{"id":325,"date":"2026-01-13T14:37:55","date_gmt":"2026-01-13T19:37:55","guid":{"rendered":"https:\/\/register.advocatero.com\/?page_id=325"},"modified":"2026-06-11T10:03:51","modified_gmt":"2026-06-11T14:03:51","slug":"patient-registration-advocate-radiation-oncology","status":"publish","type":"page","link":"https:\/\/register.advocatero.com\/es_es\/","title":{"rendered":"Patient Registration &#8211; Advocate Radiation Oncology"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"325\" class=\"elementor elementor-325\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2e156d2 e-flex e-con-boxed e-con e-parent\" data-id=\"2e156d2\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b4730a0 elementor-widget elementor-widget-image\" data-id=\"b4730a0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"537\" height=\"158\" src=\"https:\/\/register.advocatero.com\/wp-content\/uploads\/2020\/02\/Advocate-Radiation-Oncology-Logo.png\" class=\"attachment-large size-large wp-image-5\" alt=\"Advocate Radiation Oncology Logo for Website\" srcset=\"https:\/\/register.advocatero.com\/wp-content\/uploads\/2020\/02\/Advocate-Radiation-Oncology-Logo.png 537w, https:\/\/register.advocatero.com\/wp-content\/uploads\/2020\/02\/Advocate-Radiation-Oncology-Logo-300x88.png 300w, https:\/\/register.advocatero.com\/wp-content\/uploads\/2020\/02\/Advocate-Radiation-Oncology-Logo-200x59.png 200w, https:\/\/register.advocatero.com\/wp-content\/uploads\/2020\/02\/Advocate-Radiation-Oncology-Logo-400x118.png 400w\" sizes=\"(max-width: 537px) 100vw, 537px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-e55ca5f e-con-full e-flex e-con e-child\" data-id=\"e55ca5f\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-30fd2c9 e-con-full e-flex e-con e-child\" data-id=\"30fd2c9\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a38eb39 elementor-align-justify elementor-widget elementor-widget-button\" data-id=\"a38eb39\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/advocatero.com\/wp-content\/uploads\/2026\/03\/426-PHS-SPANISH-PATIENT-REGISTRATION-PACKAGE.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-pdf\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M181.9 256.1c-5-16-4.9-46.9-2-46.9 8.4 0 7.6 36.9 2 46.9zm-1.7 47.2c-7.7 20.2-17.3 43.3-28.4 62.7 18.3-7 39-17.2 62.9-21.9-12.7-9.6-24.9-23.4-34.5-40.8zM86.1 428.1c0 .8 13.2-5.4 34.9-40.2-6.7 6.3-29.1 24.5-34.9 40.2zM248 160h136v328c0 13.3-10.7 24-24 24H24c-13.3 0-24-10.7-24-24V24C0 10.7 10.7 0 24 0h200v136c0 13.2 10.8 24 24 24zm-8 171.8c-20-12.2-33.3-29-42.7-53.8 4.5-18.5 11.6-46.6 6.2-64.2-4.7-29.4-42.4-26.5-47.8-6.8-5 18.3-.4 44.1 8.1 77-11.6 27.6-28.7 64.6-40.8 85.8-.1 0-.1.1-.2.1-27.1 13.9-73.6 44.5-54.5 68 5.6 6.9 16 10 21.5 10 17.9 0 35.7-18 61.1-61.8 25.8-8.5 54.1-19.1 79-23.2 21.7 11.8 47.1 19.5 64 19.5 29.2 0 31.2-32 19.7-43.4-13.9-13.6-54.3-9.7-73.6-7.2zM377 105L279 7c-4.5-4.5-10.6-7-17-7h-6v128h128v-6.1c0-6.3-2.5-12.4-7-16.9zm-74.1 255.3c4.1-2.7-2.5-11.9-42.8-9 37.1 15.8 42.8 9 42.8 9z\"><\/path><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Formulario de Registracion<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-a3df289 e-con-full e-flex e-con e-child\" data-id=\"a3df289\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3dbc9d6 elementor-align-justify elementor-widget elementor-widget-button\" data-id=\"3dbc9d6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/advocatero.com\/wp-content\/uploads\/2026\/04\/PHS-New-Patient-Registration-Form.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-pdf\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M181.9 256.1c-5-16-4.9-46.9-2-46.9 8.4 0 7.6 36.9 2 46.9zm-1.7 47.2c-7.7 20.2-17.3 43.3-28.4 62.7 18.3-7 39-17.2 62.9-21.9-12.7-9.6-24.9-23.4-34.5-40.8zM86.1 428.1c0 .8 13.2-5.4 34.9-40.2-6.7 6.3-29.1 24.5-34.9 40.2zM248 160h136v328c0 13.3-10.7 24-24 24H24c-13.3 0-24-10.7-24-24V24C0 10.7 10.7 0 24 0h200v136c0 13.2 10.8 24 24 24zm-8 171.8c-20-12.2-33.3-29-42.7-53.8 4.5-18.5 11.6-46.6 6.2-64.2-4.7-29.4-42.4-26.5-47.8-6.8-5 18.3-.4 44.1 8.1 77-11.6 27.6-28.7 64.6-40.8 85.8-.1 0-.1.1-.2.1-27.1 13.9-73.6 44.5-54.5 68 5.6 6.9 16 10 21.5 10 17.9 0 35.7-18 61.1-61.8 25.8-8.5 54.1-19.1 79-23.2 21.7 11.8 47.1 19.5 64 19.5 29.2 0 31.2-32 19.7-43.4-13.9-13.6-54.3-9.7-73.6-7.2zM377 105L279 7c-4.5-4.5-10.6-7-17-7h-6v128h128v-6.1c0-6.3-2.5-12.4-7-16.9zm-74.1 255.3c4.1-2.7-2.5-11.9-42.8-9 37.1 15.8 42.8 9 42.8 9z\"><\/path><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Registration Form<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-caab5df e-con-full e-flex e-con e-child\" data-id=\"caab5df\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-fc9656f elementor-widget elementor-widget-shortcode\" data-id=\"fc9656f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar 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class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; se\u00f1ala los campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_6' id='gform_6'  action='\/es_es\/wp-json\/wp\/v2\/pages\/325#gf_6' data-formid='6' novalidate><input id=\"gw_page_progression\" name=\"gw_page_progression\" value=\"1\" type=\"hidden\" \/><input id=\"gpmpn_pages_visited_6\" name=\"gpmpn_pages_visited_6\" value=\"[1]\" type=\"hidden\" \/><input id=\"gpmpn_page_validity_6\" name=\"gpmpn_page_validity_6\" value=\"{&quot;1&quot;:false,&quot;2&quot;:false,&quot;3&quot;:false,&quot;4&quot;:false,&quot;5&quot;:false,&quot;6&quot;:false,&quot;7&quot;:false,&quot;8&quot;:false,&quot;9&quot;:false,&quot;10&quot;:false,&quot;11&quot;:false,&quot;12&quot;:false}\" type=\"hidden\" \/><div id='gf_page_steps_6' class='gf_page_steps'><div id='gf_step_6_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Patient Registration<\/span><\/div><div id='gf_step_6_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Medical History Forms<\/span><\/div><div id='gf_step_6_3' class='gf_step gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'>Medication Consent<\/span><\/div><div id='gf_step_6_4' class='gf_step gf_step_pending'><span class='gf_step_number'>4<\/span><span class='gf_step_label'>Family History<\/span><\/div><div id='gf_step_6_5' class='gf_step gf_step_pending'><span class='gf_step_number'>5<\/span><span class='gf_step_label'>Preventative Health Maintenance<\/span><\/div><div id='gf_step_6_6' class='gf_step gf_step_pending'><span class='gf_step_number'>6<\/span><span