{"id":5474,"date":"2023-11-03T09:39:22","date_gmt":"2023-11-03T09:39:22","guid":{"rendered":"https:\/\/cioccadermatology.com\/?page_id=5474"},"modified":"2025-03-15T01:15:15","modified_gmt":"2025-03-15T01:15:15","slug":"patient-registration-form","status":"publish","type":"page","link":"https:\/\/cioccadermatology.com\/patient-registration-forms\/patient-registration-form\/","title":{"rendered":"Patient Registration Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5474\" class=\"elementor elementor-5474\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-7c907643 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"7c907643\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-1845b2a1\" data-id=\"1845b2a1\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-f338f1c elementor-widget elementor-widget-text-editor\" data-id=\"f338f1c\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.17.0 - 08-11-2023 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#69727d;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#69727d;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<h3><span style=\"color: #ffffff;\">Expert Dermatology Care for Healthy, Radiant Skin<\/span><\/h3><p><span style=\"color: #ffffff;\">Our dedicated dermatology team prioritizes your skin\u2019s health, delivering exceptional care with a highly personalized and integrative approach. We combine cutting-edge treatments with compassionate service to ensure every patient receives the best possible care.<\/span><\/p><h4><span style=\"color: #ffffff;\">Personalized, Compassionate Skin Care<\/span><\/h4><p><span style=\"color: #ffffff;\">We foster a warm and welcoming environment where patients feel valued and supported. Our team treats each individual as part of our extended family, building lasting relationships based on trust and excellence. We believe in empowering our patients with knowledge, helping them make informed decisions about their skin health.<\/span><\/p><h4><span style=\"color: #ffffff;\">Advanced Dermatology Solutions<\/span><\/h4><p><span style=\"color: #ffffff;\">Our practice stays at the forefront of dermatological advancements, offering innovative treatments tailored to each patient\u2019s unique needs. Whether addressing medical or cosmetic concerns, we utilize the latest technology and evidence-based techniques to achieve optimal results.<\/span><\/p><h4><span style=\"color: #ffffff;\">Empowering Patients for Better Skin Health<\/span><\/h4><p><span style=\"color: #ffffff;\">Education plays a key role in our approach to dermatology. We provide patients with the tools and information they need to actively participate in their care. By understanding their skin\u2019s needs, patients can make confident, informed choices that lead to long-term health and beauty.<\/span><\/p><h4><span style=\"color: #ffffff;\">Patient Registration Form<\/span><\/h4><h4><span style=\"color: #ffffff;\">Committed to Excellence in Dermatology<\/span><\/h4><p><span style=\"color: #ffffff;\">Our team continuously refines<\/span> our expertise, ensuring we deliver the highest quality care. By blending medical innovation with compassionate service, we enhance our patients\u2019 lives and help them achieve healthier, more radiant skin.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2bc1d8ab elementor-widget elementor-widget-text-editor\" data-id=\"2bc1d8ab\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t  <div id=\"page-header-1159723477\" class=\"page-header-wrapper\">\n  <div class=\"page-title dark simple-title\">\n\n    \n    <div class=\"page-title-inner container align-center text-center flex-row-col medium-flex-wrap\" >\n              <div class=\"title-wrapper flex-col\">\n          <h1 class=\"entry-title mb-0\">\n            New Patient Form          <\/h1>\n        <\/div>\n                    <div class=\"title-content flex-col\">\n        <div class=\"title-breadcrumbs pb-half pt-half\"><\/div>      <\/div>\n    <\/div>\n\n       <\/div>\n    <\/div>\n  <div class=\"row align-center\"  id=\"row-1760254227\">\n\t<div id=\"col-512799259\" class=\"col medium-10 small-12 large-10\"  >\n\t\t\t\t<div class=\"col-inner\"  >\n\t\t\t\n\t\t\t<p>In order to serve you better, we ask you t<a href=\"https:\/\/www.dermatologyofsouthflorida.com\/\">o<\/a> complete the form below before your schedul<a href=\"https:\/\/cioccadermatology.com\/\">e<\/a> appointment.<\/p><div class=\"form_embed_shortcode_display \"><div class=\"shortcode \"><div class=\"embed_code\"><style type=\"text\/css\">#nex-forms{display:none;}<\/style><div id=\"nf_form_29263\">\r\n\r\n\t\t\t<style type=\"text\/css\">\r\n\r\n\t\t\t\t#nex-forms.registration_form_usa .nf-loader-lds-spinner div:after {background: #40C4FF; 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box-shadow: #00000033 0px 7px 16px 0px; border-radius: 4px; padding: 30px; border-color:#ddd;\"><div class=\"msg_text\"><div class=\"form_field all_fields icon html_fields wow bounceInUp\" style=\"margin-bottom: 15px\" id=\"_21501\" data-animation-name=\"bounceInUp\">\n\t\t\t\t\t\t\t  <div class=\"edit_mask\"><\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<div class=\"icon_container_wrapper icon_center\">\n\t\t\t\t\t\t\t\t  <div class=\"icon_container\" id=\"field_container\" style=\"border-width: 0px;background-color: transparent\">\n\t\t\t\t\t\t\t\t\t<div class=\"\">\n\t\t\t\t\t\t\t\t\t  <div class=\"input_container\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"the_input_element icon_element\" style=\"font-size: 50px;color: #8bc34a\"><span class=\"fas fa-check-circle\"><\/span><\/div>\n\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"form_field all_fields html html_fields wow fadeInDown\" style=\"margin-bottom: 15px\" data-animation-name=\"fadeInDown\" data-wow-delay=\"0.5s\" id=\"_92914\">\n\t\t\t\t\t\t\t  <div class=\"edit_mask\"><\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t  <div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t\t  <div class=\"col-sm-12 input_container\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"the_input_element align_center\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Thank you for connecting with us. We will respond to you shortly.