{"id":15613,"date":"2020-05-06T04:28:43","date_gmt":"2020-05-06T04:28:43","guid":{"rendered":"http:\/\/broches.queenofpcs.com\/?page_id=15613"},"modified":"2020-05-13T21:02:09","modified_gmt":"2020-05-14T01:02:09","slug":"medical-form","status":"publish","type":"page","link":"https:\/\/orthobrossard.com\/en\/medical-form\/","title":{"rendered":"Medical Form"},"content":{"rendered":"<p>[vc_row css_animation=&#8221;&#8221; row_type=&#8221;row&#8221; use_row_as_full_screen_section=&#8221;no&#8221; type=&#8221;grid&#8221; angled_section=&#8221;no&#8221; text_align=&#8221;left&#8221; background_image_as_pattern=&#8221;without_pattern&#8221; z_index=&#8221;&#8221;][vc_column]<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/en\/wp-json\/wp\/v2\/pages\/15613#gf_2' >\n        <div id='gf_progressbar_wrapper_2' class='gf_progressbar_wrapper'>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>5<\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body gform-body'><div id='gform_page_2_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_14\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_14\"><h2 class=\"gsection_title\">Basic Information<\/h2><div class='gsection_description' id='gfield_description_2_14'>To better serve you, please complete the form below. The form usually takes 5 to 15 minutes and gives you the best possible service. Thank you!<\/div><\/li><li id=\"field_2_2\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_2\"><label class='gfield_label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_2'>\n                            \n                            <span id='input_2_2_3_container' class='name_first' >\n                                                    <input type='text' name='input_2.3' id='input_2_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_2_3' >First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_2_6_container' class='name_last' >\n                                                    <input type='text' name='input_2.6' id='input_2_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_2_6' >Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_6\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\"><label class='gfield_label'  >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_6'>\n\t\t\t<li class='gchoice gchoice_2_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Male'  id='choice_2_6_0'    \/>\n\t\t\t\t<label for='choice_2_6_0' id='label_2_6_0'>Male<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='Female'  id='choice_2_6_1'    \/>\n\t\t\t\t<label for='choice_2_6_1' id='label_2_6_1'>Female<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_3\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\"><label class='gfield_label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_2_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_2_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_2_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_3_1' id='input_2_3_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_2_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_2_3_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_3_2' id='input_2_3_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_2_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_2_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_3_3' id='input_2_3_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_3_4_container' >\n                                        <select name='input_3.4' id='input_2_3_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_2_3_4' id='input_2_3_4_label' >Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_2_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_2_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_3_5' id='input_2_3_5_label' >Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_2_3_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_4\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_4\"><label class='gfield_label' for='input_2_4' >Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_2_4' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_5\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\"><label class='gfield_label' for='input_2_5' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_2_5' type='text' value='' class='medium'   placeholder='example@domain.com' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_8\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\"><label class='gfield_label' for='input_2_8' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_2_8' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_8_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_8' class='gform_hidden' value='https:\/\/orthobrossard.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_9\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\"><label class='gfield_label' for='input_2_9' >In an emergency, contact:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='medium'    placeholder='Name and phone of the person' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_10\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\"><label class='gfield_label' for='input_2_10' >Name of your dentist<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_11\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_11\"><label class='gfield_label' for='input_2_11' >Person who referred you<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_12\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_12\"><label class='gfield_label' for='input_2_12' >Reason for your visit<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_55' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_15\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\"><h2 class=\"gsection_title\">Medical History<\/h2><\/li><li id=\"field_2_23\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_23\"><label class='gfield_label'  >Are you currently followed by a doctor?