class='gf_step_label'>Symptoms<\/span><\/div><div id='gf_step_6_7' class='gf_step gf_step_pending'><span class='gf_step_number'>7<\/span><span class='gf_step_label'>Depression Screening<\/span><\/div><div id='gf_step_6_8' class='gf_step gf_step_pending'><span class='gf_step_number'>8<\/span><span class='gf_step_label'>Advance Directives<\/span><\/div><div id='gf_step_6_9' class='gf_step gf_step_pending'><span class='gf_step_number'>9<\/span><span class='gf_step_label'>General Consent<\/span><\/div><div id='gf_step_6_10' class='gf_step gf_step_pending'><span class='gf_step_number'>10<\/span><span class='gf_step_label'>HIPAA Disclosure<\/span><\/div><div id='gf_step_6_11' class='gf_step gf_step_pending'><span class='gf_step_number'>11<\/span><span class='gf_step_label'>Medical Records Release Form<\/span><\/div><div id='gf_step_6_12' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>12<\/span><span class='gf_step_label'>Review\/Submit<\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_6_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_389\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_389'>Confirmation Number<\/label><div class='ginput_container ginput_container_text'><input name='input_389' id='input_6_389' type='text' value='{entry_id}' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_326\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"text-decoration: underline;\">Patient Registration<\/h3><\/div><div id=\"field_6_311\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><span style=\"color:#b72a2a;\"><b>*Asterisk indicates required field<\/b><\/span><\/div><fieldset id=\"field_6_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >PATIENT NAME (LAST -- FIRST -- MIDDLE INITIAL)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_6_1'>\n                            \n                            <span id='input_6_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_6_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_6_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.4' id='input_6_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_1_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_6_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_6_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_2\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_2'>Patient Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_6_2' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_6_27\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_27'>Patient Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_6_27' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_5\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_5'>Patient Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_6_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Patient Cellphone - Is it an iPhone?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_7'>\n\t\t\t<div class='gchoice gchoice_6_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No'  id='choice_6_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_7_0' id='label_6_7_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes'  id='choice_6_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_7_1' id='label_6_7_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_4\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_6_4_1' value=''    aria-required='true'    \/>\n                                        <label for='input_6_4_1' id='input_6_4_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_6_4_3' value=''    aria-required='true'    \/>\n                                    <label for='input_6_4_3' id='input_6_4_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_4_4_container' >\n                                        <select name='input_4.4' id='input_6_4_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/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='Guam' >Guam<\/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='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/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='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >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_6_4_4' id='input_6_4_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_6_4_5' value=''    aria-required='true'    \/>\n                                    <label for='input_6_4_5' id='input_6_4_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_6_4_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_312\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_312'>Patient Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_312' id='input_6_312' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_312_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_312_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_312' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_8\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_8'>Patient SSN<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_6_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_9'>\n\t\t\t<div class='gchoice gchoice_6_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Male'  id='choice_6_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_9_0' id='label_6_9_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Female'  id='choice_6_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_9_1' id='label_6_9_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Marital Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_10'>\n\t\t\t<div class='gchoice gchoice_6_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Single'  id='choice_6_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_10_0' id='label_6_10_0' class='gform-field-label gform-field-label--type-inline'>Single<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Married'  id='choice_6_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_10_1' id='label_6_10_1' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_10_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='gf_other_choice'  id='choice_6_10_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_10_2' id='label_6_10_2' class='gform-field-label gform-field-label--type-inline'>Otro<\/label><br \/><input id='input_6_10_other' class='gchoice_other_control' name='input_10_other' type='text' value='Otro' aria-label='Si es otro, especif\u00edcalo, por