<\/div>\n\t\t\t\t\t\t\t\t\t\t<div style=\"clear:both\"><\/div>\n\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div data-timer-start=\"1\" data-timer-end=\"0\" class=\"inner-canvas-container ui-nex-forms-container  bootstrap\" id=\"ui-nex-forms-container-4\"  ><div class=\"current_step\" style=\"display:none;\">1<\/div><div class=\"last_visited_step\" style=\"display:none;\">1<\/div><div class=\"nex-forms-header-footer nex-forms-header timer_inline timer_right \"><div class=\"bc-outer-container \"><div style=\"\" class=\"nf_ms_breadcrumb  bc-gutter-20 bc-top bc-solid bc-connected bc-unfolded pilled \">\n\t\t\t\t\t\t\t\t\t\t<ul class=\"the_br  align_left pilled  md-color-default\" data-align-crumb=\"align_left\" data-text-pos=\"text-bottom\" data-breadcrumb-type=\"pilled\" data-theme=\"default\" 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style=\"display:none;\">message<\/div><div class=\"hidden\" id=\"nf_ajax_url\" style=\"display:none;\">https:\/\/cioccadermatology.com\/wp-admin\/admin-ajax.php<\/div><div class=\"hidden\" id=\"paypal_return_url\" style=\"display:none;\">https:\/\/cioccadermatology.com\/api-json\/wp\/v2\/pages\/5474<\/div><div class=\"hidden\" id=\"ms_scroll_to_top\" style=\"display:none;\">yes<\/div><div class=\"v7_container form_type_normal   \" style=\"background: #ffffff; box-shadow: #00000033 0px 7px 16px 0px; border-radius: 4px; padding: 30px; border-color: #dddddd; width: 100%;\"><div class=\"current_field_on_focus\" style=\"display:none\">1<\/div><form id=\"4\" class=\"submit-nex-form nex-forms-4\" data-form-id=\"4\" name=\"nex_form\" action=\"https:\/\/cioccadermatology.com\/wp-admin\/admin-ajax.php\" method=\"post\" enctype=\"multipart\/form-data\"><div class=\"step_transition_in\" style=\"display:none;\">fadeIn<\/div><div class=\"step_transition_out\" style=\"display:none;\">fadeOut<\/div><input type=\"hidden\" name=\"nex_forms_Id\" value=\"4\"><input type=\"hidden\" name=\"page\" value=\"\/api-json\/wp\/v2\/pages\/5474\"><input type=\"hidden\" name=\"ip\" value=\"216.73.217.59\"><input type=\"hidden\" name=\"nf_page_id\" value=\"5474\"><input type=\"hidden\" name=\"nf_page_title\" value=\"Patient Registration Form\"><input type=\"text\" name=\"company_url\" value=\"\" placeholder=\"enter company url\" class=\"form-control req\">\n\t\t\t\t\t\t\t<div class=\"form_field hidden\" data-id=\"_99099\" id=\"_99099\">\n\t\t\t\t\t\t\t\t<input class=\"ms_current_step\" value=\"1\" name=\"ms_current_step\" type=\"hidden\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px\" data-id=\"_83998\" id=\"_83998\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\"><h1 class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Patient details<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 has_prefix_icon is_grid\" style=\"position: relative;left: 0px;top: 0px\" data-id=\"_67265\" id=\"_67265\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_67265  col-sm-7 grid-target-0\" data-grid-width=\"7\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields required\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_8172\" id=\"_8172\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\" style=\"padding-left: 15px\"><div class=\"row\"><div class=\"label_container align_left col-sm-12\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Patient Name *<\/span><\/label><\/div><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"patient_name_\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_67265  col-sm-5 grid-target-1\" data-grid-width=\"5\" data-grid-num=\"1\"><div class=\"form_field all_fields date special_fields has_prefix_icon required\" style=\"margin-bottom: 15px;position: relative;left: 0px;top: 0px\" data-id=\"_91463\" id=\"_91463\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\" style=\"padding-left: 15px\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Date of birth *<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"DD\/MM\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #888888;background: white;border-color: #dddddd\"><span class=\"fa fa-calendar-o\" style=\"font-size: 17px\"><\/span><\/span><input type=\"text\" name=\"date_of_birth_\" class=\"error_message form-control the_input_element aling_left align_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 is_grid\" data-id=\"_92342\" id=\"_92342\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_92342  col-sm-9 grid-target-0\" data-grid-width=\"9\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields required\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_29718\" id=\"_29718\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Adress *<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"adress_\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_92342  col-sm-3 grid-target-1\" data-grid-width=\"3\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;position: relative;left: 0px;top: 0px\" data-id=\"_79815\" id=\"_79815\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Zip code<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"zip_code\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 