{"id":590,"date":"2016-01-15T16:06:03","date_gmt":"2016-01-15T21:06:03","guid":{"rendered":"http:\/\/new.cornerstonedentalva.com\/?page_id=590"},"modified":"2017-08-16T12:20:32","modified_gmt":"2017-08-16T16:20:32","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/cornerstonedentalva.com\/patient-forms\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"<ul>\n<li><a target=\"_blank\" href=\"https:\/\/cornerstonedentalva.com\/wp-content\/uploads\/2017\/01\/Privacy-Practices-and-Financial-Policy.pdf\">Privacy Practices and Financial Policy<br \/>\n<\/a><\/li>\n<li><a target=\"_blank\" href=\"https:\/\/cornerstonedentalva.com\/wp-content\/uploads\/2017\/08\/newpatient-cornerstone.pdf\">New Patient Information Form<\/a><\/li>\n<\/ul>\n<h3>Alternatively, you may complete the new patient form below.<\/h3>\n<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_chrome gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_4' style='display:none'><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_4' id='gform_4'  action='\/wp-json\/wp\/v2\/pages\/590#gf_4' ><div id='gf_page_steps_4' class='gf_page_steps'><div id='gf_step_4_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Patient Information<\/span><\/div><div id='gf_step_4_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Insurance Information<\/span><\/div><div id='gf_step_4_3' class='gf_step gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'>Phone Numbers<\/span><\/div><div id='gf_step_4_4' class='gf_step gf_step_pending'><span class='gf_step_number'>4<\/span><span class='gf_step_label'>Dental History<\/span><\/div><div id='gf_step_4_5' class='gf_step gf_step_pending'><span class='gf_step_number'>5<\/span><span class='gf_step_label'>Health History<\/span><\/div><div id='gf_step_4_6' class='gf_step gf_step_pending'><span class='gf_step_number'>6<\/span><span class='gf_step_label'>Medications, Supplements, Remedies & Allergies<\/span><\/div><div id='gf_step_4_7' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>7<\/span><span class='gf_step_label'>Physicians<\/span><\/div><\/div>\n                        <div class='gform_body gform-body'><div id='gform_page_4_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_4_2\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_2' >Todays Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_4_2' type='text' value='04\/23\/2024' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_2_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_2' class='gform_hidden' value='https:\/\/cornerstonedentalva.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_4\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Patient 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_4_4'>\n                            \n                            <span id='input_4_4_3_container' class='name_first' >\n                                                    <input type='text' name='input_4.3' id='input_4_4_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_4_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_4_6_container' class='name_last' >\n                                                    <input type='text' name='input_4.6' id='input_4_4_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_4_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_182\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_182' >Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_182' id='input_4_182' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Married' >Married<\/option><option value='Widowed' >Widowed<\/option><option value='Single' >Single<\/option><option value='Minor' >Minor<\/option><option value='Separated' >Separated<\/option><option value='Divorced' >Divorced<\/option><option value='Partenered' >Partenered<\/option><\/select><\/div><\/li><li id=\"field_4_179\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_179' >Preferred Name<\/label><div class='ginput_container ginput_container_text'><input name='input_179' id='input_4_179' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_6\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_6' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_4_6' type='text' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_4_10\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_10' >Birth Date<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_10' id='input_4_10' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_10_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_10' class='gform_hidden' value='https:\/\/cornerstonedentalva.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_9\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_9' >Age<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_4_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_8\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Sex<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_4_8'>\n\t\t\t<li class='gchoice gchoice_4_8_0'>\n\t\t\t\t<input name='input_8' type='radio' value='Male'  id='choice_4_8_0'    \/>\n\t\t\t\t<label for='choice_4_8_0' id='label_4_8_0'>Male<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_8_1'>\n\t\t\t\t<input name='input_8' type='radio' value='Female'  id='choice_4_8_1'    \/>\n\t\t\t\t<label for='choice_4_8_1' id='label_4_8_1'>Female<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_3\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_3' >SSN<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_4_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_183\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_183' >Cell 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_183' id='input_4_183' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_184\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_184' >Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_184' id='input_4_184' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_185\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_185' >Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_185' id='input_4_185' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_186\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Best way to contact you for appointment reminders:<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_4_186'>\n\t\t\t<li class='gchoice gchoice_4_186_0'>\n\t\t\t\t<input name='input_186' type='radio' value='Email'  id='choice_4_186_0'    \/>\n\t\t\t\t<label for='choice_4_186_0' id='label_4_186_0'>Email<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_186_1'>\n\t\t\t\t<input name='input_186' type='radio' value='Text'  id='choice_4_186_1'    \/>\n\t\t\t\t<label for='choice_4_186_1' id='label_4_186_1'>Text<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><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_4_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_4_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_4_5_1' value=''    aria-required='true'    \/>\n                                        <label for='input_4_5_1' id='input_4_5_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_4_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_4_5_2' value=''     aria-required='false'   \/>\n                                        <label for='input_4_5_2' id='input_4_5_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_4_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_4_5_3' value=''    aria-required='true'    \/>\n                                    <label for='input_4_5_3' id='input_4_5_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_4_5_4_container' >\n                                        <select name='input_5.4' id='input_4_5_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' selected='selected'>Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_5_4' id='input_4_5_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_4_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_4_5_5' value=''    aria-required='true'    \/>\n                                    <label for='input_4_5_5' id='input_4_5_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_4_5_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_13\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_13' >Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_4_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_12\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_12' >Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_4_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_15\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_15' >Employer&#039;s Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_4_15' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_14\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Employer&#039;s Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_4_14' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_4_14_1_container' >\n                                        <input type='text' name='input_14.1' id='input_4_14_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_14_1' id='input_4_14_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_4_14_2_container' >\n                                        <input type='text' name='input_14.2' id='input_4_14_2' value=''     aria-required='false'   \/>\n                                        <label for='input_4_14_2' id='input_4_14_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_4_14_3_container' >\n                                    <input type='text' name='input_14.3' id='input_4_14_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_14_3' id='input_4_14_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_4_14_4_container' >\n                                        <select name='input_14.4' id='input_4_14_4'     aria-required='false'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' selected='selected'>Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_14_4' id='input_4_14_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_4_14_5_container' >\n                                    <input type='text' name='input_14.5' id='input_4_14_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_14_5' id='input_4_14_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_14.6' id='input_4_14_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_16\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Spouse&#039;s Name<\/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_4_16'>\n                            \n                            <span id='input_4_16_3_container' class='name_first' >\n                                                    <input type='text' name='input_16.3' id='input_4_16_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_16_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_16_6_container' class='name_last' >\n                                                    <input type='text' name='input_16.6' id='input_4_16_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_16_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_17\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_17' >Spouse&#039;s Birth Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_17' id='input_4_17' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_17_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_17_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_17' class='gform_hidden' value='https:\/\/cornerstonedentalva.