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_23'>\n\t\t\t<li class='gchoice gchoice_2_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='Yes'  id='choice_2_23_0'    \/>\n\t\t\t\t<label for='choice_2_23_0' id='label_2_23_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='No'  id='choice_2_23_1'    \/>\n\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_17\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_17\"><label class='gfield_label' for='input_2_17' >Name of doctor, and phone number:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_25\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\"><label class='gfield_label'  >Do you currently take medication or in the last six months?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_25'>\n\t\t\t<li class='gchoice gchoice_2_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='Yes'  id='choice_2_25_0'    \/>\n\t\t\t\t<label for='choice_2_25_0' id='label_2_25_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='No'  id='choice_2_25_1'    \/>\n\t\t\t\t<label for='choice_2_25_1' id='label_2_25_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_19\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_19\"><label class='gfield_label' for='input_2_19' >Please list all medications:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_2_19' class='textarea medium'    placeholder='Enter the names and the dose.' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_56' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_56' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_20\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\"><h2 class=\"gsection_title\">Have you ever suffered or are you suffering from...<\/h2><\/li><li id=\"field_2_21\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_21\"><label class='gfield_label'  >Cardiac disorders (myocardial infarction, angina, valve problems, breathing problems)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_21'>\n\t\t\t<li class='gchoice gchoice_2_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Yes'  id='choice_2_21_0'    \/>\n\t\t\t\t<label for='choice_2_21_0' id='label_2_21_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='No'  id='choice_2_21_1'    \/>\n\t\t\t\t<label for='choice_2_21_1' id='label_2_21_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_22\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_22\"><label class='gfield_label'  >Rheumatic fever?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_22'>\n\t\t\t<li class='gchoice gchoice_2_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Yes'  id='choice_2_22_0'    \/>\n\t\t\t\t<label for='choice_2_22_0' id='label_2_22_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='No'  id='choice_2_22_1'    \/>\n\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_26\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_26\"><label class='gfield_label'  >Prolonged bleeding?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_26'>\n\t\t\t<li class='gchoice gchoice_2_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='Yes'  id='choice_2_26_0'    \/>\n\t\t\t\t<label for='choice_2_26_0' id='label_2_26_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='No'  id='choice_2_26_1'    \/>\n\t\t\t\t<label for='choice_2_26_1' id='label_2_26_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_27\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_27\"><label class='gfield_label'  >Anemia?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_27'>\n\t\t\t<li class='gchoice gchoice_2_27_0'>\n\t\t\t\t<input name='input_27' type='radio' value='Yes'  id='choice_2_27_0'    \/>\n\t\t\t\t<label for='choice_2_27_0' id='label_2_27_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_27_1'>\n\t\t\t\t<input name='input_27' type='radio' value='No'  id='choice_2_27_1'    \/>\n\t\t\t\t<label for='choice_2_27_1' id='label_2_27_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_28\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_28\"><label class='gfield_label'  >Blood pressure?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_28'>\n\t\t\t<li class='gchoice gchoice_2_28_0'>\n\t\t\t\t<input name='input_28' type='radio' value='Yes'  id='choice_2_28_0'    \/>\n\t\t\t\t<label for='choice_2_28_0' id='label_2_28_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_28_1'>\n\t\t\t\t<input name='input_28' type='radio' value='No'  id='choice_2_28_1'    \/>\n\t\t\t\t<label for='choice_2_28_1' id='label_2_28_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_29\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_29\"><label class='gfield_label'  >Frequent colds or sinusitis?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_29'>\n\t\t\t<li class='gchoice gchoice_2_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='Yes'  id='choice_2_29_0'    \/>\n\t\t\t\t<label for='choice_2_29_0' id='label_2_29_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='No'  id='choice_2_29_1'    \/>\n\t\t\t\t<label for='choice_2_29_1' id='label_2_29_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_30\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_30\"><label class='gfield_label'  >Tuberculosis or lung problems?