is_grid\" data-id=\"_98638\" id=\"_98638\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_98638  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields required\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_55043\" id=\"_55043\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Home number *<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"home_number_\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_98638  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_31528\" id=\"_31528\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Cellphone<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"cellphone\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_98638  col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"form_field all_fields text common_fields required\" style=\"margin-bottom: 15px;position: relative;left: 0px;top: 0px\" data-id=\"_66705\" id=\"_66705\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">SS number *<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"ss_number_\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields\" style=\"margin-bottom: 15px\" data-id=\"_59500\" id=\"_59500\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Can we leave detail message?<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"can_we_leave_detail_message_yes\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"can_we_leave_detail_message\" id=\"can_we_leave_detail_message_yes\" value=\"Yes\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">Yes<\/span><\/span><\/label><label class=\"radio-inline \" for=\"can_we_leave_detail_message_no\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"can_we_leave_detail_message\" id=\"can_we_leave_detail_message_no\" value=\"No\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label radio-label\">No<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 has_prefix_icon is_grid\" data-id=\"_78420\" id=\"_78420\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_78420  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields email email preset_fields has_prefix_icon\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_53748\" id=\"_53748\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Email<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\"><span class=\"input-group-addon prefix \" style=\"color: #888888;background: white;border-color: #dddddd\"><span class=\"fa fas fa-envelope\" style=\"font-size: 17px\"><\/span><\/span><input type=\"text\" name=\"email\" class=\"error_message email form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid email address\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_78420  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"panel-default\"><div class=\"panel-body\"><\/div><\/div><\/div><div class=\"grid_input_holder id-_78420  col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"panel-default\"><div class=\"panel-body\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 is_grid\" data-id=\"_78296\" id=\"_78296\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_78296  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_77792\" id=\"_77792\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Mother<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"mother\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_78296  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_77312\" id=\"_77312\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Home number<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"home_number\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_78296  col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"panel-default\"><div class=\"panel-body\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 is_grid\" data-id=\"_35835\" id=\"_35835\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_35835  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_62427\" id=\"_62427\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Father<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"father\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_35835  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_62526\" id=\"_62526\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Home number<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"home_number\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_35835  col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"panel-default\"><div class=\"panel-body\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 is_grid\" data-id=\"_11574\" id=\"_11574\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_11574  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_17802\" id=\"_17802\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Employer<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"employer\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_11574  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_43686\" id=\"_43686\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Occupation<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"occupation\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_11574  col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"panel-default\"><div class=\"panel-body\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 has_prefix_icon is_grid\" data-id=\"_15663\" id=\"_15663\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_15663  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields required\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_5841\" id=\"_5841\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Responsible