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_19\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_19' >Spouse&#039;s SS#<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_4_19' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_187\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_187' >Spouse&#039;s Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_187' id='input_4_187' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_20\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_20' >Spouse&#039;s Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_4_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_21\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_21' >Whom may we thank for referring you?<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_4_21' 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_4_22' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_4\").val(\"2\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_4\").val(\"2\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_4_23\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_23' >Who is the subscriber for your dental insurance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_4_23' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_28\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Subscriber&#039;s 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_4_28'>\n                            \n                            <span id='input_4_28_3_container' class='name_first' >\n                                                    <input type='text' name='input_28.3' id='input_4_28_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_28_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_28_6_container' class='name_last' >\n                                                    <input type='text' name='input_28.6' id='input_4_28_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_28_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_30\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_30' >SS#<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_4_30' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_24\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_24' >Relationship to Patient<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_4_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_25\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_25' >Insurance Co<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_4_25' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_180\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_180' >ID #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_180' id='input_4_180' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_26\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_26' >Group #<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_4_26' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_29\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_29' >Birth Date<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_29' id='input_4_29' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_29_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_29_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_29' class='gform_hidden' value='https:\/\/cornerstonedentalva.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_31\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_31' >Relationship to Patient<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_4_31' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_32\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_32' >Insurance Co<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_4_32' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_33\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_33' >Group #<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_4_33' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_181\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Is patient covered by additional insurance?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_181'>\n\t\t\t<li class='gchoice gchoice_4_181_0'>\n\t\t\t\t<input name='input_181' type='radio' value='Yes'  id='choice_4_181_0'    \/>\n\t\t\t\t<label for='choice_4_181_0' id='label_4_181_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_181_1'>\n\t\t\t\t<input name='input_181' type='radio' value='No'  id='choice_4_181_1'    \/>\n\t\t\t\t<label for='choice_4_181_1' id='label_4_181_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_34\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h3>Assignment and Release<\/h3>\n<p>I Certify that I, and\/or my dependent(s), have insurance coverage with the following Insurance Company(ies) and assign directly to <span>Cornerstone Dental<\/span> all insurance benefits, of any, otherwise payable to me for services rendered. I Understand that I am financially responsible for all charges whetehr or not paid by insurance. I authorize the use of my signature on all insurance submissions.<\/p><\/li><li id=\"field_4_173\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_173' >Name of Insurance Company(ies)<\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_4_173' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_174\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >I give my permission to Cornorstone Dental and its affiliates to use and disclose my health care information to the Insurance Company (ies) I so designate and their agents for the purpose of determining insurance benfits, obtaining payment for services, or the benefits payable for related services.<\/li><li id=\"field_4_35\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Name of Patient, Parent, Guardian or Personal Representative<\/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_4_35'>\n                            \n                            <span id='input_4_35_3_container' class='name_first' >\n                                                    <input type='text' name='input_35.3' id='input_4_35_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_35_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_35_6_container' class='name_last' >\n                                                    <input type='text' name='input_35.6' id='input_4_35_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_35_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_36\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_36' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_36' id='input_4_36' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'    aria-describedby=\"input_4_36_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_36_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_36' class='gform_hidden' value='https:\/\/cornerstonedentalva.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_37\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_37' >Relationship to Patient<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_4_37' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_188\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_188' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_4_188_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_4_188_valid' id='input_4_188_valid' \/><canvas id='input_4_188' width='300' height='180'><\/canvas><\/div><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_38' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_4\").val(\"1\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_4\").val(\"1\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_4_38' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_4\").val(\"3\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_4\").val(\"3\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_4_39\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_39' >Home 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_39' id='input_4_39' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_40\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_40' >Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_40' id='input_4_40' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_175\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_175' >Extension<\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_4_175' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_41\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_41' >Cell 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_41' id='input_4_41' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_42\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_42' >Spouse&#039;s Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_42' id='input_4_42' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_43\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_43' >Best time and place to reach you<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_4_43' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_44\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h3>In case of emergency, Contact<\/h3>\n<p>(Specify someone who does not live in your household)<\/p><\/li><li id=\"field_4_45\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><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_4_45'>\n                            \n                            <span id='input_4_45_3_container' class='name_first' >\n                                                    <input type='text' name='input_45.3' id='input_4_45_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_45_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_45_6_container' class='name_last' >\n                                                    <input type='text' name='input_45.6' id='input_4_45_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_45_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_46\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_46' >Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_4_46' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_47\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_47' >Home 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_47' id='input_4_47' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_48\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_48' >Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_48' id='input_4_48' 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_previous_button_4_49' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_4\").val(\"2\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_4\").val(\"2\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_4_49' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_4\").val(\"4\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_4\").val(\"4\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_4' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_4_50\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_50' >Reason for today&#039;s visit<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_4_50' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_51\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_51' >Former Dentist<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_4_51' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_52\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_52' >City \/ State<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_4_52' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_53\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_53' >Date of last dental visit<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_53' id='input_4_53' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_53_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_53_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_53' class='gform_hidden' value='https:\/\/cornerstonedentalva.