favor'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_22\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_22'>Patient Employer Name<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_6_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_15\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Employer Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_15' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_15_1_container' >\n                                        <input type='text' name='input_15.1' id='input_6_15_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_15_1' id='input_6_15_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_15_3_container' >\n                                    <input type='text' name='input_15.3' id='input_6_15_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_15_3' id='input_6_15_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_15_4_container' >\n                                        <select name='input_15.4' id='input_6_15_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/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='Guam' >Guam<\/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='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/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='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >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_6_15_4' id='input_6_15_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_15_5_container' >\n                                    <input type='text' name='input_15.5' id='input_6_15_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_15_5' id='input_6_15_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_15.6' id='input_6_15_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_16\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_16'>Patient Employer Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_6_16' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_64\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Insured\/Responsible Party Information<\/h3><\/div><fieldset id=\"field_6_18\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Insured\/Responsible Party Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_6_18'>\n                            \n                            <span id='input_6_18_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_18.3' id='input_6_18_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_18_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_6_18_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_18.4' id='input_6_18_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_18_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_6_18_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_18.6' id='input_6_18_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_18_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_314\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_314'>Relationship to Patient<\/label><div class='ginput_container ginput_container_select'><select name='input_314' id='input_6_314' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Spouse' >Spouse<\/option><option value='Parent' >Parent<\/option><option value='Guardian' >Guardian<\/option><option value='Self' >Self<\/option><\/select><\/div><\/div><fieldset id=\"field_6_25\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Insured\/Responsible Party Address (if different from patient)<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_25' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_25_1_container' >\n                                        <input type='text' name='input_25.1' id='input_6_25_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_25_1' id='input_6_25_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_25_3_container' >\n                                    <input type='text' name='input_25.3' id='input_6_25_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_25_3' id='input_6_25_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_25_4_container' >\n                                        <select name='input_25.4' id='input_6_25_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/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='Guam' >Guam<\/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='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/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='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >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_6_25_4' id='input_6_25_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_25_5_container' >\n                                    <input type='text' name='input_25.5' id='input_6_25_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_25_5' id='input_6_25_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_25.6' id='input_6_25_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_3\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_3'>Insured\/Responsible Party Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_6_3' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_28\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_28'>Insured\/Responsible Party Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_28' id='input_6_28' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_21\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_21'>Insured\/Responsible Party SSN<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_6_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_20\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_20'>Insured\/Responsible Party Birth Date<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_6_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_13\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_13'>Insured\/Responsible Party Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_6_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_24\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Insurance Information<\/h3><\/div><div id=\"field_6_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_26'>Primary Insurance Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_6_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_32\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Primary Insurance Address (from the back of the insurance