Party*<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"responsible_party\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_15663  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields date special_fields has_prefix_icon required\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_95331\" id=\"_95331\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Date Of Birth*<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"DD\/MM\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #888888;background: white;border-color: #dddddd\"><span class=\"fa fa-calendar-o\" style=\"font-size: 17px\"><\/span><\/span><input type=\"text\" name=\"date_of_birth\" class=\"error_message form-control the_input_element aling_left align_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_15663  col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"form_field all_fields text common_fields required\" style=\"margin-bottom: 15px;position: relative;left: 0px;top: 0px\" data-id=\"_49148\" id=\"_49148\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">S number*<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"s_number\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"field_spacer\" data-id=\"_46421\" id=\"_45562\"><div class=\"field_spacer\" style=\"height: 75px\"><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px\" data-id=\"_81015\" id=\"_81015\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\"><h1 class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Medical history<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 is_grid\" data-id=\"_48862\" id=\"_48862\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_48862  col-sm-8 grid-target-0\" data-grid-width=\"8\" data-grid-num=\"0\"><div class=\"form_field all_fields textarea common_fields is_focused required\" style=\"margin-bottom: 15px\" data-id=\"_56202\" id=\"_56202\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Reason for your visit *<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"reason_for_your_visit_\" placeholder=\"Type your message\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_48862  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"panel-default\"><div class=\"panel-body\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 is_grid\" data-id=\"_9302\" id=\"_9302\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_9302  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px\" data-id=\"_91174\" id=\"_91174\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Primary Care Provider<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"primary_care_provider\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_9302  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields phone_number\" style=\"margin-bottom: 15px\" data-id=\"_36488\" id=\"_36488\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Phone number<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"phone_number\" class=\"form-control error_message the_input_element aling_left align_left phone_number\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Invalid phone number format\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_9302  col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px\" data-id=\"_22043\" id=\"_22043\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Referred by<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"referred_by\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 is_grid\" data-id=\"_86094\" id=\"_86094\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_86094  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields required\" style=\"margin-bottom: 15px\" data-id=\"_1620\" id=\"_1620\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Pharmacy *<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"pharmacy_\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_86094  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px\" data-id=\"_33090\" id=\"_33090\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Zip code<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"zip_code\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_86094  col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"form_field all_fields text common_fields phone_number\" style=\"margin-bottom: 15px\" data-id=\"_47843\" id=\"_47843\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Phone number<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"phone_number\" class=\"form-control error_message the_input_element aling_left align_left phone_number\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Invalid phone number format\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 is_grid\" data-id=\"_77802\" id=\"_77802\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_77802  col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields textarea common_fields required\" style=\"margin-bottom: 15px\" data-id=\"_79970\" id=\"_79970\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Drug Allergies\/Sensitivities *<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"drug_allergiessensitivities_\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_77802  col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields textarea common_fields required\" style=\"margin-bottom: 15px\" data-id=\"_72457\" id=\"_72457\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">List Present Medication *<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"list_present_medication_\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 is_grid\" data-id=\"_71443\" id=\"_71443\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_71443  col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields textarea