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_54\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_54' >Date of last dental X-rays<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_54' id='input_4_54' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_54_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_54_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_54' class='gform_hidden' value='https:\/\/cornerstonedentalva.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_55\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>Place a mark on 'Yes' or \"No' to indicate if you had any of the following:<\/li><li id=\"field_4_56\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Bad Breath<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_4_56'>\n\t\t\t<li class='gchoice gchoice_4_56_0'>\n\t\t\t\t<input name='input_56' type='radio' value='Yes'  id='choice_4_56_0'    \/>\n\t\t\t\t<label for='choice_4_56_0' id='label_4_56_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_56_1'>\n\t\t\t\t<input name='input_56' type='radio' value='No'  id='choice_4_56_1'    \/>\n\t\t\t\t<label for='choice_4_56_1' id='label_4_56_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_57\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Bleeding gums<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_4_57'>\n\t\t\t<li class='gchoice gchoice_4_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='Yes'  id='choice_4_57_0'    \/>\n\t\t\t\t<label for='choice_4_57_0' id='label_4_57_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='No'  id='choice_4_57_1'    \/>\n\t\t\t\t<label for='choice_4_57_1' id='label_4_57_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_58\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Blisters on lips or mouth<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_4_58'>\n\t\t\t<li class='gchoice gchoice_4_58_0'>\n\t\t\t\t<input name='input_58' type='radio' value='Yes'  id='choice_4_58_0'    \/>\n\t\t\t\t<label for='choice_4_58_0' id='label_4_58_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_58_1'>\n\t\t\t\t<input name='input_58' type='radio' value='No'  id='choice_4_58_1'    \/>\n\t\t\t\t<label for='choice_4_58_1' id='label_4_58_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_59\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Are you happy with your smile?<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_4_59'>\n\t\t\t<li class='gchoice gchoice_4_59_0'>\n\t\t\t\t<input name='input_59' type='radio' value='Yes'  id='choice_4_59_0'    \/>\n\t\t\t\t<label for='choice_4_59_0' id='label_4_59_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_59_1'>\n\t\t\t\t<input name='input_59' type='radio' value='No'  id='choice_4_59_1'    \/>\n\t\t\t\t<label for='choice_4_59_1' id='label_4_59_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_60\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Burning sensation on tongue<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_4_60'>\n\t\t\t<li class='gchoice gchoice_4_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='Yes'  id='choice_4_60_0'    \/>\n\t\t\t\t<label for='choice_4_60_0' id='label_4_60_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='No'  id='choice_4_60_1'    \/>\n\t\t\t\t<label for='choice_4_60_1' id='label_4_60_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_61\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Chew on one side of mouth<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_4_61'>\n\t\t\t<li class='gchoice gchoice_4_61_0'>\n\t\t\t\t<input name='input_61' type='radio' value='Yes'  id='choice_4_61_0'    \/>\n\t\t\t\t<label for='choice_4_61_0' id='label_4_61_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_61_1'>\n\t\t\t\t<input name='input_61' type='radio' value='No'  id='choice_4_61_1'    \/>\n\t\t\t\t<label for='choice_4_61_1' id='label_4_61_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_62\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Cigarette, pipe or cigar smoking<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_4_62'>\n\t\t\t<li class='gchoice gchoice_4_62_0'>\n\t\t\t\t<input name='input_62' type='radio' value='Yes'  id='choice_4_62_0'    \/>\n\t\t\t\t<label for='choice_4_62_0' id='label_4_62_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_62_1'>\n\t\t\t\t<input name='input_62' type='radio' value='No'  id='choice_4_62_1'    \/>\n\t\t\t\t<label for='choice_4_62_1' id='label_4_62_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_63\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >clicking or popping jaw<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_4_63'>\n\t\t\t<li class='gchoice gchoice_4_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='Yes'  id='choice_4_63_0'    \/>\n\t\t\t\t<label for='choice_4_63_0' id='label_4_63_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='No'  id='choice_4_63_1'    \/>\n\t\t\t\t<label for='choice_4_63_1' id='label_4_63_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_64\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Dry mouth<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_4_64'>\n\t\t\t<li class='gchoice gchoice_4_64_0'>\n\t\t\t\t<input name='input_64' type='radio' value='Yes'  id='choice_4_64_0'    \/>\n\t\t\t\t<label for='choice_4_64_0' id='label_4_64_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_64_1'>\n\t\t\t\t<input name='input_64' type='radio' value='No'  id='choice_4_64_1'    \/>\n\t\t\t\t<label for='choice_4_64_1' id='label_4_64_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_65\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Fingernail biting<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_4_65'>\n\t\t\t<li class='gchoice gchoice_4_65_0'>\n\t\t\t\t<input name='input_65' type='radio' value='Yes'  id='choice_4_65_0'    \/>\n\t\t\t\t<label for='choice_4_65_0' id='label_4_65_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_65_1'>\n\t\t\t\t<input name='input_65' type='radio' value='No'  id='choice_4_65_1'    \/>\n\t\t\t\t<label for='choice_4_65_1' id='label_4_65_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_66\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Food collection between the teeth<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_4_66'>\n\t\t\t<li class='gchoice gchoice_4_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='Yes'  id='choice_4_66_0'    \/>\n\t\t\t\t<label for='choice_4_66_0' id='label_4_66_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='No'  id='choice_4_66_1'    \/>\n\t\t\t\t<label for='choice_4_66_1' id='label_4_66_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_67\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Foreign objects<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_4_67'>\n\t\t\t<li class='gchoice gchoice_4_67_0'>\n\t\t\t\t<input name='input_67' type='radio' value='Yes'  id='choice_4_67_0'    \/>\n\t\t\t\t<label for='choice_4_67_0' id='label_4_67_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_67_1'>\n\t\t\t\t<input name='input_67' type='radio' value='No'  id='choice_4_67_1'    \/>\n\t\t\t\t<label for='choice_4_67_1' id='label_4_67_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_68\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Grinding teeth<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_4_68'>\n\t\t\t<li class='gchoice gchoice_4_68_0'>\n\t\t\t\t<input name='input_68' type='radio' value='Yes'  id='choice_4_68_0'    \/>\n\t\t\t\t<label for='choice_4_68_0' id='label_4_68_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_68_1'>\n\t\t\t\t<input name='input_68' type='radio' value='No'  id='choice_4_68_1'    \/>\n\t\t\t\t<label for='choice_4_68_1' id='label_4_68_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_69\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Gums swollen or tender<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_4_69'>\n\t\t\t<li class='gchoice gchoice_4_69_0'>\n\t\t\t\t<input name='input_69' type='radio' value='Yes'  id='choice_4_69_0'    \/>\n\t\t\t\t<label for='choice_4_69_0' id='label_4_69_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_69_1'>\n\t\t\t\t<input name='input_69' type='radio' value='No'  id='choice_4_69_1'    \/>\n\t\t\t\t<label for='choice_4_69_1' id='label_4_69_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_70\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Jaw pain or tiredness<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_4_70'>\n\t\t\t<li class='gchoice gchoice_4_70_0'>\n\t\t\t\t<input name='input_70' type='radio' value='Yes'  id='choice_4_70_0'    \/>\n\t\t\t\t<label for='choice_4_70_0' id='label_4_70_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_70_1'>\n\t\t\t\t<input name='input_70' type='radio' value='No'  id='choice_4_70_1'    \/>\n\t\t\t\t<label for='choice_4_70_1' id='label_4_70_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_71\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Lip or cheek biting<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_4_71'>\n\t\t\t<li class='gchoice gchoice_4_71_0'>\n\t\t\t\t<input name='input_71' type='radio' value='Yes'  id='choice_4_71_0'    \/>\n\t\t\t\t<label for='choice_4_71_0' id='label_4_71_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_71_1'>\n\t\t\t\t<input name='input_71' type='radio' value='No'  id='choice_4_71_1'    \/>\n\t\t\t\t<label for='choice_4_71_1' id='label_4_71_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_72\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Loose teeth or broken