=\"1982\"> 1982 <\/option>\n                <option value=\"1981\"> 1981 <\/option>\n                <option value=\"1980\"> 1980 <\/option>\n                <option value=\"1979\"> 1979 <\/option>\n                <option value=\"1978\"> 1978 <\/option>\n                <option value=\"1977\"> 1977 <\/option>\n                <option value=\"1976\"> 1976 <\/option>\n                <option value=\"1975\"> 1975 <\/option>\n                <option value=\"1974\"> 1974 <\/option>\n                <option value=\"1973\"> 1973 <\/option>\n                <option value=\"1972\"> 1972 <\/option>\n                <option value=\"1971\"> 1971 <\/option>\n                <option value=\"1970\"> 1970 <\/option>\n                <option value=\"1969\"> 1969 <\/option>\n                <option value=\"1968\"> 1968 <\/option>\n                <option value=\"1967\"> 1967 <\/option>\n                <option value=\"1966\"> 1966 <\/option>\n                <option value=\"1965\"> 1965 <\/option>\n                <option value=\"1964\"> 1964 <\/option>\n                <option value=\"1963\"> 1963 <\/option>\n                <option value=\"1962\"> 1962 <\/option>\n                <option value=\"1961\"> 1961 <\/option>\n                <option value=\"1960\"> 1960 <\/option>\n                <option value=\"1959\"> 1959 <\/option>\n                <option value=\"1958\"> 1958 <\/option>\n                <option value=\"1957\"> 1957 <\/option>\n                <option value=\"1956\"> 1956 <\/option>\n                <option value=\"1955\"> 1955 <\/option>\n                <option value=\"1954\"> 1954 <\/option>\n                <option value=\"1953\"> 1953 <\/option>\n                <option value=\"1952\"> 1952 <\/option>\n                <option value=\"1951\"> 1951 <\/option>\n                <option value=\"1950\"> 1950 <\/option>\n                <option value=\"1949\"> 1949 <\/option>\n                <option value=\"1948\"> 1948 <\/option>\n                <option value=\"1947\"> 1947 <\/option>\n                <option value=\"1946\"> 1946 <\/option>\n                <option value=\"1945\"> 1945 <\/option>\n                <option value=\"1944\"> 1944 <\/option>\n                <option value=\"1943\"> 1943 <\/option>\n                <option value=\"1942\"> 1942 <\/option>\n                <option value=\"1941\"> 1941 <\/option>\n                <option value=\"1940\"> 1940 <\/option>\n                <option value=\"1939\"> 1939 <\/option>\n                <option value=\"1938\"> 1938 <\/option>\n                <option value=\"1937\"> 1937 <\/option>\n                <option value=\"1936\"> 1936 <\/option>\n                <option value=\"1935\"> 1935 <\/option>\n                <option value=\"1934\"> 1934 <\/option>\n                <option value=\"1933\"> 1933 <\/option>\n                <option value=\"1932\"> 1932 <\/option>\n                <option value=\"1931\"> 1931 <\/option>\n                <option value=\"1930\"> 1930 <\/option>\n                <option value=\"1929\"> 1929 <\/option>\n                <option value=\"1928\"> 1928 <\/option>\n                <option value=\"1927\"> 1927 <\/option>\n                <option value=\"1926\"> 1926 <\/option>\n                <option value=\"1925\"> 1925 <\/option>\n                <option value=\"1924\"> 1924 <\/option>\n                <option value=\"1923\"> 1923 <\/option>\n                <option value=\"1922\"> 1922 <\/option>\n                <option value=\"1921\"> 1921 <\/option>\n                <option value=\"1920\"> 1920 <\/option>\n              <\/select>\n              <label class=\"form-sub-label\" for=\"input_46_year\" id=\"sublabel_46_year\" style=\"min-height:13px\"> Year <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_address\" id=\"id_82\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_82\" for=\"input_82_addr_line1\">\n          Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_82\" class=\"form-input-wide jf-required\">\n          <table summary=\"\" class=\"form-address-table\">\n            <tbody>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_82_addr_line1\" name=\"q82_address[addr_line1]\" class=\"form-textbox validate[required] form-address-line\" autoComplete=\"address-line1\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_82 sublabel_82_addr_line1\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_82_addr_line1\" id=\"sublabel_82_addr_line1\" style=\"min-height:13px\"> Street Address <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_82_addr_line2\" name=\"q82_address[addr_line2]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line2\" size=\"46\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_82 sublabel_82_addr_line2\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_82_addr_line2\" id=\"sublabel_82_addr_line2\" style=\"min-height:13px\"> Street Address Line 2 <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_82_city\" name=\"q82_address[city]\" class=\"form-textbox validate[required] form-address-city\" autoComplete=\"address-level2\" size=\"21\" value=\"\" data-component=\"city\" aria-labelledby=\"label_82 sublabel_82_city\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_82_city\" id=\"sublabel_82_city\" style=\"min-height:13px\"> City <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_82_state\" name=\"q82_address[state]\" class=\"form-textbox validate[required] form-address-state\" autoComplete=\"address-level1\" size=\"22\" value=\"\" data-component=\"state\" aria-labelledby=\"label_82 sublabel_82_state\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_82_state\" id=\"sublabel_82_state\" style=\"min-height:13px\"> State \/ Province <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_82_postal\" name=\"q82_address[postal]\" class=\"form-textbox validate[required] form-address-postal\" autoComplete=\"postal-code\" size=\"10\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_82 sublabel_82_postal\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_82_postal\" id=\"sublabel_82_postal\" style=\"min-height:13px\"> Postal \/ Zip Code <\/label>\n                  <\/span>\n                <\/td>\n                <td style=\"display:none\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <select class=\"form-dropdown form-address-country noTranslate\" name=\"q82_address[country]\" id=\"input_82_country\" data-component=\"country\" required=\"\" aria-labelledby=\"label_82 sublabel_82_country\" autoComplete=\"new-password\">\n                      <option value=\"\"> Please Select <\/option>\n                      <option value=\"United States\"> United States <\/option>\n                      <option value=\"Afghanistan\"> Afghanistan <\/option>\n                      <option value=\"Albania\"> Albania <\/option>\n                      <option value=\"Algeria\"> Algeria <\/option>\n                      <option value=\"American Samoa\"> American Samoa <\/option>\n                      <option value=\"Andorra\"> Andorra <\/option>\n                      <option value=\"Angola\"> Angola <\/option>\n                      <option value=\"Anguilla\"> Anguilla <\/option>\n                      <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                      <option value=\"Argentina\"> Argentina <\/option>\n                      <option value=\"Armenia\"> Armenia <\/option>\n                      <option value=\"Aruba\"> Aruba <\/option>\n                      <option value=\"Australia\"> Australia <\/option>\n                      <option value=\"Austria\"> Austria <\/option>\n                      <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                      <option value=\"The Bahamas\"> The Bahamas <\/option>\n                      <option value=\"Bahrain\"> Bahrain <\/option>\n                      <option value=\"Bangladesh\"> Bangladesh <\/option>\n                      <option value=\"Barbados\"> Barbados <\/option>\n                      <option value=\"Belarus\"> Belarus <\/option>\n                      <option value=\"Belgium\"> Belgium <\/option>\n                      <option value=\"Belize\"> Belize <\/option>\n                      <option value=\"Benin\"> Benin <\/option>\n                      <option value=\"Bermuda\"> Bermuda <\/option>\n                      <option value=\"Bhutan\"> Bhutan <\/option>\n                      <option value=\"Bolivia\"> Bolivia <\/option>\n                      <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                      <option value=\"Botswana\"> Botswana <\/option>\n                      <option value=\"Brazil\"> Brazil <\/option>\n                      <option value=\"Brunei\"> Brunei <\/option>\n                      <option value=\"Bulgaria\"> Bulgaria <\/option>\n                      <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                      <option value=\"Burundi\"> Burundi <\/option>\n                      <option value=\"Cambodia\"> Cambodia <\/option>\n                      <option value=\"Cameroon\"> Cameroon <\/option>\n                      <option value=\"Canada\"> Canada <\/option>\n                      <option value=\"Cape Verde\"> Cape Verde <\/option>\n                      <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                      <option value=\"Central African Republic\"> Central African Republic <\/option>\n                      <option value=\"Chad\"> Chad <\/option>\n                      <option value=\"Chile\"> Chile <\/option>\n                      <option value=\"China\"> China <\/option>\n                      <option value=\"Christmas Island\"> Christmas Island <\/option>\n                      <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                      <option value=\"Colombia\"> Colombia <\/option>\n                      <option value=\"Comoros\"> Comoros <\/option>\n                      <option value=\"Congo\"> Congo <\/option>\n                      <option value=\"Cook Islands\"> Cook Islands <\/option>\n                      <option value=\"Costa Rica\"> Costa Rica <\/option>\n                      <option value=\"Cote d&#x27;Ivoire\"> Cote d&#x27;Ivoire <\/option>\n                      <option value=\"Croatia\"> Croatia <\/option>\n                      <option value=\"Cuba\"> Cuba <\/option>\n                      <option value=\"Cyprus\"> Cyprus <\/option>\n                      <option value=\"Czech Republic\"> Czech Republic <\/option>\n                      <option value=\"Democratic Republic of the Congo\"> Democratic Republic of the Congo <\/option>\n                      <option value=\"Denmark\"> Denmark <\/option>\n                      <option value=\"Djibouti\"> Djibouti <\/option>\n                      <option value=\"Dominica\"> Dominica <\/option>\n                      <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                      <option value=\"Ecuador\"> Ecuador <\/option>\n                      <option value=\"Egypt\"> Egypt <\/option>\n                      <option value=\"El Salvador\"> El Salvador <\/option>\n                      <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                      <option value=\"Eritrea\"> Eritrea <\/option>\n                      <option value=\"Estonia\"> Estonia <\/option>\n                      <option value=\"Ethiopia\"> Ethiopia <\/option>\n                      <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                      <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                      <option value=\"Fiji\"> Fiji <\/option>\n                      <option value=\"Finland\"> Finland <\/option>\n                      <option value=\"France\"> France <\/option>\n                      <option value=\"French Polynesia\"> French Polynesia <\/option>\n                      <option value=\"Gabon\"> Gabon <\/option>\n                      <option value=\"The