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_30'>\n\t\t\t<li class='gchoice gchoice_2_30_0'>\n\t\t\t\t<input name='input_30' type='radio' value='Yes'  id='choice_2_30_0'    \/>\n\t\t\t\t<label for='choice_2_30_0' id='label_2_30_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_30_1'>\n\t\t\t\t<input name='input_30' type='radio' value='No'  id='choice_2_30_1'    \/>\n\t\t\t\t<label for='choice_2_30_1' id='label_2_30_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_31\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_31\"><label class='gfield_label'  >Stomach problems, digestive disorders?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_31'>\n\t\t\t<li class='gchoice gchoice_2_31_0'>\n\t\t\t\t<input name='input_31' type='radio' value='Yes'  id='choice_2_31_0'    \/>\n\t\t\t\t<label for='choice_2_31_0' id='label_2_31_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_31_1'>\n\t\t\t\t<input name='input_31' type='radio' value='No'  id='choice_2_31_1'    \/>\n\t\t\t\t<label for='choice_2_31_1' id='label_2_31_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_32\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_32\"><label class='gfield_label'  >Liver problems (hepatitis A, B, C, cirrhosis)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_32'>\n\t\t\t<li class='gchoice gchoice_2_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Yes'  id='choice_2_32_0'    \/>\n\t\t\t\t<label for='choice_2_32_0' id='label_2_32_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='No'  id='choice_2_32_1'    \/>\n\t\t\t\t<label for='choice_2_32_1' id='label_2_32_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_33\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_33\"><label class='gfield_label'  >Kidney problems?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_33'>\n\t\t\t<li class='gchoice gchoice_2_33_0'>\n\t\t\t\t<input name='input_33' type='radio' value='Yes'  id='choice_2_33_0'    \/>\n\t\t\t\t<label for='choice_2_33_0' id='label_2_33_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_33_1'>\n\t\t\t\t<input name='input_33' type='radio' value='No'  id='choice_2_33_1'    \/>\n\t\t\t\t<label for='choice_2_33_1' id='label_2_33_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_34\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_34\"><label class='gfield_label'  >Diabetes?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_34'>\n\t\t\t<li class='gchoice gchoice_2_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Yes'  id='choice_2_34_0'    \/>\n\t\t\t\t<label for='choice_2_34_0' id='label_2_34_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='No'  id='choice_2_34_1'    \/>\n\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_35\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_35\"><label class='gfield_label'  >Thyroid problems?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_35'>\n\t\t\t<li class='gchoice gchoice_2_35_0'>\n\t\t\t\t<input name='input_35' type='radio' value='Yes'  id='choice_2_35_0'    \/>\n\t\t\t\t<label for='choice_2_35_0' id='label_2_35_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_35_1'>\n\t\t\t\t<input name='input_35' type='radio' value='No'  id='choice_2_35_1'    \/>\n\t\t\t\t<label for='choice_2_35_1' id='label_2_35_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_36\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_36\"><label class='gfield_label'  >Skin diseases?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_36'>\n\t\t\t<li class='gchoice gchoice_2_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='Yes'  id='choice_2_36_0'    \/>\n\t\t\t\t<label for='choice_2_36_0' id='label_2_36_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='No'  id='choice_2_36_1'    \/>\n\t\t\t\t<label for='choice_2_36_1' id='label_2_36_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_37\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_37\"><label class='gfield_label'  >Eye Problems?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_37'>\n\t\t\t<li class='gchoice gchoice_2_37_0'>\n\t\t\t\t<input name='input_37' type='radio' value='Yes'  id='choice_2_37_0'    \/>\n\t\t\t\t<label for='choice_2_37_0' id='label_2_37_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_37_1'>\n\t\t\t\t<input name='input_37' type='radio' value='No'  id='choice_2_37_1'    \/>\n\t\t\t\t<label for='choice_2_37_1' id='label_2_37_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_38\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_38\"><label class='gfield_label'  >Arthritis?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_38'>\n\t\t\t<li class='gchoice gchoice_2_38_0'>\n\t\t\t\t<input name='input_38' type='radio' value='Yes'  id='choice_2_38_0'    \/>\n\t\t\t\t<label for='choice_2_38_0' id='label_2_38_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_38_1'>\n\t\t\t\t<input name='input_38' type='radio' value='No'  id='choice_2_38_1'    \/>\n\t\t\t\t<label for='choice_2_38_1' id='label_2_38_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_39\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_39\"><label class='gfield_label'  >Epilepsy?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_39'>\n\t\t\t<li class='gchoice gchoice_2_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='Yes'  id='choice_2_39_0'    \/>\n\t\t\t\t<label for='choice_2_39_0' id='label_2_39_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='No'  id='choice_2_39_1'    \/>\n\t\t\t\t<label for='choice_2_39_1' id='label_2_39_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_40\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_40\"><label class='gfield_label'  >Frequent headaches?