fillings<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_4_72'>\n\t\t\t<li class='gchoice gchoice_4_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='Yes'  id='choice_4_72_0'    \/>\n\t\t\t\t<label for='choice_4_72_0' id='label_4_72_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='No'  id='choice_4_72_1'    \/>\n\t\t\t\t<label for='choice_4_72_1' id='label_4_72_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_73\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Mouth breathing<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_4_73'>\n\t\t\t<li class='gchoice gchoice_4_73_0'>\n\t\t\t\t<input name='input_73' type='radio' value='Yes'  id='choice_4_73_0'    \/>\n\t\t\t\t<label for='choice_4_73_0' id='label_4_73_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_73_1'>\n\t\t\t\t<input name='input_73' type='radio' value='No'  id='choice_4_73_1'    \/>\n\t\t\t\t<label for='choice_4_73_1' id='label_4_73_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_74\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Mouth pain, brushing<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_4_74'>\n\t\t\t<li class='gchoice gchoice_4_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='Yes'  id='choice_4_74_0'    \/>\n\t\t\t\t<label for='choice_4_74_0' id='label_4_74_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='No'  id='choice_4_74_1'    \/>\n\t\t\t\t<label for='choice_4_74_1' id='label_4_74_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_75\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Orthodontic treatment<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_4_75'>\n\t\t\t<li class='gchoice gchoice_4_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='Yes'  id='choice_4_75_0'    \/>\n\t\t\t\t<label for='choice_4_75_0' id='label_4_75_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='No'  id='choice_4_75_1'    \/>\n\t\t\t\t<label for='choice_4_75_1' id='label_4_75_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_76\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Pain around ear<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_4_76'>\n\t\t\t<li class='gchoice gchoice_4_76_0'>\n\t\t\t\t<input name='input_76' type='radio' value='Yes'  id='choice_4_76_0'    \/>\n\t\t\t\t<label for='choice_4_76_0' id='label_4_76_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_76_1'>\n\t\t\t\t<input name='input_76' type='radio' value='No'  id='choice_4_76_1'    \/>\n\t\t\t\t<label for='choice_4_76_1' id='label_4_76_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_77\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Periodontal treatment<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_4_77'>\n\t\t\t<li class='gchoice gchoice_4_77_0'>\n\t\t\t\t<input name='input_77' type='radio' value='Yes'  id='choice_4_77_0'    \/>\n\t\t\t\t<label for='choice_4_77_0' id='label_4_77_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_77_1'>\n\t\t\t\t<input name='input_77' type='radio' value='No'  id='choice_4_77_1'    \/>\n\t\t\t\t<label for='choice_4_77_1' id='label_4_77_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_78\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Sensitivity to cold<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_4_78'>\n\t\t\t<li class='gchoice gchoice_4_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='Yes'  id='choice_4_78_0'    \/>\n\t\t\t\t<label for='choice_4_78_0' id='label_4_78_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='No'  id='choice_4_78_1'    \/>\n\t\t\t\t<label for='choice_4_78_1' id='label_4_78_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_79\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Sensitivity to heat<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_4_79'>\n\t\t\t<li class='gchoice gchoice_4_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='Yes'  id='choice_4_79_0'    \/>\n\t\t\t\t<label for='choice_4_79_0' id='label_4_79_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='No'  id='choice_4_79_1'    \/>\n\t\t\t\t<label for='choice_4_79_1' id='label_4_79_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_80\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Sensitivity to sweets<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_4_80'>\n\t\t\t<li class='gchoice gchoice_4_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='Yes'  id='choice_4_80_0'    \/>\n\t\t\t\t<label for='choice_4_80_0' id='label_4_80_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='No'  id='choice_4_80_1'    \/>\n\t\t\t\t<label for='choice_4_80_1' id='label_4_80_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_81\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Sensitivity when biting<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_4_81'>\n\t\t\t<li class='gchoice gchoice_4_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='Yes'  id='choice_4_81_0'    \/>\n\t\t\t\t<label for='choice_4_81_0' id='label_4_81_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='No'  id='choice_4_81_1'    \/>\n\t\t\t\t<label for='choice_4_81_1' id='label_4_81_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_82\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Sores or growths in your mouth<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_4_82'>\n\t\t\t<li class='gchoice gchoice_4_82_0'>\n\t\t\t\t<input name='input_82' type='radio' value='Yes'  id='choice_4_82_0'    \/>\n\t\t\t\t<label for='choice_4_82_0' id='label_4_82_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_82_1'>\n\t\t\t\t<input name='input_82' type='radio' value='No'  id='choice_4_82_1'    \/>\n\t\t\t\t<label for='choice_4_82_1' id='label_4_82_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_83\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_83' >How often do you floss?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_4_83' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_84\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_84' >How often do you brush?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_4_84' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_85\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Do you have any dental concerns you would like to discuss?<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_4_85'>\n\t\t\t<li class='gchoice gchoice_4_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='Yes'  id='choice_4_85_0'    \/>\n\t\t\t\t<label for='choice_4_85_0' id='label_4_85_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='No'  id='choice_4_85_1'    \/>\n\t\t\t\t<label for='choice_4_85_1' id='label_4_85_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_4_86' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_4\").val(\"3\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_4\").val(\"3\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_4_86' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_4\").val(\"5\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_4\").val(\"5\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_5' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_4_87\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_87' >Primary Care Physician&#039;s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_4_87' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_88\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_88' >Primary Care Physician&#039;s Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_88' id='input_4_88' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_89\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_89' >Date of last visit<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_89' id='input_4_89' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_89_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_89_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_89' class='gform_hidden' value='https:\/\/cornerstonedentalva.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_90\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Have you ever taken any of the group of drugs collectively referred to as &quot;fen-phen&quot;? These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_90'>\n\t\t\t<li class='gchoice gchoice_4_90_0'>\n\t\t\t\t<input name='input_90' type='radio' value='Yes'  id='choice_4_90_0'    \/>\n\t\t\t\t<label for='choice_4_90_0' id='label_4_90_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_90_1'>\n\t\t\t\t<input name='input_90' type='radio' value='No'  id='choice_4_90_1'    \/>\n\t\t\t\t<label for='choice_4_90_1' id='label_4_90_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_91\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>Place a mark on 'Yes' or \"No' to indicate if you had any of the following:<\/li><li id=\"field_4_92\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >AIDS \/ HIV<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_4_92'>\n\t\t\t<li class='gchoice gchoice_4_92_0'>\n\t\t\t\t<input name='input_92' type='radio' value='Yes'  id='choice_4_92_0'    \/>\n\t\t\t\t<label for='choice_4_92_0' id='label_4_92_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_92_1'>\n\t\t\t\t<input name='input_92' type='radio' value='No'  id='choice_4_92_1'    \/>\n\t\t\t\t<label for='choice_4_92_1' id='label_4_92_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_93\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Anemia<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_4_93'>\n\t\t\t<li class='gchoice gchoice_4_93_0'>\n\t\t\t\t<input name='input_93' type='radio' value='Yes'  id='choice_4_93_0'    \/>\n\t\t\t\t<label for='choice_4_93_0' id='label_4_93_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_93_1'>\n\t\t\t\t<input name='input_93' type='radio' value='No'  id='choice_4_93_1'    \/>\n\t\t\t\t<label for='choice_4_93_1' id='label_4_93_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_94\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Arthritis, Rheumatism<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_4_94'>\n\t\t\t<li class='gchoice gchoice_4_94_0'>\n\t\t\t\t<input name='input_94' type='radio' value='Yes'  id='choice_4_94_0'    \/>\n\t\t\t\t<label for='choice_4_94_0' id='label_4_94_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_94_1'>\n\t\t\t\t<input name='input_94' type='radio' value='No'  id='choice_4_94_1'    \/>\n\t\t\t\t<label for='choice_4_94_1' id='label_4_94_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_95\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Artificial Heart Valves<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_4_95'>\n\t\t\t<li class='gchoice gchoice_4_95_0'>\n\t\t\t\t<input name='input_95' type='radio' value='Yes'  id='choice_4_95_0'    \/>\n\t\t\t\t<label for='choice_4_95_0' id='label_4_95_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_95_1'>\n\t\t\t\t<input name='input_95' type='radio' value='No'  id='choice_4_95_1'    \/>\n\t\t\t\t<label