common_fields required\" style=\"margin-bottom: 15px\" data-id=\"_95943\" id=\"_95943\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Medical Conditions *<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"medical_conditions_\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_71443  col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px\" data-id=\"_24419\" id=\"_24419\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Hospitalization\/Surgeries<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"hospitalizationsurgeries\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 is_grid\" data-id=\"_79207\" id=\"_79207\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_79207  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px\" data-id=\"_41927\" id=\"_41927\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Emergency Person<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"emergency_person\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_79207  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px\" data-id=\"_83057\" id=\"_83057\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Relationship<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"relationship\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_79207  col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px\" data-id=\"_80227\" id=\"_80227\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Emergency Contact<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"emergency_contact\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields check-group common_fields selection_fields radio-group\" style=\"margin-bottom: 15px\" data-id=\"_79634\" id=\"_79634\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Mark if applies<\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Minimum of {x} selections required\" title=\"\" data-layout=\"1c\"><div class=\"input-inner\"><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"mark_if_applies_smoke\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"mark_if_applies[]\" id=\"mark_if_applies_smoke\" value=\"smoke\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\">smoke<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"mark_if_applies__alcohol_consumption\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"mark_if_applies[]\" id=\"mark_if_applies__alcohol_consumption\" value=\" alcohol consumption\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\"> alcohol consumption<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"mark_if_applies__recreation_drug_use\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"mark_if_applies[]\" id=\"mark_if_applies__recreation_drug_use\" value=\" recreation drug use\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\"> recreation drug use<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"mark_if_applies__pregnancy\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"mark_if_applies[]\" id=\"mark_if_applies__pregnancy\" value=\" pregnancy\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\"> pregnancy<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"mark_if_applies__breastfeeding\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"mark_if_applies[]\" id=\"mark_if_applies__breastfeeding\" value=\" breastfeeding\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\"> breastfeeding<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-3 is_grid\" data-id=\"_84770\" id=\"_84770\"><div class=\"row  grid_row\"><div class=\"grid_input_holder id-_84770  col-sm-4 grid-target-0\" data-grid-width=\"4\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px\" data-id=\"_66417\" id=\"_66417\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Authorized Person to Discuss Medical Information<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"authorized_person_to_discuss_medical_information\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_84770  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px\" data-id=\"_82915\" id=\"_82915\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">Phone Number<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"phone_number\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_84770  col-sm-4 grid-target-2\" data-grid-width=\"4\" data-grid-num=\"2\"><div class=\"panel-default\"><div class=\"panel-body\"><\/div><\/div><\/div><\/div><\/div><div class=\"field_spacer\" data-id=\"_81136\" id=\"_90851\"><div class=\"field_spacer\" style=\"height: 68px\"><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px;position: relative;top: 0px\" data-id=\"_41524\" id=\"_41524\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\"><h1 class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Office Policy<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields check-group common_fields selection_fields radio-group\" style=\"margin-bottom: 15px\" data-id=\"_12868\" id=\"_12868\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\"><\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Minimum of {x} selections required\" title=\"\" data-layout=\"1c\"><div class=\"input-inner\"><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"check_boxes_it_is_the_patient\u2019s_responsibility_to_know_insurance_eligibility_and_benefits_all_copays_deductibles_and_any_other_fee_are_due_the_day_of_service_no_exceptions_we_do_not_bill_the_patient\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"undefined[]\" id=\"check_boxes_it_is_the_patient\u2019s_responsibility_to_know_insurance_eligibility_and_benefits_all_copays_deductibles_and_any_other_fee_are_due_the_day_of_service_no_exceptions_we_do_not_bill_the_patient\" value=\"it is the patient\u2019s responsibility to know insurance eligibility and benefits. all copays, deductibles, and any other fee are due the day of service. no exceptions, we do not bill the patient.