card)<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_32' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_32_1_container' >\n                                        <input type='text' name='input_32.1' id='input_6_32_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_32_1' id='input_6_32_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_32_3_container' >\n                                    <input type='text' name='input_32.3' id='input_6_32_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_32_3' id='input_6_32_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_32_4_container' >\n                                        <select name='input_32.4' id='input_6_32_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/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='Guam' >Guam<\/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='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/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='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >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_6_32_4' id='input_6_32_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_32_5_container' >\n                                    <input type='text' name='input_32.5' id='input_6_32_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_32_5' id='input_6_32_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_32.6' id='input_6_32_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_41\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_41'>Primary Insurance Group Number<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_6_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_42\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_42'>Primary Insurance ID Number<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_6_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Primary Insurance Type<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_43'>\n\t\t\t<div class='gchoice gchoice_6_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='HMO'  id='choice_6_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_43_0' id='label_6_43_0' class='gform-field-label gform-field-label--type-inline'>HMO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='PPO'  id='choice_6_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_43_1' id='label_6_43_1' class='gform-field-label gform-field-label--type-inline'>PPO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_44\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_44'>Primary Insurance Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_44' id='input_6_44' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_38\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1><\/hr><\/h1><\/div><div id=\"field_6_31\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_31'>Secondary Insurance Name<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_6_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_19\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Secondary Insurance Address (from the back of the insurance card)<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_19' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_19_1_container' >\n                                        <input type='text' name='input_19.1' id='input_6_19_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_19_1' id='input_6_19_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_19_3_container' >\n                                    <input type='text' name='input_19.3' id='input_6_19_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_19_3' id='input_6_19_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_19_4_container' >\n                                        <select name='input_19.4' id='input_6_19_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/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='Guam' >Guam<\/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='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/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='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >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_6_19_4' id='input_6_19_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_19_5_container' >\n                                    <input type='text' name='input_19.5' id='input_6_19_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_19_5' id='input_6_19_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_19.6' id='input_6_19_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_34\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_34'>Secondary Insurance Group Number<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_6_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_35\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_35'>Secondary Insurance ID Number<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_6_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Secondary Insurance Type<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_36'>\n\t\t\t<div class='gchoice gchoice_6_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='HMO'  id='choice_6_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_36_0' id='label_6_36_0' class='gform-field-label gform-field-label--type-inline'>HMO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='PPO'  id='choice_6_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_36_1' id='label_6_36_1' class='gform-field-label gform-field-label--type-inline'>PPO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_37\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_37'>Secondary Insurance Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_6_37' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_30\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Admission Information<\/h3><\/div><div id=\"field_6_45\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_45'>Primary Doctor\/Family Doctor<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_6_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_46\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_46'>Referring Doctor<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_6_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_47\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >In Case of Emergency Contact<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_47'>\n                            \n                            <span id='input_6_47_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_47.3' id='input_6_47_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_47_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_47_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_47.6' id='input_6_47_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_47_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_48\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_48'>Emergency Contact Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_6_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_49\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_49'>Emergency Contact Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_49' id='input_6_49' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently admitted to a hospital or enrolled in a Hospice or Skilled Nursing Facility?