for='choice_4_95_1' id='label_4_95_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_96\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Artificial Joints<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_4_96'>\n\t\t\t<li class='gchoice gchoice_4_96_0'>\n\t\t\t\t<input name='input_96' type='radio' value='Yes'  id='choice_4_96_0'    \/>\n\t\t\t\t<label for='choice_4_96_0' id='label_4_96_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_96_1'>\n\t\t\t\t<input name='input_96' type='radio' value='No'  id='choice_4_96_1'    \/>\n\t\t\t\t<label for='choice_4_96_1' id='label_4_96_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_97\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Asthma<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_4_97'>\n\t\t\t<li class='gchoice gchoice_4_97_0'>\n\t\t\t\t<input name='input_97' type='radio' value='Yes'  id='choice_4_97_0'    \/>\n\t\t\t\t<label for='choice_4_97_0' id='label_4_97_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_97_1'>\n\t\t\t\t<input name='input_97' type='radio' value='No'  id='choice_4_97_1'    \/>\n\t\t\t\t<label for='choice_4_97_1' id='label_4_97_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_98\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Back Problems<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_4_98'>\n\t\t\t<li class='gchoice gchoice_4_98_0'>\n\t\t\t\t<input name='input_98' type='radio' value='Yes'  id='choice_4_98_0'    \/>\n\t\t\t\t<label for='choice_4_98_0' id='label_4_98_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_98_1'>\n\t\t\t\t<input name='input_98' type='radio' value='No'  id='choice_4_98_1'    \/>\n\t\t\t\t<label for='choice_4_98_1' id='label_4_98_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_99\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Bleeding abnormally, with extractions or surgery<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_4_99'>\n\t\t\t<li class='gchoice gchoice_4_99_0'>\n\t\t\t\t<input name='input_99' type='radio' value='Yes'  id='choice_4_99_0'    \/>\n\t\t\t\t<label for='choice_4_99_0' id='label_4_99_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_99_1'>\n\t\t\t\t<input name='input_99' type='radio' value='No'  id='choice_4_99_1'    \/>\n\t\t\t\t<label for='choice_4_99_1' id='label_4_99_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_100\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Blood Disease<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_4_100'>\n\t\t\t<li class='gchoice gchoice_4_100_0'>\n\t\t\t\t<input name='input_100' type='radio' value='Yes'  id='choice_4_100_0'    \/>\n\t\t\t\t<label for='choice_4_100_0' id='label_4_100_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_100_1'>\n\t\t\t\t<input name='input_100' type='radio' value='No'  id='choice_4_100_1'    \/>\n\t\t\t\t<label for='choice_4_100_1' id='label_4_100_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_101\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Cancer<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_4_101'>\n\t\t\t<li class='gchoice gchoice_4_101_0'>\n\t\t\t\t<input name='input_101' type='radio' value='Yes'  id='choice_4_101_0'    \/>\n\t\t\t\t<label for='choice_4_101_0' id='label_4_101_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_101_1'>\n\t\t\t\t<input name='input_101' type='radio' value='No'  id='choice_4_101_1'    \/>\n\t\t\t\t<label for='choice_4_101_1' id='label_4_101_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_102\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Chemical Dependency<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_4_102'>\n\t\t\t<li class='gchoice gchoice_4_102_0'>\n\t\t\t\t<input name='input_102' type='radio' value='Yes'  id='choice_4_102_0'    \/>\n\t\t\t\t<label for='choice_4_102_0' id='label_4_102_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_102_1'>\n\t\t\t\t<input name='input_102' type='radio' value='No'  id='choice_4_102_1'    \/>\n\t\t\t\t<label for='choice_4_102_1' id='label_4_102_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_103\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Chemotheraphy<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_4_103'>\n\t\t\t<li class='gchoice gchoice_4_103_0'>\n\t\t\t\t<input name='input_103' type='radio' value='Yes'  id='choice_4_103_0'    \/>\n\t\t\t\t<label for='choice_4_103_0' id='label_4_103_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_103_1'>\n\t\t\t\t<input name='input_103' type='radio' value='No'  id='choice_4_103_1'    \/>\n\t\t\t\t<label for='choice_4_103_1' id='label_4_103_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_104\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Circulatory Problems<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_4_104'>\n\t\t\t<li class='gchoice gchoice_4_104_0'>\n\t\t\t\t<input name='input_104' type='radio' value='Yes'  id='choice_4_104_0'    \/>\n\t\t\t\t<label for='choice_4_104_0' id='label_4_104_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_104_1'>\n\t\t\t\t<input name='input_104' type='radio' value='No'  id='choice_4_104_1'    \/>\n\t\t\t\t<label for='choice_4_104_1' id='label_4_104_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_105\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Congenial heart Lesions<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_4_105'>\n\t\t\t<li class='gchoice gchoice_4_105_0'>\n\t\t\t\t<input name='input_105' type='radio' value='Yes'  id='choice_4_105_0'    \/>\n\t\t\t\t<label for='choice_4_105_0' id='label_4_105_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_105_1'>\n\t\t\t\t<input name='input_105' type='radio' value='No'  id='choice_4_105_1'    \/>\n\t\t\t\t<label for='choice_4_105_1' id='label_4_105_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_106\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Cortisone treatments<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_4_106'>\n\t\t\t<li class='gchoice gchoice_4_106_0'>\n\t\t\t\t<input name='input_106' type='radio' value='Yes'  id='choice_4_106_0'    \/>\n\t\t\t\t<label for='choice_4_106_0' id='label_4_106_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_106_1'>\n\t\t\t\t<input name='input_106' type='radio' value='No'  id='choice_4_106_1'    \/>\n\t\t\t\t<label for='choice_4_106_1' id='label_4_106_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_107\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Cough, persistent or bloody<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_4_107'>\n\t\t\t<li class='gchoice gchoice_4_107_0'>\n\t\t\t\t<input name='input_107' type='radio' value='Yes'  id='choice_4_107_0'    \/>\n\t\t\t\t<label for='choice_4_107_0' id='label_4_107_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_107_1'>\n\t\t\t\t<input name='input_107' type='radio' value='No'  id='choice_4_107_1'    \/>\n\t\t\t\t<label for='choice_4_107_1' id='label_4_107_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_108\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Diabetes<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_4_108'>\n\t\t\t<li class='gchoice gchoice_4_108_0'>\n\t\t\t\t<input name='input_108' type='radio' value='Yes'  id='choice_4_108_0'    \/>\n\t\t\t\t<label for='choice_4_108_0' id='label_4_108_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_108_1'>\n\t\t\t\t<input name='input_108' type='radio' value='No'  id='choice_4_108_1'    \/>\n\t\t\t\t<label for='choice_4_108_1' id='label_4_108_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_109\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Emphysema<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_4_109'>\n\t\t\t<li class='gchoice gchoice_4_109_0'>\n\t\t\t\t<input name='input_109' type='radio' value='Yes'  id='choice_4_109_0'    \/>\n\t\t\t\t<label for='choice_4_109_0' id='label_4_109_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_109_1'>\n\t\t\t\t<input name='input_109' type='radio' value='No'  id='choice_4_109_1'    \/>\n\t\t\t\t<label for='choice_4_109_1' id='label_4_109_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_110\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Epilepsy<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_4_110'>\n\t\t\t<li class='gchoice gchoice_4_110_0'>\n\t\t\t\t<input name='input_110' type='radio' value='Yes'  id='choice_4_110_0'    \/>\n\t\t\t\t<label for='choice_4_110_0' id='label_4_110_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_110_1'>\n\t\t\t\t<input name='input_110' type='radio' value='No'  id='choice_4_110_1'    \/>\n\t\t\t\t<label for='choice_4_110_1' id='label_4_110_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_111\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Fainting or dizziness<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_4_111'>\n\t\t\t<li class='gchoice gchoice_4_111_0'>\n\t\t\t\t<input name='input_111' type='radio' value='Yes'  id='choice_4_111_0'    \/>\n\t\t\t\t<label for='choice_4_111_0' id='label_4_111_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_111_1'>\n\t\t\t\t<input name='input_111' type='radio' value='No'  id='choice_4_111_1'    \/>\n\t\t\t\t<label for='choice_4_111_1' id='label_4_111_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_112\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Glaucoma<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_4_112'>\n\t\t\t<li class='gchoice gchoice_4_112_0'>\n\t\t\t\t<input name='input_112' type='radio' value='Yes'  id='choice_4_112_0'    \/>\n\t\t\t\t<label for='choice_4_112_0' id='label_4_112_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_112_1'>\n\t\t\t\t<input name='input_112' type='radio' value='No'  id='choice_4_112_1'    \/>\n\t\t\t\t<label for='choice_4_112_1' id='label_4_112_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_113\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Headaches<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_4_113'>\n\t\t\t<li class='gchoice gchoice_4_113_0'>\n\t\t\t\t<input name='input_113' type='radio' value='Yes'  id='choice_4_113_0'    \/>\n\t\t\t\t<label for='choice_4_113_0' id='label_4_113_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_113_1'>\n\t\t\t\t<input name='input_113' type='radio' value='No'  id='choice_4_113_1'    \/>\n\t\t\t\t<label for='choice_4_113_1' id='label_4_113_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_114\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Heart Murmur<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_4_114'>\n\t\t\t<li class='gchoice gchoice_4_114_0'>\n\t\t\t\t<input name='input_114' type='radio' value='Yes'  id='choice_4_114_0'    \/>\n\t\t\t\t<label for='choice_4_114_0' id='label_4_114_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_114_1'>\n\t\t\t\t<input name='input_114' type='radio' value='No'  id='choice_4_114_1'    \/>\n\t\t\t\t<label for='choice_4_114_1' id='label_4_114_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_115\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Heart