\" style=\"display: none\"><a class=\"ui-state-default\" style=\"background: #ffffff\"><\/a><\/div><span class=\"input-label check-label\">it is the patient\u2019s responsibility to know insurance eligibility and benefits. all copays, deductibles, and any other fee are due the day of service. no exceptions, we do not bill the patient.<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"check_boxes__all_patients_are_required_to_provide_a_financial_responsible_party_with_a_social_security_number_for_financial_responsibility_liability_in_case_of_payment_not_receive_within_a_timely_manner_after_120_days_the_account_will_be_sent_to_a_collection_agency_fees_will_apply_15\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"undefined[]\" id=\"check_boxes__all_patients_are_required_to_provide_a_financial_responsible_party_with_a_social_security_number_for_financial_responsibility_liability_in_case_of_payment_not_receive_within_a_timely_manner_after_120_days_the_account_will_be_sent_to_a_collection_agency_fees_will_apply_15\" value=\" all patients are required to provide a financial responsible party with a social security number for financial responsibility liability in case of payment not receive within a timely manner, after 120 days the account will be sent to a collection agency *fees will apply $15*\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\"> all patients are required to provide a financial responsible party with a social security number for financial responsibility liability in case of payment not receive within a timely manner, after 120 days the account will be sent to a collection agency *fees will apply $15*<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"check_boxes__it_is_the_patient\u2019s_responsibility_to_obtain_any_referral_or_authorizations_if_needed_prior_to_their_appointment\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"undefined[]\" id=\"check_boxes__it_is_the_patient\u2019s_responsibility_to_obtain_any_referral_or_authorizations_if_needed_prior_to_their_appointment\" value=\" it is the patient\u2019s responsibility to obtain any referral or authorizations if needed prior to their appointment.\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\"> it is the patient\u2019s responsibility to obtain any referral or authorizations if needed prior to their appointment.<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"check_boxes__if_you_arrive_to_your_appointment_15_minutes_late_or_later_your_appointment_will_be_rescheduled\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"undefined[]\" id=\"check_boxes__if_you_arrive_to_your_appointment_15_minutes_late_or_later_your_appointment_will_be_rescheduled\" value=\" if you arrive to your appointment 15 minutes late or later your appointment will be rescheduled.\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\"> if you arrive to your appointment 15 minutes late or later your appointment will be rescheduled.<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"check_boxes__it_is_the_patient\u2019s_responsibility_to_contact_our_office_if_you_are_not_able_to_keep_your_appointment_fees_will_apply\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"undefined[]\" id=\"check_boxes__it_is_the_patient\u2019s_responsibility_to_contact_our_office_if_you_are_not_able_to_keep_your_appointment_fees_will_apply\" value=\" it is the patient\u2019s responsibility to contact our office if you are not able to keep your appointment. *fees will apply*\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\"> it is the patient\u2019s responsibility to contact our office if you are not able to keep your appointment. *fees will apply*<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio_selected radio-inline\" for=\"check_boxes__it_is_the_patient\u2019s_responsibility_to_notify_our_office_with_any_new_information_regarding_the_patient_address_phone_number_insurance_etc\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"undefined[]\" id=\"check_boxes__it_is_the_patient\u2019s_responsibility_to_notify_our_office_with_any_new_information_regarding_the_patient_address_phone_number_insurance_etc\" value=\" it is the patient\u2019s responsibility to notify our office with any new information regarding the patient. (address, phone number, insurance etc.)\" style=\"display: none\"><a class=\"checked ui-state-active ui-state-default\" style=\"background: #8bc34a\"><\/a><span style=\"color:#ffffff\" class=\"check-icon checked fa fa-check\"><\/span><\/div><span class=\"input-label check-label\"> it is the patient\u2019s responsibility to notify our office with any new information regarding the patient. (address, phone number, insurance etc.)<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"check_boxes__all_calls_will_go_through_our_triage_department_the_triage_department_will_speak_with_our_providers_andor_the_ma\u2019s_regarding_your_concerns_and_they_will_contact_you_our_staff_are_not_able_to_speak_to_patients_over_the_phone_during_office_hours\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"undefined[]\" id=\"check_boxes__all_calls_will_go_through_our_triage_department_the_triage_department_will_speak_with_our_providers_andor_the_ma\u2019s_regarding_your_concerns_and_they_will_contact_you_our_staff_are_not_able_to_speak_to_patients_over_the_phone_during_office_hours\" value=\" all calls will go through our triage department. the triage department will speak with our providers and\/or the ma\u2019s regarding your concerns and they will contact you (our staff are not able to speak to patients over the phone during office hours).