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_40'>\n\t\t\t<li class='gchoice gchoice_2_40_0'>\n\t\t\t\t<input name='input_40' type='radio' value='Yes'  id='choice_2_40_0'    \/>\n\t\t\t\t<label for='choice_2_40_0' id='label_2_40_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_40_1'>\n\t\t\t\t<input name='input_40' type='radio' value='No'  id='choice_2_40_1'    \/>\n\t\t\t\t<label for='choice_2_40_1' id='label_2_40_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_41\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_41\"><label class='gfield_label'  >Dizziness, fainting?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_41'>\n\t\t\t<li class='gchoice gchoice_2_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='Yes'  id='choice_2_41_0'    \/>\n\t\t\t\t<label for='choice_2_41_0' id='label_2_41_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='No'  id='choice_2_41_1'    \/>\n\t\t\t\t<label for='choice_2_41_1' id='label_2_41_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_42\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_42\"><label class='gfield_label'  >Earache?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_42'>\n\t\t\t<li class='gchoice gchoice_2_42_0'>\n\t\t\t\t<input name='input_42' type='radio' value='Yes'  id='choice_2_42_0'    \/>\n\t\t\t\t<label for='choice_2_42_0' id='label_2_42_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_42_1'>\n\t\t\t\t<input name='input_42' type='radio' value='No'  id='choice_2_42_1'    \/>\n\t\t\t\t<label for='choice_2_42_1' id='label_2_42_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_43\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_43\"><label class='gfield_label'  >Asthma?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_43'>\n\t\t\t<li class='gchoice gchoice_2_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='Yes'  id='choice_2_43_0'    \/>\n\t\t\t\t<label for='choice_2_43_0' id='label_2_43_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='No'  id='choice_2_43_1'    \/>\n\t\t\t\t<label for='choice_2_43_1' id='label_2_43_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_44\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_44\"><label class='gfield_label'  >Sleep apnea?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_44'>\n\t\t\t<li class='gchoice gchoice_2_44_0'>\n\t\t\t\t<input name='input_44' type='radio' value='Yes'  id='choice_2_44_0'    \/>\n\t\t\t\t<label for='choice_2_44_0' id='label_2_44_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_44_1'>\n\t\t\t\t<input name='input_44' type='radio' value='No'  id='choice_2_44_1'    \/>\n\t\t\t\t<label for='choice_2_44_1' id='label_2_44_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_45\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_45\"><label class='gfield_label'  >Are you a smoker?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_45'>\n\t\t\t<li class='gchoice gchoice_2_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='Yes'  id='choice_2_45_0'    \/>\n\t\t\t\t<label for='choice_2_45_0' id='label_2_45_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='No'  id='choice_2_45_1'    \/>\n\t\t\t\t<label for='choice_2_45_1' id='label_2_45_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_46\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_46\"><label class='gfield_label'  >Have you ever had radiation treatment or chemotherapy?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_46'>\n\t\t\t<li class='gchoice gchoice_2_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Yes'  id='choice_2_46_0'    \/>\n\t\t\t\t<label for='choice_2_46_0' id='label_2_46_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='No'  id='choice_2_46_1'    \/>\n\t\t\t\t<label for='choice_2_46_1' id='label_2_46_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_47\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_47\"><label class='gfield_label'  >Do you have artificial joints?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_47'>\n\t\t\t<li class='gchoice gchoice_2_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='Yes'  id='choice_2_47_0'    \/>\n\t\t\t\t<label for='choice_2_47_0' id='label_2_47_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='No'  id='choice_2_47_1'    \/>\n\t\t\t\t<label for='choice_2_47_1' id='label_2_47_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_48\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_48\"><label class='gfield_label'  >Do you have any allergies to food or medications?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_48'>\n\t\t\t<li class='gchoice gchoice_2_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='Yes'  id='choice_2_48_0'    \/>\n\t\t\t\t<label for='choice_2_48_0' id='label_2_48_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='No'  id='choice_2_48_1'    \/>\n\t\t\t\t<label for='choice_2_48_1' id='label_2_48_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_49\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_49\"><label class='gfield_label' for='input_2_49' >Do you have an allergy to latex or any metal?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_49' id='input_2_49' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_51\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_51\"><label class='gfield_label'  >Do you have an allergy to latex or any metal?