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_52'>\n\t\t\t<div class='gchoice gchoice_6_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Yes'  id='choice_6_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_52_0' id='label_6_52_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='No'  id='choice_6_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_52_1' id='label_6_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_53\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_53'>Facility Name<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_6_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_57\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_57'>Facility Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_57' id='input_6_57' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_58\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Facility Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_58' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_58_1_container' >\n                                        <input type='text' name='input_58.1' id='input_6_58_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_58_1' id='input_6_58_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_58_3_container' >\n                                    <input type='text' name='input_58.3' id='input_6_58_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_58_3' id='input_6_58_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_58_4_container' >\n                                        <select name='input_58.4' id='input_6_58_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/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='Guam' >Guam<\/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='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/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='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >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_6_58_4' id='input_6_58_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_58_5_container' >\n                                    <input type='text' name='input_58.5' id='input_6_58_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_58_5' id='input_6_58_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_58.6' id='input_6_58_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_59\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1><\/hr><\/h1><\/div><fieldset id=\"field_6_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you receiving benefits from the Veterans Administration?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_55'>\n\t\t\t<div class='gchoice gchoice_6_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_6_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_55_0' id='label_6_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_6_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_55_1' id='label_6_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_56\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_56'>VA Name<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_6_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_54\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_54'>VA Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_54' id='input_6_54' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_51\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >VA Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_51' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_51_1_container' >\n                                        <input type='text' name='input_51.1' id='input_6_51_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_51_1' id='input_6_51_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_51_3_container' >\n                                    <input type='text' name='input_51.3' id='input_6_51_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_51_3' id='input_6_51_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_51_4_container' >\n                                        <select name='input_51.4' id='input_6_51_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/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='Guam' >Guam<\/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='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/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='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >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_6_51_4' id='input_6_51_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_51_5_container' >\n                                    <input type='text' name='input_51.5' id='input_6_51_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_51_5' id='input_6_51_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_51.6' id='input_6_51_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_40\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1><\/hr><\/h1><\/div><fieldset id=\"field_6_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Which of the following best describe your race?