Problems<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_4_115'>\n\t\t\t<li class='gchoice gchoice_4_115_0'>\n\t\t\t\t<input name='input_115' type='radio' value='Yes'  id='choice_4_115_0'    \/>\n\t\t\t\t<label for='choice_4_115_0' id='label_4_115_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_115_1'>\n\t\t\t\t<input name='input_115' type='radio' value='No'  id='choice_4_115_1'    \/>\n\t\t\t\t<label for='choice_4_115_1' id='label_4_115_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_116\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Hepatitis<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_4_116'>\n\t\t\t<li class='gchoice gchoice_4_116_0'>\n\t\t\t\t<input name='input_116' type='radio' value='Yes'  id='choice_4_116_0'    \/>\n\t\t\t\t<label for='choice_4_116_0' id='label_4_116_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_116_1'>\n\t\t\t\t<input name='input_116' type='radio' value='No'  id='choice_4_116_1'    \/>\n\t\t\t\t<label for='choice_4_116_1' id='label_4_116_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_178\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_178' >Hepatitis Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_178' id='input_4_178' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_117\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Herpes<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_4_117'>\n\t\t\t<li class='gchoice gchoice_4_117_0'>\n\t\t\t\t<input name='input_117' type='radio' value='Yes'  id='choice_4_117_0'    \/>\n\t\t\t\t<label for='choice_4_117_0' id='label_4_117_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_117_1'>\n\t\t\t\t<input name='input_117' type='radio' value='No'  id='choice_4_117_1'    \/>\n\t\t\t\t<label for='choice_4_117_1' id='label_4_117_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_118\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >High blood pressure<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_4_118'>\n\t\t\t<li class='gchoice gchoice_4_118_0'>\n\t\t\t\t<input name='input_118' type='radio' value='Yes'  id='choice_4_118_0'    \/>\n\t\t\t\t<label for='choice_4_118_0' id='label_4_118_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_118_1'>\n\t\t\t\t<input name='input_118' type='radio' value='No'  id='choice_4_118_1'    \/>\n\t\t\t\t<label for='choice_4_118_1' id='label_4_118_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_119\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Jaundice<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_4_119'>\n\t\t\t<li class='gchoice gchoice_4_119_0'>\n\t\t\t\t<input name='input_119' type='radio' value='Yes'  id='choice_4_119_0'    \/>\n\t\t\t\t<label for='choice_4_119_0' id='label_4_119_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_119_1'>\n\t\t\t\t<input name='input_119' type='radio' value='No'  id='choice_4_119_1'    \/>\n\t\t\t\t<label for='choice_4_119_1' id='label_4_119_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_120\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Jaw pain<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_4_120'>\n\t\t\t<li class='gchoice gchoice_4_120_0'>\n\t\t\t\t<input name='input_120' type='radio' value='Yes'  id='choice_4_120_0'    \/>\n\t\t\t\t<label for='choice_4_120_0' id='label_4_120_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_120_1'>\n\t\t\t\t<input name='input_120' type='radio' value='No'  id='choice_4_120_1'    \/>\n\t\t\t\t<label for='choice_4_120_1' id='label_4_120_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_121\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Kidney Disease<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_4_121'>\n\t\t\t<li class='gchoice gchoice_4_121_0'>\n\t\t\t\t<input name='input_121' type='radio' value='Yes'  id='choice_4_121_0'    \/>\n\t\t\t\t<label for='choice_4_121_0' id='label_4_121_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_121_1'>\n\t\t\t\t<input name='input_121' type='radio' value='No'  id='choice_4_121_1'    \/>\n\t\t\t\t<label for='choice_4_121_1' id='label_4_121_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_122\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Liver Disease<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_4_122'>\n\t\t\t<li class='gchoice gchoice_4_122_0'>\n\t\t\t\t<input name='input_122' type='radio' value='Yes'  id='choice_4_122_0'    \/>\n\t\t\t\t<label for='choice_4_122_0' id='label_4_122_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_122_1'>\n\t\t\t\t<input name='input_122' type='radio' value='No'  id='choice_4_122_1'    \/>\n\t\t\t\t<label for='choice_4_122_1' id='label_4_122_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_123\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Low blood pressure<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_4_123'>\n\t\t\t<li class='gchoice gchoice_4_123_0'>\n\t\t\t\t<input name='input_123' type='radio' value='Yes'  id='choice_4_123_0'    \/>\n\t\t\t\t<label for='choice_4_123_0' id='label_4_123_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_123_1'>\n\t\t\t\t<input name='input_123' type='radio' value='No'  id='choice_4_123_1'    \/>\n\t\t\t\t<label for='choice_4_123_1' id='label_4_123_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_124\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Mitral valve prolapse<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_4_124'>\n\t\t\t<li class='gchoice gchoice_4_124_0'>\n\t\t\t\t<input name='input_124' type='radio' value='Yes'  id='choice_4_124_0'    \/>\n\t\t\t\t<label for='choice_4_124_0' id='label_4_124_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_124_1'>\n\t\t\t\t<input name='input_124' type='radio' value='No'  id='choice_4_124_1'    \/>\n\t\t\t\t<label for='choice_4_124_1' id='label_4_124_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_125\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Nervous problems<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_4_125'>\n\t\t\t<li class='gchoice gchoice_4_125_0'>\n\t\t\t\t<input name='input_125' type='radio' value='Yes'  id='choice_4_125_0'    \/>\n\t\t\t\t<label for='choice_4_125_0' id='label_4_125_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_125_1'>\n\t\t\t\t<input name='input_125' type='radio' value='No'  id='choice_4_125_1'    \/>\n\t\t\t\t<label for='choice_4_125_1' id='label_4_125_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_126\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Pacemaker<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_4_126'>\n\t\t\t<li class='gchoice gchoice_4_126_0'>\n\t\t\t\t<input name='input_126' type='radio' value='Yes'  id='choice_4_126_0'    \/>\n\t\t\t\t<label for='choice_4_126_0' id='label_4_126_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_126_1'>\n\t\t\t\t<input name='input_126' type='radio' value='No'  id='choice_4_126_1'    \/>\n\t\t\t\t<label for='choice_4_126_1' id='label_4_126_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_127\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Psychiatric care<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_4_127'>\n\t\t\t<li class='gchoice gchoice_4_127_0'>\n\t\t\t\t<input name='input_127' type='radio' value='Yes'  id='choice_4_127_0'    \/>\n\t\t\t\t<label for='choice_4_127_0' id='label_4_127_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_127_1'>\n\t\t\t\t<input name='input_127' type='radio' value='No'  id='choice_4_127_1'    \/>\n\t\t\t\t<label for='choice_4_127_1' id='label_4_127_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_128\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Radiation treatment<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_4_128'>\n\t\t\t<li class='gchoice gchoice_4_128_0'>\n\t\t\t\t<input name='input_128' type='radio' value='Yes'  id='choice_4_128_0'    \/>\n\t\t\t\t<label for='choice_4_128_0' id='label_4_128_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_128_1'>\n\t\t\t\t<input name='input_128' type='radio' value='No'  id='choice_4_128_1'    \/>\n\t\t\t\t<label for='choice_4_128_1' id='label_4_128_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_129\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Respiratory Disease<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_4_129'>\n\t\t\t<li class='gchoice gchoice_4_129_0'>\n\t\t\t\t<input name='input_129' type='radio' value='Yes'  id='choice_4_129_0'    \/>\n\t\t\t\t<label for='choice_4_129_0' id='label_4_129_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_129_1'>\n\t\t\t\t<input name='input_129' type='radio' value='No'  id='choice_4_129_1'    \/>\n\t\t\t\t<label for='choice_4_129_1' id='label_4_129_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_130\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Rheumatic fever<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_4_130'>\n\t\t\t<li class='gchoice gchoice_4_130_0'>\n\t\t\t\t<input name='input_130' type='radio' value='Yes'  id='choice_4_130_0'    \/>\n\t\t\t\t<label for='choice_4_130_0' id='label_4_130_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_130_1'>\n\t\t\t\t<input name='input_130' type='radio' value='No'  id='choice_4_130_1'    \/>\n\t\t\t\t<label for='choice_4_130_1' id='label_4_130_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_131\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Scarlet fever<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_4_131'>\n\t\t\t<li class='gchoice gchoice_4_131_0'>\n\t\t\t\t<input name='input_131' type='radio' value='Yes'  id='choice_4_131_0'    \/>\n\t\t\t\t<label for='choice_4_131_0' id='label_4_131_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_131_1'>\n\t\t\t\t<input name='input_131' type='radio' value='No'  id='choice_4_131_1'    \/>\n\t\t\t\t<label for='choice_4_131_1' id='label_4_131_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_132\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Shortness of breath<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_4_132'>\n\t\t\t<li class='gchoice gchoice_4_132_0'>\n\t\t\t\t<input name='input_132' type='radio' value='Yes'  id='choice_4_132_0'    \/>\n\t\t\t\t<label for='choice_4_132_0' id='label_4_132_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_132_1'>\n\t\t\t\t<input name='input_132' type='radio' value='No'  id='choice_4_132_1'    \/>\n\t\t\t\t<label for='choice_4_132_1' id='label_4_132_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_133\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Sinus trouble<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_4_133'>\n\t\t\t<li class='gchoice gchoice_4_133_0'>\n\t\t\t\t<input name='input_133' type='radio' value='Yes'  id='choice_4_133_0'    \/>\n\t\t\t\t<label for='choice_4_133_0' id='label_4_133_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_133_1'>\n\t\t\t\t<input name='input_133' type='radio' value='No'  