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_51'>\n\t\t\t<li class='gchoice gchoice_2_51_0'>\n\t\t\t\t<input name='input_51' type='radio' value='Yes'  id='choice_2_51_0'    \/>\n\t\t\t\t<label for='choice_2_51_0' id='label_2_51_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_51_1'>\n\t\t\t\t<input name='input_51' type='radio' value='No'  id='choice_2_51_1'    \/>\n\t\t\t\t<label for='choice_2_51_1' id='label_2_51_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_52\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_52\"><label class='gfield_label'  >Have you ever been hospitalized or undergone surgery other than dental?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_52'>\n\t\t\t<li class='gchoice gchoice_2_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='Yes'  id='choice_2_52_0'    \/>\n\t\t\t\t<label for='choice_2_52_0' id='label_2_52_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='No'  id='choice_2_52_1'    \/>\n\t\t\t\t<label for='choice_2_52_1' id='label_2_52_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_53\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_53\"><label class='gfield_label' for='input_2_53' >Please describe the date, surgery type, doctor and hospital:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_2_53' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_54\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_54\"><label class='gfield_label' for='input_2_54' >Comments:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_54' id='input_2_54' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_58' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_58' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_4' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_57\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_57\"><h2 class=\"gsection_title\">Dental History<\/h2><\/li><li id=\"field_2_60\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_60\"><label class='gfield_label' for='input_2_60' >Last dental visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_2_60' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='0-6 months' >0-6 months<\/option><option value='6-12 months' >6-12 months<\/option><option value='12 months or more' >12 months or more<\/option><\/select><\/div><\/li><li id=\"field_2_61\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_61\"><label class='gfield_label' for='input_2_61' >Treatments received<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_61' id='input_2_61' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_62\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_62\"><label class='gfield_label'  >Do you have pain in the mouth or joints?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_62'>\n\t\t\t<li class='gchoice gchoice_2_62_0'>\n\t\t\t\t<input name='input_62' type='radio' value='Yes'  id='choice_2_62_0'    \/>\n\t\t\t\t<label for='choice_2_62_0' id='label_2_62_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_62_1'>\n\t\t\t\t<input name='input_62' type='radio' value='No'  id='choice_2_62_1'    \/>\n\t\t\t\t<label for='choice_2_62_1' id='label_2_62_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_63\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_63\"><label class='gfield_label'  >Have any permanent teeth been removed?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_63'>\n\t\t\t<li class='gchoice gchoice_2_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='Yes'  id='choice_2_63_0'    \/>\n\t\t\t\t<label for='choice_2_63_0' id='label_2_63_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='No'  id='choice_2_63_1'    \/>\n\t\t\t\t<label for='choice_2_63_1' id='label_2_63_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_64\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_64\"><label class='gfield_label'  >Have any permanent teeth been injured or chipped by an accident?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_64'>\n\t\t\t<li class='gchoice gchoice_2_64_0'>\n\t\t\t\t<input name='input_64' type='radio' value='Yes'  id='choice_2_64_0'    \/>\n\t\t\t\t<label for='choice_2_64_0' id='label_2_64_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_64_1'>\n\t\t\t\t<input name='input_64' type='radio' value='No'  id='choice_2_64_1'    \/>\n\t\t\t\t<label for='choice_2_64_1' id='label_2_64_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_65\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_65\"><label class='gfield_label'  >Do you have any head or face injuries?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_65'>\n\t\t\t<li class='gchoice gchoice_2_65_0'>\n\t\t\t\t<input name='input_65' type='radio' value='Yes'  id='choice_2_65_0'    \/>\n\t\t\t\t<label for='choice_2_65_0' id='label_2_65_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_65_1'>\n\t\t\t\t<input name='input_65' type='radio' value='No'  id='choice_2_65_1'    \/>\n\t\t\t\t<label for='choice_2_65_1' id='label_2_65_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_66\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_66\"><label class='gfield_label'  >Do you have any speech problems?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_66'>\n\t\t\t<li class='gchoice gchoice_2_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='Yes'  id='choice_2_66_0'    \/>\n\t\t\t\t<label for='choice_2_66_0' id='label_2_66_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='No'  id='choice_2_66_1'    \/>\n\t\t\t\t<label for='choice_2_66_1' id='label_2_66_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_68\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_68\"><label class='gfield_label'  >Have you ever sucked a thumb or fingers?