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_60'>\n\t\t\t<div class='gchoice gchoice_6_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Asian'  id='choice_6_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_0' id='label_6_60_0' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Caucasian'  id='choice_6_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_1' id='label_6_60_1' class='gform-field-label gform-field-label--type-inline'>Caucasian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Black \/ African American'  id='choice_6_60_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_2' id='label_6_60_2' class='gform-field-label gform-field-label--type-inline'>Black \/ African American<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Hispanic'  id='choice_6_60_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_3' id='label_6_60_3' class='gform-field-label gform-field-label--type-inline'>Hispanic<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Subcontinent Asian American'  id='choice_6_60_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_4' id='label_6_60_4' class='gform-field-label gform-field-label--type-inline'>Subcontinent Asian American<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Asian Pacific American'  id='choice_6_60_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_5' id='label_6_60_5' class='gform-field-label gform-field-label--type-inline'>Asian Pacific American<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Native American'  id='choice_6_60_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_6' id='label_6_60_6' class='gform-field-label gform-field-label--type-inline'>Native American<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='American Indian \/ Alaskan Native'  id='choice_6_60_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_7' id='label_6_60_7' class='gform-field-label gform-field-label--type-inline'>American Indian \/ Alaskan Native<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Hawaiian'  id='choice_6_60_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_8' id='label_6_60_8' class='gform-field-label gform-field-label--type-inline'>Hawaiian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Pacific Islander'  id='choice_6_60_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_9' id='label_6_60_9' class='gform-field-label gform-field-label--type-inline'>Pacific Islander<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='More than one race'  id='choice_6_60_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_10' id='label_6_60_10' class='gform-field-label gform-field-label--type-inline'>More than one race<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Other'  id='choice_6_60_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_11' id='label_6_60_11' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Decline'  id='choice_6_60_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_12' id='label_6_60_12' class='gform-field-label gform-field-label--type-inline'>Decline<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Please select one ethnic group that best describes your race:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_61'>\n\t\t\t<div class='gchoice gchoice_6_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Hispanic or Latino'  id='choice_6_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_61_0' id='label_6_61_0' class='gform-field-label gform-field-label--type-inline'>Hispanic or Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Non-Hispanic or Latino'  id='choice_6_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_61_1' id='label_6_61_1' class='gform-field-label gform-field-label--type-inline'>Non-Hispanic or Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_61_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Decline'  id='choice_6_61_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_61_2' id='label_6_61_2' class='gform-field-label gform-field-label--type-inline'>Decline<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_61_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Don\u2019t know'  id='choice_6_61_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_61_3' id='label_6_61_3' class='gform-field-label gform-field-label--type-inline'>Don\u2019t know<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What language do you feel most comfortable using when discussing your healthcare?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_62'>\n\t\t\t<div class='gchoice gchoice_6_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='English'  id='choice_6_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_0' id='label_6_62_0' class='gform-field-label gform-field-label--type-inline'>English<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Spanish'  id='choice_6_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_1' id='label_6_62_1' class='gform-field-label gform-field-label--type-inline'>Spanish<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='German'  id='choice_6_62_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_2' id='label_6_62_2' class='gform-field-label gform-field-label--type-inline'>German<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='French'  id='choice_6_62_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_3' id='label_6_62_3' class='gform-field-label gform-field-label--type-inline'>French<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Italian'  id='choice_6_62_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_4' id='label_6_62_4' class='gform-field-label gform-field-label--type-inline'>Italian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Russian'  id='choice_6_62_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_5' id='label_6_62_5' class='gform-field-label gform-field-label--type-inline'>Russian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Portuguese'  id='choice_6_62_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_6' id='label_6_62_6' class='gform-field-label gform-field-label--type-inline'>Portuguese<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Chinese'  id='choice_6_62_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_7' id='label_6_62_7' class='gform-field-label gform-field-label--type-inline'>Chinese<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Other'  id='choice_6_62_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_8' id='label_6_62_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Decline'  id='choice_6_62_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_9' id='label_6_62_9' class='gform-field-label gform-field-label--type-inline'>Decline<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Don\u2019t know'  id='choice_6_62_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_10' id='label_6_62_10' class='gform-field-label gform-field-label--type-inline'>Don\u2019t know<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >How often do you use internet for gathering information?