Gambia\"> The Gambia <\/option>\n                      <option value=\"Georgia\"> Georgia <\/option>\n                      <option value=\"Germany\"> Germany <\/option>\n                      <option value=\"Ghana\"> Ghana <\/option>\n                      <option value=\"Gibraltar\"> Gibraltar <\/option>\n                      <option value=\"Greece\"> Greece <\/option>\n                      <option value=\"Greenland\"> Greenland <\/option>\n                      <option value=\"Grenada\"> Grenada <\/option>\n                      <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                      <option value=\"Guam\"> Guam <\/option>\n                      <option value=\"Guatemala\"> Guatemala <\/option>\n                      <option value=\"Guernsey\"> Guernsey <\/option>\n                      <option value=\"Guinea\"> Guinea <\/option>\n                      <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                      <option value=\"Guyana\"> Guyana <\/option>\n                      <option value=\"Haiti\"> Haiti <\/option>\n                      <option value=\"Honduras\"> Honduras <\/option>\n                      <option value=\"Hong Kong\"> Hong Kong <\/option>\n                      <option value=\"Hungary\"> Hungary <\/option>\n                      <option value=\"Iceland\"> Iceland <\/option>\n                      <option value=\"India\"> India <\/option>\n                      <option value=\"Indonesia\"> Indonesia <\/option>\n                      <option value=\"Iran\"> Iran <\/option>\n                      <option value=\"Iraq\"> Iraq <\/option>\n                      <option value=\"Ireland\"> Ireland <\/option>\n                      <option value=\"Israel\"> Israel <\/option>\n                      <option value=\"Italy\"> Italy <\/option>\n                      <option value=\"Jamaica\"> Jamaica <\/option>\n                      <option value=\"Japan\"> Japan <\/option>\n                      <option value=\"Jersey\"> Jersey <\/option>\n                      <option value=\"Jordan\"> Jordan <\/option>\n                      <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                      <option value=\"Kenya\"> Kenya <\/option>\n                      <option value=\"Kiribati\"> Kiribati <\/option>\n                      <option value=\"North Korea\"> North Korea <\/option>\n                      <option value=\"South Korea\"> South Korea <\/option>\n                      <option value=\"Kosovo\"> Kosovo <\/option>\n                      <option value=\"Kuwait\"> Kuwait <\/option>\n                      <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                      <option value=\"Laos\"> Laos <\/option>\n                      <option value=\"Latvia\"> Latvia <\/option>\n                      <option value=\"Lebanon\"> Lebanon <\/option>\n                      <option value=\"Lesotho\"> Lesotho <\/option>\n                      <option value=\"Liberia\"> Liberia <\/option>\n                      <option value=\"Libya\"> Libya <\/option>\n                      <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                      <option value=\"Lithuania\"> Lithuania <\/option>\n                      <option value=\"Luxembourg\"> Luxembourg <\/option>\n                      <option value=\"Macau\"> Macau <\/option>\n                      <option value=\"Macedonia\"> Macedonia <\/option>\n                      <option value=\"Madagascar\"> Madagascar <\/option>\n                      <option value=\"Malawi\"> Malawi <\/option>\n                      <option value=\"Malaysia\"> Malaysia <\/option>\n                      <option value=\"Maldives\"> Maldives <\/option>\n                      <option value=\"Mali\"> Mali <\/option>\n                      <option value=\"Malta\"> Malta <\/option>\n                      <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                      <option value=\"Martinique\"> Martinique <\/option>\n                      <option value=\"Mauritania\"> Mauritania <\/option>\n                      <option value=\"Mauritius\"> Mauritius <\/option>\n                      <option value=\"Mayotte\"> Mayotte <\/option>\n                      <option value=\"Mexico\"> Mexico <\/option>\n                      <option value=\"Micronesia\"> Micronesia <\/option>\n                      <option value=\"Moldova\"> Moldova <\/option>\n                      <option value=\"Monaco\"> Monaco <\/option>\n                      <option value=\"Mongolia\"> Mongolia <\/option>\n                      <option value=\"Montenegro\"> Montenegro <\/option>\n                      <option value=\"Montserrat\"> Montserrat <\/option>\n                      <option value=\"Morocco\"> Morocco <\/option>\n                      <option value=\"Mozambique\"> Mozambique <\/option>\n                      <option value=\"Myanmar\"> Myanmar <\/option>\n                      <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                      <option value=\"Namibia\"> Namibia <\/option>\n                      <option value=\"Nauru\"> Nauru <\/option>\n                      <option value=\"Nepal\"> Nepal <\/option>\n                      <option value=\"Netherlands\"> Netherlands <\/option>\n                      <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                      <option value=\"New Caledonia\"> New Caledonia <\/option>\n                      <option value=\"New Zealand\"> New Zealand <\/option>\n                      <option value=\"Nicaragua\"> Nicaragua <\/option>\n                      <option value=\"Niger\"> Niger <\/option>\n                      <option value=\"Nigeria\"> Nigeria <\/option>\n                      <option value=\"Niue\"> Niue <\/option>\n                      <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                      <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                      <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                      <option value=\"Norway\"> Norway <\/option>\n                      <option value=\"Oman\"> Oman <\/option>\n                      <option value=\"Pakistan\"> Pakistan <\/option>\n                      <option value=\"Palau\"> Palau <\/option>\n                      <option value=\"Palestine\"> Palestine <\/option>\n                      <option value=\"Panama\"> Panama <\/option>\n                      <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                      <option value=\"Paraguay\"> Paraguay <\/option>\n                      <option value=\"Peru\"> Peru <\/option>\n                      <option value=\"Philippines\"> Philippines <\/option>\n                      <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                      <option value=\"Poland\"> Poland <\/option>\n                      <option value=\"Portugal\"> Portugal <\/option>\n                      <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                      <option value=\"Qatar\"> Qatar <\/option>\n                      <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n                      <option value=\"Romania\"> Romania <\/option>\n                      <option value=\"Russia\"> Russia <\/option>\n                      <option value=\"Rwanda\"> Rwanda <\/option>\n                      <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                      <option value=\"Saint Helena\"> Saint Helena <\/option>\n                      <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                      <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                      <option value=\"Saint Martin\"> Saint Martin <\/option>\n                      <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                      <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                      <option value=\"Samoa\"> Samoa <\/option>\n                      <option value=\"San Marino\"> San Marino <\/option>\n                      <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                      <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                      <option value=\"Senegal\"> Senegal <\/option>\n                      <option value=\"Serbia\"> Serbia <\/option>\n                      <option value=\"Seychelles\"> Seychelles <\/option>\n                      <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                      <option value=\"Singapore\"> Singapore <\/option>\n                      <option value=\"Slovakia\"> Slovakia <\/option>\n                      <option value=\"Slovenia\"> Slovenia <\/option>\n                      <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                      <option value=\"Somalia\"> Somalia <\/option>\n                      <option value=\"Somaliland\"> Somaliland <\/option>\n                      <option value=\"South Africa\"> South Africa <\/option>\n                      <option value=\"South Ossetia\"> South Ossetia <\/option>\n                      <option value=\"South Sudan\"> South Sudan <\/option>\n                      <option value=\"Spain\"> Spain <\/option>\n                      <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                      <option value=\"Sudan\"> Sudan <\/option>\n                      <option value=\"Suriname\"> Suriname <\/option>\n                      <option value=\"Svalbard\"> Svalbard <\/option>\n                      <option value=\"eSwatini\"> eSwatini <\/option>\n                      <option value=\"Sweden\"> Sweden <\/option>\n                      <option value=\"Switzerland\"> Switzerland <\/option>\n                      <option value=\"Syria\"> Syria <\/option>\n                      <option value=\"Taiwan\"> Taiwan <\/option>\n                      <option value=\"Tajikistan\"> Tajikistan <\/option>\n                      <option value=\"Tanzania\"> Tanzania <\/option>\n                      <option value=\"Thailand\"> Thailand <\/option>\n                      <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                      <option value=\"Togo\"> Togo <\/option>\n                      <option value=\"Tokelau\"> Tokelau <\/option>\n                      <option value=\"Tonga\"> Tonga <\/option>\n                      <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                      <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                      <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                      <option value=\"Tunisia\"> Tunisia <\/option>\n                      <option value=\"Turkey\"> Turkey <\/option>\n                      <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                      <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                      <option value=\"Tuvalu\"> Tuvalu <\/option>\n                      <option value=\"Uganda\"> Uganda <\/option>\n                      <option value=\"Ukraine\"> Ukraine <\/option>\n                      <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                      <option value=\"United Kingdom\"> United Kingdom <\/option>\n                      <option value=\"Uruguay\"> Uruguay <\/option>\n                      <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                      <option value=\"Vanuatu\"> Vanuatu <\/option>\n                      <option value=\"Vatican City\"> Vatican City <\/option>\n                      <option value=\"Venezuela\"> Venezuela <\/option>\n                      <option value=\"Vietnam\"> Vietnam <\/option>\n                      <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                      <option value=\"Isle of Man\"> Isle of Man <\/option>\n                      <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                      <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                      <option value=\"Western Sahara\"> Western Sahara <\/option>\n                      <option value=\"Yemen\"> Yemen <\/option>\n                      <option value=\"Zambia\"> Zambia <\/option>\n                      <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                      <option value=\"other\"> Other <\/option>\n                    <\/select>\n                    <label class=\"form-sub-label\" for=\"input_82_country\" id=\"sublabel_82_country\" style=\"min-height:13px\"> Country <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n            <\/tbody>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_83\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_83\" for=\"input_83_area\">\n          Home Phone\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_83\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_83_area\" name=\"q83_phoneNumber[area]\" class=\"form-textbox validate[required]\" size=\"6\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_83 sublabel_83_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_83_area\" id=\"sublabel_83_area\" style=\"min-height:13px\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_83_phone\" name=\"q83_phoneNumber[phone]\" class=\"form-textbox validate[required]\" size=\"12\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_83 sublabel_83_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_83_phone\" id=\"sublabel_83_phone\" style=\"min-height:13px\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_84\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_84\" for=\"input_84_area\">\n          Mobile\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_84\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_84_area\" name=\"q84_phoneNumber84[area]\" class=\"form-textbox validate[required]\" size=\"6\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_84 sublabel_84_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_84_area\" id=\"sublabel_84_area\" style=\"min-height:13px\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_84_phone\" name=\"q84_phoneNumber84[phone]\" class=\"form-textbox validate[required]\" size=\"12\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_84 sublabel_84_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_84_phone\" id=\"sublabel_84_phone\" style=\"min-height:13px\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_email\" id=\"id_74\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_74\" for=\"input_74\">\n          E-Mail\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_74\" class=\"form-input-wide jf-required\">\n          <input type=\"email\" id=\"input_74\" name=\"q74_email\" class=\"form-textbox validate[required, Email]\" size=\"32\" value=\"\" placeholder=\"ex: myname@example.com\" data-component=\"email\" aria-labelledby=\"label_74\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_widget\" id=\"id_107\">\n        <label class=\"form-label form-label-top\" id=\"label_107\" for=\"input_107\"> We Will send you email communications from time to time, including our regular newsletter and offers. Please select NO if you DO NOT wish to receive communication with us. <\/label>\n        <div id=\"cid_107\" class=\"form-input-wide\">\n          <div style=\"width:100%;text-align:Left\" data-component=\"widget-field\">\n            <iframe title=\"Bootstrap Switch Field\" frameBorder=\"0\" scrolling=\"no\" allowtransparency=\"true\" allow=\"geolocation; microphone; camera; autoplay; encrypted-media; fullscreen\" data-type=\"iframe\" class=\"custom-field-frame\" id=\"customFieldFrame_107\" src=\"\" style=\"border:none;width:200px;height:50px\" data-width=\"200\" data-height=\"50\">\n            <\/iframe>\n            <div class=\"widget-inputs-wrapper\">\n              <input type=\"hidden\" id=\"input_107\" class=\"form-hidden form-widget  \" name=\"q107_weWill107\" value=\"\" \/>\n              <input type=\"hidden\" id=\"widget_settings_107\" class=\"form-hidden form-widget-settings\" value=\"%5B%7B%22name%22%3A%22onText%22%2C%22value%22%3A%22YES%22%7D%2C%7B%22name%22%3A%22onColor%22%2C%22value%22%3A%22green%22%7D%2C%7B%22name%22%3A%22offText%22%2C%22value%22%3A%22NO%22%7D%2C%7B%22name%22%3A%22offColor%22%2C%22value%22%3A%22red%22%7D%2C%7B%22name%22%3A%22size%22%2C%22value%22%3A%22small%22%7D%2C%7B%22name%22%3A%22dState%22%2C%22value%22%3A%22ON%22%7D%5D\" data-version=\"2\" \/>\n            <\/div>\n            <script type=\"text\/javascript\">\n            setTimeout(function()\n{\n  var _cFieldFrame = document.getElementById(\"customFieldFrame_107\");\n  if (_cFieldFrame)\n  {\n    _cFieldFrame.onload = function()\n    {\n      if (typeof widgetFrameLoaded !== 'undefined')\n      {\n        widgetFrameLoaded(107, {\n          \"formID\": 92912873556165\n        })\n      }\n    };\n    _cFieldFrame.src = \"\/\/widgets.jotform.io\/bootstrap-switch\/?qid=107&ref=\" + encodeURIComponent(window.location.protocol + \"\/\/\" + window.location.host);\n    _cFieldFrame.addClassName(\"custom-field-frame-rendered\");\n  }\n}, 0);\n            <\/script>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_86\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_86\" for=\"input_86\"> Occupation <\/label>\n        <div id=\"cid_86\" class=\"form-input-wide\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_86\" name=\"q86_occupation\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_86 sublabel_input_86\" \/>\n            <label class=\"form-sub-label\" for=\"input_86\" id=\"sublabel_input_86\" style=\"min-height:13px\"> eg. Teacher <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_87\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_87\" for=\"input_87\"> Company <\/label>\n        <div id=\"cid_87\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_87\" name=\"q87_company\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_87\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_address\" id=\"id_88\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_88\" for=\"input_88_addr_line1\"> Work Address <\/label>\n        <div id=\"cid_88\" class=\"form-input-wide\">\n          <table summary=\"\" class=\"form-address-table\">\n            <tbody>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_88_addr_line1\" name=\"q88_workAddress[addr_line1]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line1\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_88 sublabel_88_addr_line1\" \/>\n                    <label class=\"form-sub-label\" for=\"input_88_addr_line1\" id=\"sublabel_88_addr_line1\" style=\"min-height:13px\"> Street Address <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_88_addr_line2\" name=\"q88_workAddress[addr_line2]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line2\" size=\"46\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_88 sublabel_88_addr_line2\" \/>\n                    <label class=\"form-sub-label\" for=\"input_88_addr_line2\" id=\"sublabel_88_addr_line2\" style=\"min-height:13px\"> Street Address Line 2 <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_88_city\" name=\"q88_workAddress[city]\" class=\"form-textbox form-address-city\" autoComplete=\"address-level2\" size=\"21\" value=\"\" data-component=\"city\" aria-labelledby=\"label_88 sublabel_88_city\" \/>\n                    <label class=\"form-sub-label\" for=\"input_88_city\" id=\"sublabel_88_city\" style=\"min-height:13px\"> City <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_88_state\" name=\"q88_workAddress[state]\" class=\"form-textbox form-address-state\" autoComplete=\"address-level1\" size=\"22\" value=\"\" data-component=\"state\" aria-labelledby=\"label_88 sublabel_88_state\" \/>\n                    <label class=\"form-sub-label\" for=\"input_88_state\" id=\"sublabel_88_state\" style=\"min-height:13px\"> State \/ Province <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_88_postal\" name=\"q88_workAddress[postal]\" class=\"form-textbox form-address-postal\" autoComplete=\"postal-code\" size=\"10\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_88 sublabel_88_postal\" \/>\n                    <label class=\"form-sub-label\" for=\"input_88_postal\" id=\"sublabel_88_postal\" style=\"min-height:13px\"> Postal \/ Zip Code <\/label>\n                  <\/span>\n                <\/td>\n                <td style=\"display:none\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                    <select class=\"form-dropdown form-address-country noTranslate\" name=\"q88_workAddress[country]\" id=\"input_88_country\" data-component=\"country\" aria-labelledby=\"label_88 sublabel_88_country\" autoComplete=\"new-password\">\n                      <option value=\"\"> Please Select <\/option>\n                      <option value=\"United States\"> United States <\/option>\n                      <option value=\"Afghanistan\"> Afghanistan <\/option>\n                      <option value=\"Albania\"> Albania <\/option>\n                      <option value=\"Algeria\"> Algeria <\/option>\n                      <option value=\"American Samoa\"> American Samoa <\/option>\n                      <option value=\"Andorra\"> Andorra <\/option>\n                      <option value=\"Angola\"> Angola <\/option>\n                      <option value=\"Anguilla\"> Anguilla <\/option>\n                      <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                      <option value=\"Argentina\"> Argentina <\/option>\n                      <option value=\"Armenia\"> Armenia <\/option>\n                      <option value=\"Aruba\"> Aruba <\/option>\n                      <option value=\"Australia\"> Australia <\/option>\n                      <option value=\"Austria\"> Austria <\/option>\n                      <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                      <option value=\"The Bahamas\"> The Bahamas <\/option>\n                      <option value=\"Bahrain\"> Bahrain <\/option>\n                      <option value=\"Bangladesh\"> Bangladesh <\/option>\n                      <option value=\"Barbados\"> Barbados <\/option>\n                      <option value=\"Belarus\"> Belarus <\/option>\n                      <option value=\"Belgium\"> Belgium <\/option>\n                      <option value=\"Belize\"> Belize <\/option>\n                      <option value=\"Benin\"> Benin <\/option>\n                      <option value=\"Bermuda\"> Bermuda <\/option>\n                      <option value=\"Bhutan\"> Bhutan <\/option>\n                      <option value=\"Bolivia\"> Bolivia <\/option>\n                      <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                      <option value=\"Botswana\"> Botswana <\/option>\n                      <option value=\"Brazil\"> Brazil <\/option>\n                      <option value=\"Brunei\"> Brunei <\/option>\n                      <option value=\"Bulgaria\"> Bulgaria <\/option>\n                      <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                      <option value=\"Burundi\"> Burundi <\/option>\n                      <option value=\"Cambodia\"> Cambodia <\/option>\n                      <option value=\"Cameroon\"> Cameroon <\/option>\n                      <option value=\"Canada\"> Canada <\/option>\n                      <option value=\"Cape Verde\"> Cape Verde <\/option>\n                      <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                      <option value=\"Central African Republic\"> Central African Republic <\/option>\n                      <option value=\"Chad\"> Chad <\/option>\n                      <option value=\"Chile\"> Chile <\/option>\n                      <option value=\"China\"> China <\/option>\n                      <option value=\"Christmas Island\"> Christmas Island <\/option>\n                      <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                      <option value=\"Colombia\"> Colombia <\/option>\n                      <option value=\"Comoros\"> Comoros <\/option>\n                      <option value=\"Congo\"> Congo <\/option>\n                      <option value=\"Cook Islands\"> Cook Islands <\/option>\n                      <option value=\"Costa Rica\"> Costa Rica <\/option>\n                      <option value=\"Cote d&#x27;Ivoire\"> Cote d&#x27;Ivoire <\/option>\n                      <option value=\"Croatia\"> Croatia <\/option>\n                      <option value=\"Cuba\"> Cuba <\/option>\n                      <option value=\"Cyprus\"> Cyprus <\/option>\n                      <option value=\"Czech Republic\"> Czech Republic <\/option>\n                      <option value=\"Democratic Republic of the Congo\"> Democratic Republic of the Congo <\/option>\n                      <option value=\"Denmark\"> Denmark <\/option>\n                      <option value=\"Djibouti\"> Djibouti <\/option>\n                      <option value=\"Dominica\"> Dominica <\/option>\n                      <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                      <option value=\"Ecuador\"> Ecuador <\/option>\n                      <option value=\"Egypt\"> Egypt <\/option>\n                      <option value=\"El Salvador\"> El Salvador <\/option>\n                      <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                      <option value=\"Eritrea\"> Eritrea <\/option>\n                      <option value=\"Estonia\"> Estonia <\/option>\n                      <option value=\"Ethiopia\"> Ethiopia <\/option>\n                      <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                      <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                      <option value=\"Fiji\"> Fiji <\/option>\n                      <option value=\"Finland\"> Finland <\/option>\n                      <option value=\"France\"> France <\/option>\n                      <option value=\"French Polynesia\"> French Polynesia <\/option>\n                      <option value=\"Gabon\"> Gabon <\/option>\n                      <option value=\"The Gambia\"> The Gambia <\/option>\n                      <option value=\"Georgia\"> Georgia <\/option>\n                      <option value=\"Germany\"> Germany <\/option>\n                      <option value=\"Ghana\"> Ghana <\/option>\n                      <option value=\"Gibraltar\"> Gibraltar <\/option>\n                      <option value=\"Greece\"> Greece <\/option>\n                      <option value=\"Greenland\"> Greenland <\/option>\n                      <option value=\"Grenada\"> Grenada <\/option>\n                      <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                      <option value=\"Guam\"> Guam <\/option>\n                      <option value=\"Guatemala\"> Guatemala <\/option>\n                      <option value=\"Guernsey\"> Guernsey <\/option>\n                      <option value=\"Guinea\"> Guinea <\/option>\n                      <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                      <option value=\"Guyana\"> Guyana <\/option>\n                      <option value=\"Haiti\"> Haiti <\/option>\n                      <option value=\"Honduras\"> Honduras <\/option>\n                      <option value=\"Hong Kong\"> Hong Kong <\/option>\n                      <option value=\"Hungary\"> Hungary <\/option>\n                      <option value=\"Iceland\"> Iceland <\/option>\n                      <option value=\"India\"> India <\/option>\n                      <option value=\"Indonesia\"> Indonesia <\/option>\n                      <option value=\"Iran\"> Iran <\/option>\n                      <option value=\"Iraq\"> Iraq <\/option>\n                      <option value=\"Ireland\"> Ireland <\/option>\n                      <option value=\"Israel\"> Israel <\/option>\n                      <option value=\"Italy\"> Italy <\/option>\n                      <option value=\"Jamaica\"> Jamaica <\/option>\n                      <option value=\"Japan\"> Japan <\/option>\n                      <option value=\"Jersey\"> Jersey <\/option>\n                      <option value=\"Jordan\"> Jordan <\/option>\n                      <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                      <option value=\"Kenya\"> Kenya <\/option>\n                      <option value=\"Kiribati\"> Kiribati <\/option>\n                      <option value=\"North Korea\"> North Korea <\/option>\n                      <option value=\"South Korea\"> South Korea <\/option>\n                      <option value=\"Kosovo\"> Kosovo <\/option>\n                      <option value=\"Kuwait\"> Kuwait <\/option>\n                      <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                      <option value=\"Laos\"> Laos <\/option>\n                      <option value=\"Latvia\"> Latvia <\/option>\n                      <option value=\"Lebanon\"> Lebanon <\/option>\n                      <option value=\"Lesotho\"> Lesotho <\/option>\n                      <option value=\"Liberia\"> Liberia <\/option>\n                      <option value=\"Libya\"> Libya <\/option>\n                      <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                      <option value=\"Lithuania\"> Lithuania <\/option>\n                      <option value=\"Luxembourg\"> Luxembourg <\/option>\n                      <option value=\"Macau\"> Macau <\/option>\n                      <option value=\"Macedonia\"> Macedonia <\/option>\n                      <option value=\"Madagascar\"> Madagascar <\/option>\n                      <option value=\"Malawi\"> Malawi <\/option>\n                      <option value=\"Malaysia\"> Malaysia <\/option>\n                      <option value=\"Maldives\"> Maldives <\/option>\n                      <option value=\"Mali\"> Mali <\/option>\n                      <option value=\"Malta\"> Malta <\/option>\n                      <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                      <option value=\"Martinique\"> Martinique <\/option>\n                      <option value=\"Mauritania\"> Mauritania <\/option>\n                      <option value=\"Mauritius\"> Mauritius <\/option>\n                      <option value=\"Mayotte\"> Mayotte <\/option>\n                      <option value=\"Mexico\"> Mexico <\/option>\n                      <option value=\"Micronesia\"> Micronesia <\/option>\n                      <option value=\"Moldova\"> Moldova <\/option>\n                      <option value=\"Monaco\"> Monaco <\/option>\n                      <option value=\"Mongolia\"> Mongolia <\/option>\n                      <option value=\"Montenegro\"> Montenegro <\/option>\n                      <option value=\"Montserrat\"> Montserrat <\/option>\n                      <option value=\"Morocco\"> Morocco <\/option>\n                      <option value=\"Mozambique\"> Mozambique <\/option>\n                      <option value=\"Myanmar\"> Myanmar <\/option>\n                      <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                      <option value=\"Namibia\"> Namibia <\/option>\n                      <option value=\"Nauru\"> Nauru <\/option>\n                      <option value=\"Nepal\"> Nepal <\/option>\n                      <option value=\"Netherlands\"> Netherlands <\/option>\n                      <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                      <option value=\"New Caledonia\"> New Caledonia <\/option>\n                      <option value=\"New Zealand\"> New Zealand <\/option>\n                      <option value=\"Nicaragua\"> Nicaragua <\/option>\n                      <option value=\"Niger\"> Niger <\/option>\n                      <option value=\"Nigeria\"> Nigeria <\/option>\n                      <option value=\"Niue\"> Niue <\/option>\n                      <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                      <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                      <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                      <option value=\"Norway\"> Norway <\/option>\n                      <option value=\"Oman\"> Oman <\/option>\n                      <option value=\"Pakistan\"> Pakistan <\/option>\n                      <option value=\"Palau\"> Palau <\/option>\n                      <option value=\"Palestine\"> Palestine <\/option>\n                      <option value=\"Panama\"> Panama <\/option>\n                      <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                      <option value=\"Paraguay\"> Paraguay <\/option>\n                      <option value=\"Peru\"> Peru <\/option>\n                      <option value=\"Philippines\"> Philippines <\/option>\n                      <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                      <option value=\"Poland\"> Poland <\/option>\n                      <option value=\"Portugal\"> Portugal <\/option>\n                      <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                      <option value=\"Qatar\"> Qatar <\/option>\n                      <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n                      <option value=\"Romania\"> Romania <\/option>\n                      <option value=\"Russia\"> Russia <\/option>\n                      <option value=\"Rwanda\"> Rwanda <\/option>\n                      <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                      <option value=\"Saint Helena\"> Saint Helena <\/option>\n                      <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                      <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                      <option value=\"Saint Martin\"> Saint Martin <\/option>\n                      <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                      <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                      <option value=\"Samoa\"> Samoa <\/option>\n                      <option value=\"San Marino\"> San Marino <\/option>\n                      <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                      <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                      <option value=\"Senegal\"> Senegal <\/option>\n                      <option value=\"Serbia\"> Serbia <\/option>\n                      <option value=\"Seychelles\"> Seychelles <\/option>\n                      <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                      <option value=\"Singapore\"> Singapore <\/option>\n                      <option value=\"Slovakia\"> Slovakia <\/option>\n                      <option value=\"Slovenia\"> Slovenia <\/option>\n                      <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                      <option value=\"Somalia\"> Somalia <\/option>\n                      <option value=\"Somaliland\"> Somaliland <\/option>\n                      <option value=\"South Africa\"> South Africa <\/option>\n                      <option value=\"South Ossetia\"> South Ossetia <\/option>\n                      <option value=\"South Sudan\"> South Sudan <\/option>\n                      <option value=\"Spain\"> Spain <\/option>\n                      <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                      <option value=\"Sudan\"> Sudan <\/option>\n                      <option value=\"Suriname\"> Suriname <\/option>\n                      <option value=\"Svalbard\"> Svalbard <\/option>\n                      <option value=\"eSwatini\"> eSwatini <\/option>\n                      <option value=\"Sweden\"> Sweden <\/option>\n                      <option value=\"Switzerland\"> Switzerland <\/option>\n                      <option