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_68'>\n\t\t\t<li class='gchoice gchoice_2_68_0'>\n\t\t\t\t<input name='input_68' type='radio' value='Yes'  id='choice_2_68_0'    \/>\n\t\t\t\t<label for='choice_2_68_0' id='label_2_68_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_68_1'>\n\t\t\t\t<input name='input_68' type='radio' value='No'  id='choice_2_68_1'    \/>\n\t\t\t\t<label for='choice_2_68_1' id='label_2_68_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_67\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_67\"><label class='gfield_label' for='input_2_67' >Until what age?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_67' id='input_2_67' type='text'    value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_2_69\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_69\"><label class='gfield_label'  >Do you breathe predominantly by the mouth?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_69'>\n\t\t\t<li class='gchoice gchoice_2_69_0'>\n\t\t\t\t<input name='input_69' type='radio' value='Yes'  id='choice_2_69_0'    \/>\n\t\t\t\t<label for='choice_2_69_0' id='label_2_69_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_69_1'>\n\t\t\t\t<input name='input_69' type='radio' value='No'  id='choice_2_69_1'    \/>\n\t\t\t\t<label for='choice_2_69_1' id='label_2_69_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_70\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_70\"><label class='gfield_label'  >Do you have tongue thrust?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_70'>\n\t\t\t<li class='gchoice gchoice_2_70_0'>\n\t\t\t\t<input name='input_70' type='radio' value='Yes'  id='choice_2_70_0'    \/>\n\t\t\t\t<label for='choice_2_70_0' id='label_2_70_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_70_1'>\n\t\t\t\t<input name='input_70' type='radio' value='No'  id='choice_2_70_1'    \/>\n\t\t\t\t<label for='choice_2_70_1' id='label_2_70_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_71\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_71\"><label class='gfield_label'  >Do you grind or clench teeth?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_71'>\n\t\t\t<li class='gchoice gchoice_2_71_0'>\n\t\t\t\t<input name='input_71' type='radio' value='Yes'  id='choice_2_71_0'    \/>\n\t\t\t\t<label for='choice_2_71_0' id='label_2_71_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_71_1'>\n\t\t\t\t<input name='input_71' type='radio' value='No'  id='choice_2_71_1'    \/>\n\t\t\t\t<label for='choice_2_71_1' id='label_2_71_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_72\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_72\"><label class='gfield_label'  >Do you play a wind instrument?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_72'>\n\t\t\t<li class='gchoice gchoice_2_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='Yes'  id='choice_2_72_0'    \/>\n\t\t\t\t<label for='choice_2_72_0' id='label_2_72_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='No'  id='choice_2_72_1'    \/>\n\t\t\t\t<label for='choice_2_72_1' id='label_2_72_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_73\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_73\"><label class='gfield_label'  >Have you seen another orthodontist?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_73'>\n\t\t\t<li class='gchoice gchoice_2_73_0'>\n\t\t\t\t<input name='input_73' type='radio' value='Yes'  id='choice_2_73_0'    \/>\n\t\t\t\t<label for='choice_2_73_0' id='label_2_73_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_73_1'>\n\t\t\t\t<input name='input_73' type='radio' value='No'  id='choice_2_73_1'    \/>\n\t\t\t\t<label for='choice_2_73_1' id='label_2_73_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_74\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_74\"><label class='gfield_label'  >Do you have any recent radiographs? (x-rays)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_74'>\n\t\t\t<li class='gchoice gchoice_2_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='Yes'  id='choice_2_74_0'    \/>\n\t\t\t\t<label for='choice_2_74_0' id='label_2_74_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='No'  id='choice_2_74_1'    \/>\n\t\t\t\t<label for='choice_2_74_1' id='label_2_74_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_75\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_75\"><label class='gfield_label'  >Do you have any clicking, cracking or pain in jaw?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_75'>\n\t\t\t<li class='gchoice gchoice_2_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='Yes'  id='choice_2_75_0'    \/>\n\t\t\t\t<label for='choice_2_75_0' id='label_2_75_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='No'  id='choice_2_75_1'    \/>\n\t\t\t\t<label for='choice_2_75_1' id='label_2_75_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_76' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_76' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_5' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_77\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_77\"><h2 class=\"gsection_title\">Have you ever had the following dental treatment or services...<\/h2><\/li><li id=\"field_2_78\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_78\"><label class='gfield_label'  >Demonstration of oral hygiene?