id='choice_4_133_1'    \/>\n\t\t\t\t<label for='choice_4_133_1' id='label_4_133_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_134\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Skin Rash<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_4_134'>\n\t\t\t<li class='gchoice gchoice_4_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='Yes'  id='choice_4_134_0'    \/>\n\t\t\t\t<label for='choice_4_134_0' id='label_4_134_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='No'  id='choice_4_134_1'    \/>\n\t\t\t\t<label for='choice_4_134_1' id='label_4_134_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_135\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Special Diet<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_4_135'>\n\t\t\t<li class='gchoice gchoice_4_135_0'>\n\t\t\t\t<input name='input_135' type='radio' value='Yes'  id='choice_4_135_0'    \/>\n\t\t\t\t<label for='choice_4_135_0' id='label_4_135_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_135_1'>\n\t\t\t\t<input name='input_135' type='radio' value='No'  id='choice_4_135_1'    \/>\n\t\t\t\t<label for='choice_4_135_1' id='label_4_135_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_136\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Stroke<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_4_136'>\n\t\t\t<li class='gchoice gchoice_4_136_0'>\n\t\t\t\t<input name='input_136' type='radio' value='Yes'  id='choice_4_136_0'    \/>\n\t\t\t\t<label for='choice_4_136_0' id='label_4_136_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_136_1'>\n\t\t\t\t<input name='input_136' type='radio' value='No'  id='choice_4_136_1'    \/>\n\t\t\t\t<label for='choice_4_136_1' id='label_4_136_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_137\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Swollen feet or Ankles<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_4_137'>\n\t\t\t<li class='gchoice gchoice_4_137_0'>\n\t\t\t\t<input name='input_137' type='radio' value='Yes'  id='choice_4_137_0'    \/>\n\t\t\t\t<label for='choice_4_137_0' id='label_4_137_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_137_1'>\n\t\t\t\t<input name='input_137' type='radio' value='No'  id='choice_4_137_1'    \/>\n\t\t\t\t<label for='choice_4_137_1' id='label_4_137_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_138\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Swollen neck glands<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_4_138'>\n\t\t\t<li class='gchoice gchoice_4_138_0'>\n\t\t\t\t<input name='input_138' type='radio' value='Yes'  id='choice_4_138_0'    \/>\n\t\t\t\t<label for='choice_4_138_0' id='label_4_138_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_138_1'>\n\t\t\t\t<input name='input_138' type='radio' value='No'  id='choice_4_138_1'    \/>\n\t\t\t\t<label for='choice_4_138_1' id='label_4_138_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_139\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Thyroid problems<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_4_139'>\n\t\t\t<li class='gchoice gchoice_4_139_0'>\n\t\t\t\t<input name='input_139' type='radio' value='Yes'  id='choice_4_139_0'    \/>\n\t\t\t\t<label for='choice_4_139_0' id='label_4_139_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_139_1'>\n\t\t\t\t<input name='input_139' type='radio' value='No'  id='choice_4_139_1'    \/>\n\t\t\t\t<label for='choice_4_139_1' id='label_4_139_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_140\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Tonsilitis<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_4_140'>\n\t\t\t<li class='gchoice gchoice_4_140_0'>\n\t\t\t\t<input name='input_140' type='radio' value='Yes'  id='choice_4_140_0'    \/>\n\t\t\t\t<label for='choice_4_140_0' id='label_4_140_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_140_1'>\n\t\t\t\t<input name='input_140' type='radio' value='No'  id='choice_4_140_1'    \/>\n\t\t\t\t<label for='choice_4_140_1' id='label_4_140_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_141\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Tuberculosis<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_4_141'>\n\t\t\t<li class='gchoice gchoice_4_141_0'>\n\t\t\t\t<input name='input_141' type='radio' value='Yes'  id='choice_4_141_0'    \/>\n\t\t\t\t<label for='choice_4_141_0' id='label_4_141_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_141_1'>\n\t\t\t\t<input name='input_141' type='radio' value='No'  id='choice_4_141_1'    \/>\n\t\t\t\t<label for='choice_4_141_1' id='label_4_141_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_142\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Tumor or growth on head or neck<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_4_142'>\n\t\t\t<li class='gchoice gchoice_4_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='Yes'  id='choice_4_142_0'    \/>\n\t\t\t\t<label for='choice_4_142_0' id='label_4_142_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='No'  id='choice_4_142_1'    \/>\n\t\t\t\t<label for='choice_4_142_1' id='label_4_142_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_143\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Ulcer<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_4_143'>\n\t\t\t<li class='gchoice gchoice_4_143_0'>\n\t\t\t\t<input name='input_143' type='radio' value='Yes'  id='choice_4_143_0'    \/>\n\t\t\t\t<label for='choice_4_143_0' id='label_4_143_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_143_1'>\n\t\t\t\t<input name='input_143' type='radio' value='No'  id='choice_4_143_1'    \/>\n\t\t\t\t<label for='choice_4_143_1' id='label_4_143_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_144\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Venereal disease<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_4_144'>\n\t\t\t<li class='gchoice gchoice_4_144_0'>\n\t\t\t\t<input name='input_144' type='radio' value='Yes'  id='choice_4_144_0'    \/>\n\t\t\t\t<label for='choice_4_144_0' id='label_4_144_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_144_1'>\n\t\t\t\t<input name='input_144' type='radio' value='No'  id='choice_4_144_1'    \/>\n\t\t\t\t<label for='choice_4_144_1' id='label_4_144_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_145\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Weight loss, unexplained<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_4_145'>\n\t\t\t<li class='gchoice gchoice_4_145_0'>\n\t\t\t\t<input name='input_145' type='radio' value='Yes'  id='choice_4_145_0'    \/>\n\t\t\t\t<label for='choice_4_145_0' id='label_4_145_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_145_1'>\n\t\t\t\t<input name='input_145' type='radio' value='No'  id='choice_4_145_1'    \/>\n\t\t\t\t<label for='choice_4_145_1' id='label_4_145_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_146\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Have you ever been told you need to take pre-medication before a dental procedure?<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_4_146'>\n\t\t\t<li class='gchoice gchoice_4_146_0'>\n\t\t\t\t<input name='input_146' type='radio' value='Yes'  id='choice_4_146_0'    \/>\n\t\t\t\t<label for='choice_4_146_0' id='label_4_146_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_146_1'>\n\t\t\t\t<input name='input_146' type='radio' value='No'  id='choice_4_146_1'    \/>\n\t\t\t\t<label for='choice_4_146_1' id='label_4_146_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_147\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Do you wear contact lenses?<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_4_147'>\n\t\t\t<li class='gchoice gchoice_4_147_0'>\n\t\t\t\t<input name='input_147' type='radio' value='Yes'  id='choice_4_147_0'    \/>\n\t\t\t\t<label for='choice_4_147_0' id='label_4_147_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_147_1'>\n\t\t\t\t<input name='input_147' type='radio' value='No'  id='choice_4_147_1'    \/>\n\t\t\t\t<label for='choice_4_147_1' id='label_4_147_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_148\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h3>Women<\/h3><\/li><li id=\"field_4_149\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Are you pregnant?<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_4_149'>\n\t\t\t<li class='gchoice gchoice_4_149_0'>\n\t\t\t\t<input name='input_149' type='radio' value='Yes'  id='choice_4_149_0'    \/>\n\t\t\t\t<label for='choice_4_149_0' id='label_4_149_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_149_1'>\n\t\t\t\t<input name='input_149' type='radio' value='No'  id='choice_4_149_1'    \/>\n\t\t\t\t<label for='choice_4_149_1' id='label_4_149_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_152\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_152' >Due Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_152' id='input_4_152' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_152_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_152_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_152' class='gform_hidden' value='https:\/\/cornerstonedentalva.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_150\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Are you nursing?<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_4_150'>\n\t\t\t<li class='gchoice gchoice_4_150_0'>\n\t\t\t\t<input name='input_150' type='radio' value='Yes'  id='choice_4_150_0'    \/>\n\t\t\t\t<label for='choice_4_150_0' id='label_4_150_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_150_1'>\n\t\t\t\t<input name='input_150' type='radio' value='No'  id='choice_4_150_1'    \/>\n\t\t\t\t<label for='choice_4_150_1' id='label_4_150_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_151\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Taking birth control pills?<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_4_151'>\n\t\t\t<li class='gchoice gchoice_4_151_0'>\n\t\t\t\t<input name='input_151' type='radio' value='Yes'  id='choice_4_151_0'    \/>\n\t\t\t\t<label for='choice_4_151_0' id='label_4_151_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_151_1'>\n\t\t\t\t<input name='input_151' type='radio' value='No'  id='choice_4_151_1'    \/>\n\t\t\t\t<label for='choice_4_151_1' id='label_4_151_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_4_153' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_4\").val(\"4\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_4\").val(\"4\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_4_153' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_4\").val(\"6\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_4\").val(\"6\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_6' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_6' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_4_190\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Are you currently taking any medications?