\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\"> all calls will go through our triage department. the triage department will speak with our providers and\/or the ma\u2019s regarding your concerns and they will contact you (our staff are not able to speak to patients over the phone during office hours).<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"check_boxes__when_requesting_a_letter_or_forms_to_be_filled_out_by_our_staff_please_allow_3_business_days_for_paperwork_or_letter_to_be_completed\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"undefined[]\" id=\"check_boxes__when_requesting_a_letter_or_forms_to_be_filled_out_by_our_staff_please_allow_3_business_days_for_paperwork_or_letter_to_be_completed\" value=\" when requesting a letter or forms to be filled out by our staff please allow 3 business days for paperwork or letter to be completed.\" style=\"display: none\"><a class=\"ui-state-default\" style=\"background: #ffffff\"><\/a><\/div><span class=\"input-label check-label\"> when requesting a letter or forms to be filled out by our staff please allow 3 business days for paperwork or letter to be completed.<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"check_boxes__when_requesting_medical_records_we_can_give_you_access_to_the_patient\u2019s_portal_if_a_printout_is_needed_allow_7_business_days_fees_will_apply\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"undefined[]\" id=\"check_boxes__when_requesting_medical_records_we_can_give_you_access_to_the_patient\u2019s_portal_if_a_printout_is_needed_allow_7_business_days_fees_will_apply\" value=\" when requesting medical records, we can give you access to the patient\u2019s portal. if a printout is needed allow 7 business days. *fees will apply*\" style=\"display: none\"><a class=\"fa ui-state-default\"><\/a><\/div><span class=\"input-label check-label\"> when requesting medical records, we can give you access to the patient\u2019s portal. if a printout is needed allow 7 business days. *fees will apply*<\/span><\/span><\/label><label class=\"checkbox-inline col-sm-12 display-block radio-inline\" for=\"check_boxes__our_office_reserve_the_right_to_deny_treatment_to_any_patient_whose_unable_to_follow_our_office_policy\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"undefined[]\" id=\"check_boxes__our_office_reserve_the_right_to_deny_treatment_to_any_patient_whose_unable_to_follow_our_office_policy\" value=\" our office reserve the right to deny treatment to any patient whose unable to follow our office policy.\" style=\"display: none\"><a class=\"ui-state-default\" style=\"background: #ffffff\"><\/a><\/div><span class=\"input-label check-label\"> our office reserve the right to deny treatment to any patient whose unable to follow our office policy.<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields paragraph paragraph html_fields\" style=\"margin-bottom: 15px\" data-id=\"_64077\" id=\"_64077\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\"><div class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">By signing this form, I hereby give my consent for Ciocca Dermatology, PA to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided describes such uses and disclosures more completely.) I have the right to review the Notice of Privacy Practices prior to signing this consent. Ciocca Dermatology reserves the right to revise its Notice of Privacy Practices at any time. I understand any charges, copays, coinsurance and deductibles will be collected at the time of service. If I do not sign this consent, or later revoke it Ciocca Dermatology, PA may decline to provide treatment to me. There is a NOSHow fee. All accounts past due will be send to collections, collections fee will apply.<br><br>By signing this form I have read and understood all of the office policy. I agree to follow all policies and understand if I don&#8217;t agree to the office policy I will not be accepted as a patient.<\/div><div style=\"clear:both\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields digital-signature special_fields required\" style=\"margin-bottom: 15px\" data-id=\"_72452\" id=\"_72452\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"label_container align_left col-sm-12\"><label class=\"nf_title \"><span class=\"the_label style_bold\" style=\"font-size: 13px;color: #9e9e9e\">*Your signature<\/span><small class=\"sub-text style_italic\">Sign Here<\/small><\/label><\/div><div class=\"input_container col-sm-12\"><textarea name=\"your_signature\" class=\"the_input_element digital-signature-data error_message align_left required\" data-content=\"Required\" style=\"font-size: 13px;color: #9e9e9e;background: white;border-color: #dddddd\"><\/textarea><div class=\"clear_digital_siganture\"><span class=\"fa fa-eraser\"><\/span><\/div><div class=\"js-signature\" data-width=\"550\" data-height=\"150\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields submit-button submit-button the_submit button_fields common_fields preset_fields special_fields selection_fields\" style=\"margin-bottom: 15px\" data-id=\"_65141\" id=\"_65141\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container align_center\"><button class=\"nex-submit svg_ready the_input_element btn btn-default add_shine btn-lg\" data-ga=\"\" style=\"border-width: 1px\">SUBMIT FORM<\/button><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><\/form><\/div><\/div><\/div><\/div><\/div><style type=\"text\/css\" class=\"nex-forms-custom-css\"><\/style><\/div><\/div><\/div>\t<div id=\"gap-401930298\" class=\"gap-element