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_63'>\n\t\t\t<div class='gchoice gchoice_6_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Always'  id='choice_6_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_63_0' id='label_6_63_0' class='gform-field-label gform-field-label--type-inline'>Always<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Usually'  id='choice_6_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_63_1' id='label_6_63_1' class='gform-field-label gform-field-label--type-inline'>Usually<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_63_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Sometimes'  id='choice_6_63_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_63_2' id='label_6_63_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_63_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Never'  id='choice_6_63_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_63_3' id='label_6_63_3' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_6_88' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_2' class='gform_page' data-js='page-field-id-88' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_89\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Medical History Forms<\/h3><\/div><div id=\"field_6_66\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_66'>Cancer diagnosis or reason for consultation:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_66' id='input_6_66' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_67\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px; text-decoration: underline;\">Past Medical History<\/h3><\/div><fieldset id=\"field_6_68\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please check all that apply:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_68'><div class='gchoice gchoice_6_68_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.1' type='checkbox'  value='Allergies'  id='choice_6_68_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_1' id='label_6_68_1' class='gform-field-label gform-field-label--type-inline'>Allergies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.2' type='checkbox'  value='COPD'  id='choice_6_68_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_2' id='label_6_68_2' class='gform-field-label gform-field-label--type-inline'>COPD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.3' type='checkbox'  value='High blood pressure'  id='choice_6_68_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_3' id='label_6_68_3' class='gform-field-label gform-field-label--type-inline'>High blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.4' type='checkbox'  value='Anxiety'  id='choice_6_68_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_4' id='label_6_68_4' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.5' type='checkbox'  value='Depression'  id='choice_6_68_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_5' id='label_6_68_5' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.6' type='checkbox'  value='Inflammatory Bowel Disease (Crohn\u2019s disease, colitis, etc)'  id='choice_6_68_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_6' id='label_6_68_6' class='gform-field-label gform-field-label--type-inline'>Inflammatory Bowel Disease (Crohn\u2019s disease, colitis, etc)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.7' type='checkbox'  value='Anemia\/Blood Disorder'  id='choice_6_68_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_7' id='label_6_68_7' class='gform-field-label gform-field-label--type-inline'>Anemia\/Blood Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.8' type='checkbox'  value='Diabetes'  id='choice_6_68_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_8' id='label_6_68_8' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.9' type='checkbox'  value='Migraines\/headaches'  id='choice_6_68_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_9' id='label_6_68_9' class='gform-field-label gform-field-label--type-inline'>Migraines\/headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.11' type='checkbox'  value='Arthritis'  id='choice_6_68_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_11' id='label_6_68_11' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.12' type='checkbox'  value='Diverticulitis'  id='choice_6_68_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_12' id='label_6_68_12' class='gform-field-label gform-field-label--type-inline'>Diverticulitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.13' type='checkbox'  value='Neuropathy'  id='choice_6_68_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_13' id='label_6_68_13' class='gform-field-label gform-field-label--type-inline'>Neuropathy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.14' type='checkbox'  value='Asthma'  id='choice_6_68_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_14' id='label_6_68_14' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.15' type='checkbox'  value='Erectile dysfunction'  id='choice_6_68_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_15' id='label_6_68_15' class='gform-field-label gform-field-label--type-inline'>Erectile dysfunction<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.16' type='checkbox'  value='Psychosis'  id='choice_6_68_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_16' id='label_6_68_16' class='gform-field-label gform-field-label--type-inline'>Psychosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.17' type='checkbox'  value='Atrial fibrillation\/irregular heartbeat'  id='choice_6_68_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_17' id='label_6_68_17' class='gform-field-label gform-field-label--type-inline'>Atrial fibrillation\/irregular heartbeat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.18' type='checkbox'  value='Fibromyalgia'  id='choice_6_68_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_18' id='label_6_68_18' class='gform-field-label gform-field-label--type-inline'>Fibromyalgia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.19' type='checkbox'  value='Rheumatoid Arthritis'  id='choice_6_68_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_19' id='label_6_68_19' class='gform-field-label