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_78'>\n\t\t\t<li class='gchoice gchoice_2_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='Yes'  id='choice_2_78_0'    \/>\n\t\t\t\t<label for='choice_2_78_0' id='label_2_78_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='No'  id='choice_2_78_1'    \/>\n\t\t\t\t<label for='choice_2_78_1' id='label_2_78_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_79\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_79\"><label class='gfield_label'  >Gum treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_79'>\n\t\t\t<li class='gchoice gchoice_2_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='Yes'  id='choice_2_79_0'    \/>\n\t\t\t\t<label for='choice_2_79_0' id='label_2_79_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='No'  id='choice_2_79_1'    \/>\n\t\t\t\t<label for='choice_2_79_1' id='label_2_79_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_81\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_81\"><label class='gfield_label'  >Orthodontic treatment (braces)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_81'>\n\t\t\t<li class='gchoice gchoice_2_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='Yes'  id='choice_2_81_0'    \/>\n\t\t\t\t<label for='choice_2_81_0' id='label_2_81_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='No'  id='choice_2_81_1'    \/>\n\t\t\t\t<label for='choice_2_81_1' id='label_2_81_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_80\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_80\"><label class='gfield_label'  >Root canal?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_80'>\n\t\t\t<li class='gchoice gchoice_2_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='Yes'  id='choice_2_80_0'    \/>\n\t\t\t\t<label for='choice_2_80_0' id='label_2_80_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='No'  id='choice_2_80_1'    \/>\n\t\t\t\t<label for='choice_2_80_1' id='label_2_80_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_83\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_83\"><label class='gfield_label'  >Dental surgery or extraction?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_83'>\n\t\t\t<li class='gchoice gchoice_2_83_0'>\n\t\t\t\t<input name='input_83' type='radio' value='Yes'  id='choice_2_83_0'    \/>\n\t\t\t\t<label for='choice_2_83_0' id='label_2_83_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_83_1'>\n\t\t\t\t<input name='input_83' type='radio' value='No'  id='choice_2_83_1'    \/>\n\t\t\t\t<label for='choice_2_83_1' id='label_2_83_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_82\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_82\"><label class='gfield_label'  >Dental implants?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_82'>\n\t\t\t<li class='gchoice gchoice_2_82_0'>\n\t\t\t\t<input name='input_82' type='radio' value='Yes'  id='choice_2_82_0'    \/>\n\t\t\t\t<label for='choice_2_82_0' id='label_2_82_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_82_1'>\n\t\t\t\t<input name='input_82' type='radio' value='No'  id='choice_2_82_1'    \/>\n\t\t\t\t<label for='choice_2_82_1' id='label_2_82_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_84\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_84\"><label class='gfield_label' for='input_2_84' >CAPTCHA<\/label><div id='input_2_84' class='ginput_container ginput_recaptcha' data-sitekey='6LegAfYUAAAAAIP_ySWbx2RwwNZ-5OUfi4RbrKmP'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_2' class='gform_previous_button button' value='Previous'  onclick='if(window[\"gf_submitting_2\"]){return false;}  window[\"gf_submitting_2\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} window[\"gf_submitting_2\"]=true;  jQuery(\"#gform_2\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_2' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_2\"]){return false;}  window[\"gf_submitting_2\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} window[\"gf_submitting_2\"]=true;  jQuery(\"#gform_2\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='WyJbXSIsIjJlNzA0NjE2YWQxM2YzMTk5MzFlYmRhOGIwNjc5NmEzIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div>[\/vc_column][\/vc_row][vc_row css_animation=&#8221;&#8221; row_type=&#8221;row&#8221; use_row_as_full_screen_section=&#8221;no&#8221; type=&#8221;grid&#8221; angled_section=&#8221;no&#8221; text_align=&#8221;left&#8221; background_image_as_pattern=&#8221;without_pattern&#8221; background_color=&#8221;#494949&#8243; z_index=&#8221;&#8221; el_class=&#8221;call_to_action_footer_fix&#8221;][vc_column]<div class=\"call_to_action normal\" style=\"background-color: rgba(0,0,0,0.01);\"><div class=\"two_columns_75_25 clearfix\"><div class=\"text_wrapper column1\"><div class=\"call_to_action_text \" style=\"\">Contact us today to book a consultation!<\/div><\/div><div class=\"button_wrapper column2\"><a itemprop=\"url\" href=\"\/en\/contact\/\" class=\"qbutton white \" target=\"\" style=\"\" >Book a consultation<\/a><\/div><\/div><\/div>[\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>[vc_row css_animation=&#8221;&#8221; row_type=&#8221;row&#8221; use_row_as_full_screen_section=&#8221;no&#8221; type=&#8221;grid&#8221; angled_section=&#8221;no&#8221; text_align=&#8221;left&#8221; background_image_as_pattern=&#8221;without_pattern&#8221; z_index=&#8221;&#8221;][vc_column][\/vc_column][\/vc_row][vc_row css_animation=&#8221;&#8221; row_type=&#8221;row&#8221; use_row_as_full_screen_section=&#8221;no&#8221; type=&#8221;grid&#8221; angled_section=&#8221;no&#8221; text_align=&#8221;left&#8221; background_image_as_pattern=&#8221;without_pattern&#8221; background_color=&#8221;#494949&#8243; z_index=&#8221;&#8221; 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