<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_4_190'>\n\t\t\t<li class='gchoice gchoice_4_190_0'>\n\t\t\t\t<input name='input_190' type='radio' value='Yes'  id='choice_4_190_0'    \/>\n\t\t\t\t<label for='choice_4_190_0' id='label_4_190_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_190_1'>\n\t\t\t\t<input name='input_190' type='radio' value='No'  id='choice_4_190_1'    \/>\n\t\t\t\t<label for='choice_4_190_1' id='label_4_190_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_154\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_154' >Please list any medications, supplements or homeopathic remedies you are currently taking and the correlating diagnosis.  If none, please type &quot;none.&quot;<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_154' id='input_4_154' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_155\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_155' >Pharmacy Name<\/label><div class='ginput_container ginput_container_text'><input name='input_155' id='input_4_155' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_156\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_156' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_156' id='input_4_156' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_176\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h3>Allergies<\/h3><\/li><li id=\"field_4_158\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_158'><li class='gchoice gchoice_4_158_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.1' type='checkbox'  value='Aspirin'  id='choice_4_158_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_158_1' id='label_4_158_1'>Aspirin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_158_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.2' type='checkbox'  value='Barbiturate (Sleeping pills)'  id='choice_4_158_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_158_2' id='label_4_158_2'>Barbiturate (Sleeping pills)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_158_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.3' type='checkbox'  value='Codeine'  id='choice_4_158_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_158_3' id='label_4_158_3'>Codeine<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_158_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.4' type='checkbox'  value='Iodine'  id='choice_4_158_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_158_4' id='label_4_158_4'>Iodine<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_158_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.5' type='checkbox'  value='Latex'  id='choice_4_158_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_158_5' id='label_4_158_5'>Latex<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_158_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.6' type='checkbox'  value='Local Anesthetic'  id='choice_4_158_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_158_6' id='label_4_158_6'>Local Anesthetic<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_158_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.7' type='checkbox'  value='Penicillin'  id='choice_4_158_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_158_7' id='label_4_158_7'>Penicillin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_158_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.8' type='checkbox'  value='Sulfa'  id='choice_4_158_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_158_8' id='label_4_158_8'>Sulfa<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_158_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.9' type='checkbox'  value='Other'  id='choice_4_158_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_158_9' id='label_4_158_9'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_158_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.11' type='checkbox'  value='None'  id='choice_4_158_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_158_11' id='label_4_158_11'>None<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_177\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_177' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_177' id='input_4_177' 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_previous_button_4_159' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_4\").val(\"5\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_4\").val(\"5\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_4_159' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_4\").val(\"7\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_4\").val(\"7\");  jQuery(\"#gform_4\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_7' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_7' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_4_160\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>Please list names, location and phone numbers of all your attending doctors.<\/p><\/li><li id=\"field_4_164\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><\/li><li id=\"field_4_161\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_161' >1st Dr Name<\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_4_161' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_162\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_162' >Location<\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_4_162' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_163\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_163' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_163' id='input_4_163' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_165\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><\/li><li id=\"field_4_166\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_166' >2nd Doctor Name<\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_4_166' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_167\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_167' >Location<\/label><div class='ginput_container ginput_container_text'><input name='input_167' id='input_4_167' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_168\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_168' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_168' id='input_4_168' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_169\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_169' >Please list any surgeries or medical conditions you have or have ever had.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_169' id='input_4_169' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_170\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><ul><li>We invite you to discuss with us any questions regarding our services. The best dental health services are based on a friendly mutual understanding between provider and patient.<\/li>\n<li>Our policy requires payment in full at the time services are rendered, unless other formal written arrangements have been made with our office management. If the account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for all legal fees, collection agency fees, interest charges and any other expenses incurred for collection of the debt.<\/li>\n<li>I authorize the staff of Cornerstone Dental to perform any necessary services needed during diagnosis and treatment.<\/li>\n<li>Filing of insurance claims is a courtesy we provide to our patients. I authorize Cornerstone Dental to release any information required to process my insurance claims.<\/li>\n<li> I understand the above information and state this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to this information I provided.<\/li><\/ul><\/li><li id=\"field_4_171\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Print name of Patient, Parent, Guardian or Personal Representative<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_4_171'>\n                            \n                            <span id='input_4_171_3_container' class='name_first' >\n                                                    <input type='text' name='input_171.3' id='input_4_171_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_171_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_171_6_container' class='name_last' >\n                                                    <input type='text' name='input_171.6' id='input_4_171_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_171_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_172\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_172' >Date<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_172' id='input_4_172' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_172_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_172_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_172' class='gform_hidden' value='https:\/\/cornerstonedentalva.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_189\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_4_189' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_4_189_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_4_189_valid' id='input_4_189_valid' \/><canvas id='input_4_189' width='300' height='180'><\/canvas><\/div><\/div><\/li><\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_4' class='gform_previous_button button' value='Previous'  onclick='if(window[\"gf_submitting_4\"]){return false;}  window[\"gf_submitting_4\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_4\"]){return false;} window[\"gf_submitting_4\"]=true;  jQuery(\"#gform_4\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_4' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_4\"]){return false;}  window[\"gf_submitting_4\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_4\"]){return false;} window[\"gf_submitting_4\"]=true;  jQuery(\"#gform_4\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=4&amp;title=&amp;description=&amp;tabindex=0' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_4' value='WyJbXSIsIjI3ODIwZjI5YWNhZDhiNDZiODAyMGFmZGRiMzdkYzE2Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_4' id='gform_target_page_number_4' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_4' id='gform_source_page_number_4' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div>\n                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_4' id='gform_ajax_frame_4' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 4, 'https:\/\/cornerstonedentalva.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery('#gform_ajax_frame_4').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_4');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_4').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_4').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_4').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_4').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_4').offset().top - mt); 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