value=\"Syria\"> Syria <\/option>\n                      <option value=\"Taiwan\"> Taiwan <\/option>\n                      <option value=\"Tajikistan\"> Tajikistan <\/option>\n                      <option value=\"Tanzania\"> Tanzania <\/option>\n                      <option value=\"Thailand\"> Thailand <\/option>\n                      <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                      <option value=\"Togo\"> Togo <\/option>\n                      <option value=\"Tokelau\"> Tokelau <\/option>\n                      <option value=\"Tonga\"> Tonga <\/option>\n                      <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                      <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                      <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                      <option value=\"Tunisia\"> Tunisia <\/option>\n                      <option value=\"Turkey\"> Turkey <\/option>\n                      <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                      <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                      <option value=\"Tuvalu\"> Tuvalu <\/option>\n                      <option value=\"Uganda\"> Uganda <\/option>\n                      <option value=\"Ukraine\"> Ukraine <\/option>\n                      <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                      <option value=\"United Kingdom\"> United Kingdom <\/option>\n                      <option value=\"Uruguay\"> Uruguay <\/option>\n                      <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                      <option value=\"Vanuatu\"> Vanuatu <\/option>\n                      <option value=\"Vatican City\"> Vatican City <\/option>\n                      <option value=\"Venezuela\"> Venezuela <\/option>\n                      <option value=\"Vietnam\"> Vietnam <\/option>\n                      <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                      <option value=\"Isle of Man\"> Isle of Man <\/option>\n                      <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                      <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                      <option value=\"Western Sahara\"> Western Sahara <\/option>\n                      <option value=\"Yemen\"> Yemen <\/option>\n                      <option value=\"Zambia\"> Zambia <\/option>\n                      <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                      <option value=\"other\"> Other <\/option>\n                    <\/select>\n                    <label class=\"form-sub-label\" for=\"input_88_country\" id=\"sublabel_88_country\" style=\"min-height:13px\"> Country <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n            <\/tbody>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_50\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_50\" for=\"input_50\">\n          Reason for seeing the dentist:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_50\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_50\" name=\"q50_reasonFor\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"32\" value=\"\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_50\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_99\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_99\" for=\"first_99\">\n          Doctor's Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_99\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_99\" name=\"q99_doctorsName99[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_99 sublabel_99_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_99\" id=\"sublabel_99_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_99\" name=\"q99_doctorsName99[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_99 sublabel_99_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_99\" id=\"sublabel_99_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_100\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_100\" for=\"input_100_area\">\n          Doctor's Phone\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_100\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_100_area\" name=\"q100_doctorsPhone100[area]\" class=\"form-textbox validate[required]\" size=\"6\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_100 sublabel_100_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_100_area\" id=\"sublabel_100_area\" style=\"min-height:13px\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_100_phone\" name=\"q100_doctorsPhone100[phone]\" class=\"form-textbox validate[required]\" size=\"12\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_100 sublabel_100_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_100_phone\" id=\"sublabel_100_phone\" style=\"min-height:13px\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_91\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_91\" for=\"input_91\">\n          Doctor's Practice:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_91\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_91\" name=\"q91_doctorsPractice\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"50\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_91\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_92\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_92\" for=\"first_92\">\n          Emergency Contact Name:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_92\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_92\" name=\"q92_emergencyContact[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_92 sublabel_92_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_92\" id=\"sublabel_92_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_92\" name=\"q92_emergencyContact[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_92 sublabel_92_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_92\" id=\"sublabel_92_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_93\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_93\" for=\"input_93_area\">\n          Emergency Contact Phone:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_93\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_93_area\" name=\"q93_emergencyContact93[area]\" class=\"form-textbox validate[required]\" size=\"6\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_93 sublabel_93_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_93_area\" id=\"sublabel_93_area\" style=\"min-height:13px\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_93_phone\" name=\"q93_emergencyContact93[phone]\" class=\"form-textbox validate[required]\" size=\"12\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_93 sublabel_93_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_93_phone\" id=\"sublabel_93_phone\" style=\"min-height:13px\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_94\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_94\" for=\"input_94\">\n          Emergency Contact Relationship\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_94\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_94\" name=\"q94_emergencyContact94\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"40\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_94\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li id=\"cid_130\" class=\"form-input-wide\" data-type=\"control_pagebreak\">\n        <div class=\"form-pagebreak\" data-component=\"pagebreak\">\n          <div class=\"form-pagebreak-back-container\">\n            <button id=\"form-pagebreak-back_130\" type=\"button\" class=\"form-pagebreak-back \" data-component=\"pagebreak-back\">\n              Back\n            <\/button>\n          <\/div>\n          <div class=\"form-pagebreak-next-container\">\n            <button id=\"form-pagebreak-next_130\" type=\"button\" class=\"form-pagebreak-next \" data-component=\"pagebreak-next\">\n              Next\n            <\/button>\n          <\/div>\n          <div style=\"clear:both\" class=\"pageInfo form-sub-label\" id=\"pageInfo_130\">\n          <\/div>\n        <\/div>\n      <\/li>\n    <\/ul>\n    <ul class=\"form-section page-section\" style=\"display:none;\">\n      <li id=\"cid_75\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httac htvam\">\n            <h2 id=\"header_75\" class=\"form-header\" data-component=\"header\">\n              Medical History\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_52\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_52\" for=\"input_52\">\n          Are you allergic or have you reacted adversely to any of the following: (Please check all that apply)\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_52\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_52\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_52_0\" name=\"q52_areYou52[]\" value=\"Penicillin\" required=\"\" \/>\n              <label id=\"label_input_52_0\" for=\"input_52_0\"> Penicillin <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_52_1\" name=\"q52_areYou52[]\" value=\"Hay Fever\" required=\"\" \/>\n              <label id=\"label_input_52_1\" for=\"input_52_1\"> Hay Fever <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_52_2\" name=\"q52_areYou52[]\" value=\"Anti-Tetanus Serum\" required=\"\" \/>\n              <label id=\"label_input_52_2\" for=\"input_52_2\"> Anti-Tetanus Serum <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_52_3\" name=\"q52_areYou52[]\" value=\"Eczema\" required=\"\" \/>\n              <label id=\"label_input_52_3\" for=\"input_52_3\"> Eczema <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_52_4\" name=\"q52_areYou52[]\" value=\"General Anaesthetic\" required=\"\" \/>\n              <label id=\"label_input_52_4\" for=\"input_52_4\"> General Anaesthetic <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_52_5\" name=\"q52_areYou52[]\" value=\"Local Anaesthetic\" required=\"\" \/>\n              <label id=\"label_input_52_5\" for=\"input_52_5\"> Local Anaesthetic <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_52_6\" name=\"q52_areYou52[]\" value=\"Latex, Metals, Plastic\" required=\"\" \/>\n              <label id=\"label_input_52_6\" for=\"input_52_6\"> Latex, Metals, Plastic <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_52_7\" name=\"q52_areYou52[]\" value=\"Medicines\" required=\"\" \/>\n              <label id=\"label_input_52_7\" for=\"input_52_7\"> Medicines <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_52_8\" name=\"q52_areYou52[]\" value=\"Plants\" required=\"\" \/>\n              <label id=\"label_input_52_8\" for=\"input_52_8\"> Plants <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_52_9\" name=\"q52_areYou52[]\" value=\"Foods\" required=\"\" \/>\n              <label id=\"label_input_52_9\" for=\"input_52_9\"> Foods <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_52_10\" name=\"q52_areYou52[]\" value=\"Aspirin\" required=\"\" \/>\n              <label id=\"label_input_52_10\" for=\"input_52_10\"> Aspirin <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_52_11\" name=\"q52_areYou52[]\" value=\"None\" required=\"\" \/>\n              <label id=\"label_input_52_11\" for=\"input_52_11\"> None <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <input type=\"checkbox\" class=\"form-checkbox-other form-checkbox validate[required]\" name=\"q52_areYou52[other]\" id=\"other_52\" value=\"other\" \/>\n              <label id=\"label_other_52\" style=\"text-indent:0\" for=\"other_52\">  <\/label>\n              <input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q52_areYou52[other]\" data-otherhint=\"Other\" placeholder=\"Other\" size=\"15\" id=\"input_52\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_51\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_51\" for=\"input_51\"> Please list any drug allergies <\/label>\n        <div id=\"cid_51\" class=\"form-input-wide\">\n          <textarea id=\"input_51\" class=\"form-textarea\" name=\"q51_pleaseList\" cols=\"40\" rows=\"6\" data-component=\"textarea\" aria-labelledby=\"label_51\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_97\">\n        <div id=\"cid_97\" class=\"form-input-wide\">\n          <div id=\"text_97\" class=\"form-html\" data-component=\"text\">\n            <p><strong>Check any of the following medical conditions that you have had or have at the present:<\/strong><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_96\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_96\" for=\"input_96\">\n          Heart\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_96\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_96\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_96_0\" name=\"q96_heart[]\" value=\"Rheumatic fever\" required=\"\" \/>\n              <label id=\"label_input_96_0\" for=\"input_96_0\"> Rheumatic fever <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_96_1\" name=\"q96_heart[]\" value=\"Heart murmur\" required=\"\" \/>\n              <label id=\"label_input_96_1\" for=\"input_96_1\"> Heart murmur <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_96_2\" name=\"q96_heart[]\" value=\"High\/low blood pressure\" required=\"\" \/>\n              <label id=\"label_input_96_2\" for=\"input_96_2\"> High\/low blood pressure <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_96_3\" name=\"q96_heart[]\" value=\"Heart surgery\" required=\"\" \/>\n              <label id=\"label_input_96_3\" for=\"input_96_3\"> Heart surgery <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_96_4\" name=\"q96_heart[]\" value=\"Pacemaker\" required=\"\" \/>\n              <label id=\"label_input_96_4\" for=\"input_96_4\"> Pacemaker <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_96_5\" name=\"q96_heart[]\" value=\"Angina\" required=\"\" \/>\n              <label id=\"label_input_96_5\" for=\"input_96_5\"> Angina <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_96_6\" name=\"q96_heart[]\" value=\"Thrombosis\" required=\"\" \/>\n              <label id=\"label_input_96_6\" for=\"input_96_6\"> Thrombosis <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_96_7\" name=\"q96_heart[]\" value=\"None\" required=\"\" \/>\n              <label id=\"label_input_96_7\" for=\"input_96_7\"> None <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <input type=\"checkbox\" class=\"form-checkbox-other form-checkbox validate[required]\" name=\"q96_heart[other]\" id=\"other_96\" value=\"other\" \/>\n              <label id=\"label_other_96\" style=\"text-indent:0\" for=\"other_96\">  <\/label>\n              <input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q96_heart[other]\" data-otherhint=\"Other \" placeholder=\"Other \" size=\"15\" id=\"input_96\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_98\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_98\" for=\"input_98\">\n          Blood\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_98\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_98\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_98_0\" name=\"q98_blood[]\" value=\"Hepatitis A,B, C or D\" required=\"\" \/>\n              <label id=\"label_input_98_0\" for=\"input_98_0\"> Hepatitis A,B, C or D <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_98_1\" name=\"q98_blood[]\" value=\"Anaemia\" required=\"\" \/>\n              <label id=\"label_input_98_1\" for=\"input_98_1\"> Anaemia <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_98_2\" name=\"q98_blood[]\" value=\"AIDS or HIV\" required=\"\" \/>\n              <label id=\"label_input_98_2\" for=\"input_98_2\"> AIDS or HIV <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_98_3\" name=\"q98_blood[]\" value=\"Sickle cell disease\/traits\" required=\"\" \/>\n              <label id=\"label_input_98_3\" for=\"input_98_3\"> Sickle cell disease\/traits <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_98_4\" name=\"q98_blood[]\" value=\"Abnormal blood test\" required=\"\" \/>\n              <label id=\"label_input_98_4\" for=\"input_98_4\"> Abnormal blood test <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_98_5\" name=\"q98_blood[]\" value=\"Haemophilia\" required=\"\" \/>\n              <label id=\"label_input_98_5\" for=\"input_98_5\"> Haemophilia <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_98_6\" name=\"q98_blood[]\" value=\"Blood refused by transfusion service\" required=\"\" \/>\n              <label id=\"label_input_98_6\" for=\"input_98_6\"> Blood refused by transfusion service <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_98_7\" name=\"q98_blood[]\" value=\"None\" required=\"\" \/>\n              <label id=\"label_input_98_7\" for=\"input_98_7\"> None <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <input type=\"checkbox\" class=\"form-checkbox-other form-checkbox validate[required]\" name=\"q98_blood[other]\" id=\"other_98\" value=\"other\" \/>\n              <label id=\"label_other_98\" style=\"text-indent:0\" for=\"other_98\">  <\/label>\n              <input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q98_blood[other]\" data-otherhint=\"Other \" placeholder=\"Other \" size=\"15\" id=\"input_98\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_101\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_101\" for=\"input_101\">\n          Chest\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_101\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_101\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_101_0\" name=\"q101_chest[]\" value=\"Bronchitis\" required=\"\" \/>\n              <label id=\"label_input_101_0\" for=\"input_101_0\"> Bronchitis <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_101_1\" name=\"q101_chest[]\" value=\"Emphysema\" required=\"\" \/>\n              <label id=\"label_input_101_1\" for=\"input_101_1\"> Emphysema <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_101_2\" name=\"q101_chest[]\" value=\"Cystic Fibrosis\" required=\"\" \/>\n              <label id=\"label_input_101_2\" for=\"input_101_2\"> Cystic Fibrosis <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_101_3\" name=\"q101_chest[]\" value=\"Pneumonia\" required=\"\" \/>\n              <label id=\"label_input_101_3\" for=\"input_101_3\"> Pneumonia <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_101_4\" name=\"q101_chest[]\" value=\"Pleurisy\" required=\"\" \/>\n              <label id=\"label_input_101_4\" for=\"input_101_4\"> Pleurisy <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_101_5\" name=\"q101_chest[]\" value=\"Chest surgery\" required=\"\" \/>\n              <label id=\"label_input_101_5\" for=\"input_101_5\"> Chest surgery <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_101_6\" name=\"q101_chest[]\" value=\"Asthmatic\" required=\"\" \/>\n              <label id=\"label_input_101_6\" for=\"input_101_6\"> Asthmatic <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_101_7\" name=\"q101_chest[]\" value=\"None\" required=\"\" \/>\n              <label id=\"label_input_101_7\" for=\"input_101_7\"> None <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <input type=\"checkbox\" class=\"form-checkbox-other form-checkbox validate[required]\" name=\"q101_chest[other]\" id=\"other_101\" value=\"other\" \/>\n              <label id=\"label_other_101\" style=\"text-indent:0\" for=\"other_101\">  <\/label>\n              <input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q101_chest[other]\" data-otherhint=\"Other \" placeholder=\"Other \" size=\"15\" id=\"input_101\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_102\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_102\" for=\"input_102\">\n          Warnings\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_102\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_102\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_102_0\" name=\"q102_warnings[]\" value=\"Hearing\/sight impairment\" required=\"\" \/>\n              <label id=\"label_input_102_0\" for=\"input_102_0\"> Hearing\/sight impairment <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_102_1\" name=\"q102_warnings[]\" value=\"Trouble being reclined\" required=\"\" \/>\n              <label id=\"label_input_102_1\" for=\"input_102_1\"> Trouble being reclined <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_102_2\" name=\"q102_warnings[]\" value=\"Antibiotic cover required\" required=\"\" \/>\n              <label id=\"label_input_102_2\" for=\"input_102_2\"> Antibiotic cover required <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_102_3\" name=\"q102_warnings[]\" value=\"Steroids within 2 years\" required=\"\" \/>\n              <label id=\"label_input_102_3\" for=\"input_102_3\"> Steroids within 2 years <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_102_4\" name=\"q102_warnings[]\" value=\"Bruising\/persistent bleeding\" required=\"\" \/>\n              <label id=\"label_input_102_4\" for=\"input_102_4\"> Bruising\/persistent bleeding <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_102_5\" name=\"q102_warnings[]\" value=\"Warning card\" required=\"\" \/>\n              <label id=\"label_input_102_5\" for=\"input_102_5\"> Warning card <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_102_6\" name=\"q102_warnings[]\" value=\"Currently under treatment\" required=\"\" \/>\n              <label id=\"label_input_102_6\" for=\"input_102_6\"> Currently under treatment <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_102_7\" name=\"q102_warnings[]\" value=\"Treatment requiring hospitalisation\" required=\"\" \/>\n              <label id=\"label_input_102_7\" for=\"input_102_7\"> Treatment requiring hospitalisation <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_102_8\" name=\"q102_warnings[]\" value=\"None\" required=\"\" \/>\n              <label id=\"label_input_102_8\" for=\"input_102_8\"> None <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <input type=\"checkbox\" class=\"form-checkbox-other form-checkbox validate[required]\" name=\"q102_warnings[other]\" id=\"other_102\" value=\"other\" \/>\n              <label id=\"label_other_102\" style=\"text-indent:0\" for=\"other_102\">  <\/label>\n              <input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q102_warnings[other]\" data-otherhint=\"Other \" placeholder=\"Other \" size=\"15\" id=\"input_102\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_103\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_103\" for=\"input_103\">\n          Other\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_103\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_103\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_0\" name=\"q103_other[]\" value=\"Liver disease\" required=\"\" \/>\n              <label id=\"label_input_103_0\" for=\"input_103_0\"> Liver disease <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_1\" name=\"q103_other[]\" value=\"Past serious or infectious disease\" required=\"\" \/>\n              <label id=\"label_input_103_1\" for=\"input_103_1\"> Past serious or infectious disease <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_2\" name=\"q103_other[]\" value=\"Diabetes (patient or family)\" required=\"\" \/>\n              <label id=\"label_input_103_2\" for=\"input_103_2\"> Diabetes (patient or family) <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_3\" name=\"q103_other[]\" value=\"Depressive illness\" required=\"\" \/>\n              <label id=\"label_input_103_3\" for=\"input_103_3\"> Depressive illness <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_4\" name=\"q103_other[]\" value=\"Acid reflux or eating disorder\" required=\"\" \/>\n              <label id=\"label_input_103_4\" for=\"input_103_4\"> Acid reflux or eating disorder <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_5\" name=\"q103_other[]\" value=\"Nervous problems\" required=\"\" \/>\n              <label id=\"label_input_103_5\" for=\"input_103_5\"> Nervous problems <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_6\" name=\"q103_other[]\" value=\"Bone or joint disease\" required=\"\" \/>\n              <label id=\"label_input_103_6\" for=\"input_103_6\"> Bone or joint disease <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_7\" name=\"q103_other[]\" value=\"Severe headaches\" required=\"\" \/>\n              <label id=\"label_input_103_7\" for=\"input_103_7\"> Severe headaches <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_8\" name=\"q103_other[]\" value=\"Fainting attacks or blackouts\" required=\"\" \/>\n              <label id=\"label_input_103_8\" for=\"input_103_8\"> Fainting attacks or blackouts <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_9\" name=\"q103_other[]\" value=\"Kidney disease\" required=\"\" \/>\n              <label id=\"label_input_103_9\" for=\"input_103_9\"> Kidney disease <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_10\" name=\"q103_other[]\" value=\"Epilepsy\" required=\"\" \/>\n              <label id=\"label_input_103_10\" for=\"input_103_10\"> Epilepsy <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_11\" name=\"q103_other[]\" value=\"Hiatus hernia\" required=\"\" \/>\n              <label id=\"label_input_103_11\" for=\"input_103_11\"> Hiatus hernia <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_12\" name=\"q103_other[]\" value=\"Artificial joint\" required=\"\" \/>\n              <label id=\"label_input_103_12\" for=\"input_103_12\"> Artificial joint <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_13\" name=\"q103_other[]\" value=\"Giddiness\" required=\"\" \/>\n              <label id=\"label_input_103_13\" for=\"input_103_13\"> Giddiness <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_14\" name=\"q103_other[]\" value=\"Cancer\/radiotherapy\" required=\"\" \/>\n              <label id=\"label_input_103_14\" for=\"input_103_14\"> Cancer\/radiotherapy <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_15\" name=\"q103_other[]\" value=\"Stroke\" required=\"\" \/>\n              <label id=\"label_input_103_15\" for=\"input_103_15\"> Stroke <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_16\" name=\"q103_other[]\" value=\"Tuberculosis\" required=\"\" \/>\n              <label id=\"label_input_103_16\" for=\"input_103_16\"> Tuberculosis <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_17\" name=\"q103_other[]\" value=\"Cold sores\" required=\"\" \/>\n              <label id=\"label_input_103_17\" for=\"input_103_17\"> Cold sores <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_103_18\" name=\"q103_other[]\" value=\"None\" required=\"\" \/>\n              <label id=\"label_input_103_18\" for=\"input_103_18\"> None <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <input type=\"checkbox\" class=\"form-checkbox-other form-checkbox validate[required]\" name=\"q103_other[other]\" id=\"other_103\" value=\"other\" \/>\n              <label id=\"label_other_103\" style=\"text-indent:0\" for=\"other_103\">  <\/label>\n              <input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q103_other[other]\" data-otherhint=\"Other \" placeholder=\"Other \" size=\"15\" id=\"input_103\" \/>\n              <br\/>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_104\">\n        <div id=\"cid_104\" class=\"form-input-wide\">\n          <div id=\"text_104\" class=\"form-html\" data-component=\"text\">\n            <p><em>! Patients with special needs, cognitive issues or physical disabilities, please complete the additional special care dental form.<\/em><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_69\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_69\" for=\"input_69\"> Please list any other medical conditions: <\/label>\n        <div id=\"cid_69\" class=\"form-input-wide\">\n          <textarea id=\"input_69\" class=\"form-textarea\" name=\"q69_pleaseList69\" cols=\"40\" rows=\"6\" data-component=\"textarea\" aria-labelledby=\"label_69\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_105\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_105\" for=\"input_105\"> Major Surgeries (type and year) : <\/label>\n        <div id=\"cid_105\" class=\"form-input-wide\">\n          <textarea id=\"input_105\" class=\"form-textarea\" name=\"q105_majorSurgeries105\" cols=\"40\" rows=\"6\" data-component=\"textarea\" aria-labelledby=\"label_105\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_68\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_68\" for=\"input_68\"> Please list your Current Medications <\/label>\n        <div id=\"cid_68\" class=\"form-input-wide\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <textarea id=\"input_68\" class=\"form-textarea\" name=\"q68_pleaseList68\" cols=\"40\" rows=\"6\" data-component=\"textarea\" aria-labelledby=\"label_68 sublabel_input_68\"><\/textarea>\n            <label class=\"form-sub-label\" for=\"input_68\" id=\"sublabel_input_68\" style=\"min-height:13px\"> Including prescription drugs, over-the-counter drugs, vitamins, herbal remedies and supplements <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_106\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_106\" for=\"input_106\">\n          Have you been hospitalized during the past two years?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_106\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_106\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_106_0\" name=\"q106_haveYou\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_106_0\" for=\"input_106_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_106_1\" name=\"q106_haveYou\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_106_1\" for=\"input_106_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_108\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_108\" for=\"input_108\">\n          Have you been asked by your medical doctor to pre-medicate before any dental treatment?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_108\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_108\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_108_0\" name=\"q108_haveYou108\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_108_0\" for=\"input_108_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_108_1\" name=\"q108_haveYou108\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_108_1\" for=\"input_108_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_109\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_109\" for=\"input_109\">\n          Do you have any disease, condition or problem not listed?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_109\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_109\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_109_0\" name=\"q109_doYou109\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_109_0\" for=\"input_109_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_109_1\" name=\"q109_doYou109\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_109_1\" for=\"input_109_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_110\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_110\" for=\"input_110\">\n          Do you smoke or use chewing tobacco?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_110\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_110\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_110_0\" name=\"q110_doYou110\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_110_0\" for=\"input_110_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_110_1\" name=\"q110_doYou110\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_110_1\" for=\"input_110_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_111\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_111\" for=\"input_111\">\n          Do you use any recreational drugs?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_111\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_111\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_111_0\" name=\"q111_doYou111\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_111_0\" for=\"input_111_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_111_1\" name=\"q111_doYou111\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_111_1\" for=\"input_111_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_112\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_112\" for=\"input_112\">\n          Do you drink alcohol? If yes, please specify.\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_112\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_112\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_112_0\" name=\"q112_doYou112\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_112_0\" for=\"input_112_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_112_1\" name=\"q112_doYou112\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_112_1\" for=\"input_112_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_129\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_129\" for=\"input_129\"> How often and in what quantity: <\/label>\n        <div id=\"cid_129\" class=\"form-input-wide\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <textarea id=\"input_129\" class=\"form-textarea\" name=\"q129_howOften\" cols=\"40\" rows=\"6\" data-component=\"textarea\" aria-labelledby=\"label_129 sublabel_input_129\"><\/textarea>\n            <label class=\"form-sub-label\" for=\"input_129\" id=\"sublabel_input_129\" style=\"min-height:13px\"> eg. 2 bottles of beer a week <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li id=\"cid_127\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httac htvam\">\n            <h2 id=\"header_127\" class=\"form-header\" data-component=\"header\">\n              For Women Only\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_113\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_113\" for=\"input_113\"> Are you pregnant? If yes, please specify due date. <\/label>\n        <div id=\"cid_113\" class=\"form-input-wide\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_113\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_113_0\" name=\"q113_areYou113\" value=\"Yes\" \/>\n              <label id=\"label_input_113_0\" for=\"input_113_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_113_1\" name=\"q113_areYou113\" value=\"No\" \/>\n              <label id=\"label_input_113_1\" for=\"input_113_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_datetime\" id=\"id_116\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_116\" for=\"day_116\"> Due Date <\/label>\n        <div id=\"cid_116\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"day_116\" name=\"q116_dueDate[day]\" size=\"2\" data-maxlength=\"2\" value=\"\" aria-labelledby=\"label_116 sublabel_116_day\" \/>\n              <span class=\"date-separate\" aria-hidden=\"true\">\n                \u00a0\/\n              <\/span>\n              <label class=\"form-sub-label\" for=\"day_116\" id=\"sublabel_116_day\" style=\"min-height:13px\"> Day <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"month_116\" name=\"q116_dueDate[month]\" size=\"2\" data-maxlength=\"2\" value=\"\" aria-labelledby=\"label_116 sublabel_116_month\" \/>\n              <span class=\"date-separate\" aria-hidden=\"true\">\n                \u00a0\/\n              <\/span>\n              <label class=\"form-sub-label\" for=\"month_116\" id=\"sublabel_116_month\" style=\"min-height:13px\"> Month <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"year_116\" name=\"q116_dueDate[year]\" size=\"4\" data-maxlength=\"4\" value=\"\" aria-labelledby=\"label_116 sublabel_116_year\" \/>\n              <label class=\"form-sub-label\" for=\"year_116\" id=\"sublabel_116_year\" style=\"min-height:13px\"> Year <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <img class=\"showAutoCalendar\" alt=\"Pick a Date\" id=\"input_116_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" style=\"vertical-align:middle;margin-left:5px\" data-component=\"datetime\" aria-hidden=\"true\" \/>\n              <label class=\"form-sub-label\" for=\"input_116_pick\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\"> Date Picker Icon <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_115\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_115\" for=\"input_115\"> Are you taking birth control pills? <\/label>\n        <div id=\"cid_115\" class=\"form-input-wide\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_115\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_115_0\" name=\"q115_areYou\" value=\"Yes\" \/>\n              <label id=\"label_input_115_0\" for=\"input_115_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_115_1\" name=\"q115_areYou\" value=\"No\" \/>\n              <label id=\"label_input_115_1\" for=\"input_115_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_117\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_117\" for=\"input_117\"> Could you be pregnant? <\/label>\n        <div id=\"cid_117\" class=\"form-input-wide\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_117\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_117_0\" name=\"q117_couldYou\" value=\"Yes\" \/>\n              <label id=\"label_input_117_0\" for=\"input_117_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_117_1\" name=\"q117_couldYou\" value=\"No\" \/>\n              <label id=\"label_input_117_1\" for=\"input_117_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_118\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_118\" for=\"input_118\"> Are you nursing? <\/label>\n        <div id=\"cid_118\" class=\"form-input-wide\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_118\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_118_0\" name=\"q118_areYou118\" value=\"Yes\" \/>\n              <label id=\"label_input_118_0\" for=\"input_118_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_118_1\" name=\"q118_areYou118\" value=\"No\" \/>\n              <label id=\"label_input_118_1\" for=\"input_118_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_119\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_119\" for=\"input_119\"> Hormone replacement? <\/label>\n        <div id=\"cid_119\" class=\"form-input-wide\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_119\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_119_0\" name=\"q119_hormoneReplacement\" value=\"Yes\" \/>\n              <label id=\"label_input_119_0\" for=\"input_119_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_119_1\" name=\"q119_hormoneReplacement\" value=\"No\" \/>\n              <label id=\"label_input_119_1\" for=\"input_119_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_131\" class=\"form-input-wide\" data-type=\"control_pagebreak\">\n        <div class=\"form-pagebreak\" data-component=\"pagebreak\">\n          <div class=\"form-pagebreak-back-container\">\n            <button id=\"form-pagebreak-back_131\" type=\"button\" class=\"form-pagebreak-back \" data-component=\"pagebreak-back\">\n              Back\n            <\/button>\n          <\/div>\n          <div class=\"form-pagebreak-next-container\">\n            <button id=\"form-pagebreak-next_131\" type=\"button\" class=\"form-pagebreak-next \" data-component=\"pagebreak-next\">\n              Next\n            <\/button>\n          <\/div>\n          <div style=\"clear:both\" class=\"pageInfo form-sub-label\" id=\"pageInfo_131\">\n          <\/div>\n        <\/div>\n      <\/li>\n    <\/ul>\n    <ul class=\"form-section page-section\" style=\"display:none;\">\n      <li id=\"cid_79\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httac htvam\">\n            <h2 id=\"header_79\" class=\"form-header\" data-component=\"header\">\n              Healthy &amp; Unhealthy Habits\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_80\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_80\" for=\"input_80\"> Exercise <\/label>\n        <div id=\"cid_80\" class=\"form-input-wide\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_80\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_80_0\" name=\"q80_exercise\" value=\"Never\" \/>\n              <label id=\"label_input_80_0\" for=\"input_80_0\"> Never <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_80_1\" name=\"q80_exercise\" value=\"1-2 days\" \/>\n              <label id=\"label_input_80_1\" for=\"input_80_1\"> 1-2 days <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_80_2\" name=\"q80_exercise\" value=\"3-4 days\" \/>\n              <label id=\"label_input_80_2\" for=\"input_80_2\"> 3-4 days <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_80_3\" name=\"q80_exercise\" value=\"5+ days\" \/>\n              <label id=\"label_input_80_3\" for=\"input_80_3\"> 5+ days <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_81\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_81\" for=\"input_81\"> Eating following a diet <\/label>\n        <div id=\"cid_81\" class=\"form-input-wide\">\n          <div class=\"form-multiple-column\" data-columncount=\"3\" role=\"group\" aria-labelledby=\"label_81\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_81_0\" name=\"q81_eatingFollowing\" value=\"I have a loose diet\" \/>\n              <label id=\"label_input_81_0\" for=\"input_81_0\"> I have a loose diet <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_81_1\" name=\"q81_eatingFollowing\" value=\"I have a strict diet\" \/>\n              <label id=\"label_input_81_1\" for=\"input_81_1\"> I have a strict diet <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_81_2\" name=\"q81_eatingFollowing\" value=\"I don&#x27;t have a diet plan\" \/>\n              <label id=\"label_input_81_2\" for=\"input_81_2\"> I don't have a diet plan <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_76\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_76\" for=\"input_76\"> Alcohol Consumption <\/label>\n        <div id=\"cid_76\" class=\"form-input-wide\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_76\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_76_0\" name=\"q76_alcoholConsumption\" value=\"I don&#x27;t drink\" \/>\n              <label id=\"label_input_76_0\" for=\"input_76_0\"> I don't drink <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_76_1\" name=\"q76_alcoholConsumption\" value=\"1-2 glasses\/day\" \/>\n              <label id=\"label_input_76_1\" for=\"input_76_1\"> 1-2 glasses\/day <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_76_2\" name=\"q76_alcoholConsumption\" value=\"3-4 glasses\/day\" \/>\n              <label id=\"label_input_76_2\" for=\"input_76_2\"> 3-4 glasses\/day <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_76_3\" name=\"q76_alcoholConsumption\" value=\"5+ glasses\/day\" \/>\n              <label id=\"label_input_76_3\" for=\"input_76_3\"> 5+ glasses\/day <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_77\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_77\" for=\"input_77\"> Caffeine Consumption <\/label>\n        <div id=\"cid_77\" class=\"form-input-wide\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_77\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_77_0\" name=\"q77_caffeineConsumption77\" value=\"I don&#x27;t use caffeine\" \/>\n              <label id=\"label_input_77_0\" for=\"input_77_0\"> I don't use caffeine <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_77_1\" name=\"q77_caffeineConsumption77\" value=\"1-2 cups\/day\" \/>\n              <label id=\"label_input_77_1\" for=\"input_77_1\"> 1-2 cups\/day <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n             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role=\"group\" aria-labelledby=\"label_78\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_78_0\" name=\"q78_doYou\" value=\"No\" \/>\n              <label id=\"label_input_78_0\" for=\"input_78_0\"> No <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_78_1\" name=\"q78_doYou\" value=\"0-1 pack\/day\" \/>\n              <label id=\"label_input_78_1\" for=\"input_78_1\"> 0-1 pack\/day <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_78_2\" name=\"q78_doYou\" value=\"1-2 packs\/day\" \/>\n              <label id=\"label_input_78_2\" for=\"input_78_2\"> 1-2 packs\/day <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_78_3\" name=\"q78_doYou\" value=\"2+ packs\/day\" \/>\n              <label id=\"label_input_78_3\" for=\"input_78_3\"> 2+ packs\/day <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_17\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_17\" for=\"input_17\"> Include other comments regarding your Medical History <\/label>\n        <div id=\"cid_17\" class=\"form-input-wide\">\n          <textarea id=\"input_17\" class=\"form-textarea\" name=\"q17_includeOther\" cols=\"40\" rows=\"9\" data-component=\"textarea\" aria-labelledby=\"label_17\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li id=\"cid_132\" class=\"form-input-wide\" data-type=\"control_pagebreak\">\n        <div class=\"form-pagebreak\" data-component=\"pagebreak\">\n          <div class=\"form-pagebreak-back-container\">\n            <button id=\"form-pagebreak-back_132\" type=\"button\" class=\"form-pagebreak-back \" data-component=\"pagebreak-back\">\n              Back\n            <\/button>\n          <\/div>\n          <div class=\"form-pagebreak-next-container\">\n            <button id=\"form-pagebreak-next_132\" type=\"button\" class=\"form-pagebreak-next \" data-component=\"pagebreak-next\">\n              Next\n            <\/button>\n          <\/div>\n          <div style=\"clear:both\" class=\"pageInfo form-sub-label\" id=\"pageInfo_132\">\n          <\/div>\n        <\/div>\n      <\/li>\n    <\/ul>\n    <ul class=\"form-section page-section\" style=\"display:none;\">\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_120\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_120\" for=\"input_120\"> This form is designed to solicit information typically required to plan treatment.The space below is for you to inform us other information you believe we should take into account when planning your treatment: <\/label>\n        <div id=\"cid_120\" class=\"form-input-wide\">\n          <textarea id=\"input_120\" class=\"form-textarea\" name=\"q120_thisForm\" cols=\"40\" rows=\"9\" data-component=\"textarea\" aria-labelledby=\"label_120\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_122\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_122\" for=\"input_122\"> Previous Dental Experience: <\/label>\n        <div id=\"cid_122\" class=\"form-input-wide\">\n          <textarea id=\"input_122\" class=\"form-textarea\" name=\"q122_previousDental\" cols=\"40\" rows=\"9\" data-component=\"textarea\" aria-labelledby=\"label_122\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_123\">\n        <div id=\"cid_123\" class=\"form-input-wide\">\n          <div id=\"text_123\" class=\"form-html\" data-component=\"text\">\n            <p>If you have any questions about this form or are unsure how to answer any questions, we\u2019d be happy to assist you, please ask!<\/p>\n            <p><strong>Authorization:<\/strong> I have reviewed the information on this form, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. 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JotForm<\/a>\n    <\/div>\n  <\/div>\n<\/form><\/body>\n<\/html>\n","New Patient Dental and Medical History Form",Array);(function(){window.handleIFrameMessage=function(e){if(!e.data||!e.data.split)return;var args=e.data.split(":");if(args[2]!="92912873556165"){return;}
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