clearfix\" style=\"display:block; height:auto;\">\n\t\t\n<style>\n#gap-401930298 {\n  padding-top: 150px;\n}\n<\/style>\n\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\n\t<\/div>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2cdf9c1 elementor-widget elementor-widget-text-editor\" data-id=\"2cdf9c1\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<p><span style=\"color: #ffffff;\"><strong>Patient Registration: A Visionary Approach to Dermatological Care<\/strong><\/span><\/p><p><span style=\"color: #ffffff;\"><strong>A Dream Realized by Dr. Ciocca<\/strong><\/span><\/p><p><span style=\"color: #ffffff;\">Patient registration at Ciocca Dermatology is the embodiment of a visionary dream brought to life by our founder, Dr. Ciocca. Her mission was clear: to create a dermatology service that provides top-tier scientific care for patients of all ages, from newborns to seniors. This commitment to comprehensive care sets us apart, as we cater to families by offering services suitable for every age group.<\/span><\/p><p><span style=\"color: #ffffff;\"><strong>A Comprehensive and Inclusive Service<\/strong><\/span><\/p><p><span style=\"color: #ffffff;\">Unlike many dermatology practices that limit their patient base, Ciocca Dermatology is uniquely trained to serve patients across the lifespan. Whether a child with eczema or an adult with acne, our team is equipped to address the diverse needs of our patients. This inclusivity and expertise ensure that our services are truly comprehensive, providing effective dermatological care for everyone in the family.<\/span><\/p><p><span style=\"color: #ffffff;\"><strong>Our Dedication to Exceptional Care<\/strong><\/span><\/p><p><span style=\"color: #ffffff;\">Our team\u2019s dedication has been key to realizing Dr. Ciocca\u2019s vision. Through hard work, unwavering commitment, and collaborative effort, we have grown to become a leading provider of dermatological services. Our core mission is to offer outstanding care while ensuring our patients feel safe, secure, and supported. We recognize that skin conditions can affect not only physical health but also emotional and psychological well-being.<\/span><\/p><p><span style=\"color: #ffffff;\"><strong>Fostering Confidence and Well-Being<\/strong><\/span><\/p><p><span style=\"color: #ffffff;\">At Ciocca Dermatology, we strive to create a nurturing environment where patients feel cared for and valued. We believe in promoting the overall health and confidence of those<\/span> <span style=\"color: #ffffff;\">we serve, recognizing that exceptional dermatological care goes beyond the surface. Our goal is to improve not just the appearance of the skin, but also the confidence and peace<\/span> of mind of our patients.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-d8c4a49 elementor-widget elementor-widget-image\" data-id=\"d8c4a49\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.17.0 - 08-11-2023 *\/\n.elementor-widget-image{text-align:center}.elementor-widget-image a{display:inline-block}.elementor-widget-image a img[src$=\".svg\"]{width:48px}.elementor-widget-image img{vertical-align:middle;display:inline-block}<\/style>\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"110\" height=\"61\" src=\"https:\/\/cioccadermatology.com\/my_uploads\/2025\/03\/Screenshot-2025-03-15-064956-1.png\" class=\"attachment-large size-large wp-image-8954\" alt=\"Patient Registration Form\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Expert Dermatology Care for Healthy, Radiant Skin Our dedicated dermatology team prioritizes your skin\u2019s health, delivering exceptional care with a highly personalized and integrative approach. We combine cutting-edge treatments with compassionate service to ensure every patient receives the best possible care. Personalized, Compassionate Skin Care We foster a warm and welcoming environment where patients feel [&#8230;]\n","protected":false},"author":1,"featured_media":0,"parent":5489,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-blank.php","meta":{"inline_featured_image":false,"footnotes":""},"class_list":["post-5474","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.5 (Yoast SEO v24.5) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Patient Registration Form - Ciocca Dermatology<\/title>\n<meta name=\"description\" content=\"Patient Registration Form In order to serve you better, we ask you to complete the form below before your schedule appointment.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/cioccadermatology.com\/patient-registration-forms\/patient-registration-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Patient Registration Form\" \/>\n<meta property=\"og:description\" content=\"Patient Registration Form In order to serve you better, we ask you to complete the form below before your schedule appointment.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/cioccadermatology.com\/patient-registration-forms\/patient-registration-form\/\" \/>\n<meta property=\"og:site_name\" content=\"Ciocca Dermatology\" \/>\n<meta property=\"article:modified_time\" content=\"2025-03-15T01:15:15+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/cioccadermatology.com\/my_uploads\/2025\/03\/Screenshot-2025-03-15-064956-1.png\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"3 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/cioccadermatology.com\/patient-registration-forms\/patient-registration-form\/\",\"url\":\"https:\/\/cioccadermatology.com\/patient-registration-forms\/patient-registration-form\/\",\"name\":\"Patient Registration Form - 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