gform-field-label--type-inline'>Rheumatoid Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.21' type='checkbox'  value='Autoimmune disorder (lupus, scleroderma, RA, etc)'  id='choice_6_68_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_21' id='label_6_68_21' class='gform-field-label gform-field-label--type-inline'>Autoimmune disorder (lupus, scleroderma, RA, etc)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.22' type='checkbox'  value='GERD'  id='choice_6_68_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_22' id='label_6_68_22' class='gform-field-label gform-field-label--type-inline'>GERD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.23' type='checkbox'  value='Seizures'  id='choice_6_68_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_23' id='label_6_68_23' class='gform-field-label gform-field-label--type-inline'>Seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.24' type='checkbox'  value='Bipolar Disorder'  id='choice_6_68_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_24' id='label_6_68_24' class='gform-field-label gform-field-label--type-inline'>Bipolar Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.25' type='checkbox'  value='Gout'  id='choice_6_68_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_25' id='label_6_68_25' class='gform-field-label gform-field-label--type-inline'>Gout<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.26' type='checkbox'  value='Stroke'  id='choice_6_68_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_26' id='label_6_68_26' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.27' type='checkbox'  value='Blood clots or pulmonary embolism'  id='choice_6_68_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_27' id='label_6_68_27' class='gform-field-label gform-field-label--type-inline'>Blood clots or pulmonary embolism<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.28' type='checkbox'  value='Heart Attack'  id='choice_6_68_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_28' id='label_6_68_28' class='gform-field-label gform-field-label--type-inline'>Heart Attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.29' type='checkbox'  value='Thyroid Disorder'  id='choice_6_68_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_29' id='label_6_68_29' class='gform-field-label gform-field-label--type-inline'>Thyroid Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.31' type='checkbox'  value='BPH (prostate)'  id='choice_6_68_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_31' id='label_6_68_31' class='gform-field-label gform-field-label--type-inline'>BPH (prostate)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.32' type='checkbox'  value='Heart Disease'  id='choice_6_68_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_32' id='label_6_68_32' class='gform-field-label gform-field-label--type-inline'>Heart Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.33' type='checkbox'  value='Tremors'  id='choice_6_68_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_33' id='label_6_68_33' class='gform-field-label gform-field-label--type-inline'>Tremors<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.34' type='checkbox'  value='CAD (coronary artery disease)'  id='choice_6_68_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_34' id='label_6_68_34' class='gform-field-label gform-field-label--type-inline'>CAD (coronary artery disease)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.35' type='checkbox'  value='High cholesterol'  id='choice_6_68_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_35' id='label_6_68_35' class='gform-field-label gform-field-label--type-inline'>High cholesterol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.36' type='checkbox'  value='Osteoporosis'  id='choice_6_68_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_36' id='label_6_68_36' class='gform-field-label gform-field-label--type-inline'>Osteoporosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_71\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_71'>Cancer, prior history:<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_6_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_72\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_72'>Infectious disease (HIV, hepatitis, Tuberculosis, etc)?<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_6_72' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_73\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_73'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_6_73' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_83\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever received radiation therapy?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_83'>\n\t\t\t<div class='gchoice gchoice_6_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Yes'  id='choice_6_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_83_0' id='label_6_83_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='No'  id='choice_6_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_83_1' id='label_6_83_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_84\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_84'>If yes, when?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_84' id='input_6_84' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_84_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_84_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_84' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_77\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_77'>Radiation Therapy Physician\u2019s Name\/Facility<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_6_77' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_86\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_86'>Radiation Therapy Facility Address<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_6_86' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_366\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_366'>What area was treated?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_366' id='input_6_366' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_6_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever received chemotherapy?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_74'>\n\t\t\t<div class='gchoice gchoice_6_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Yes'  id='choice_6_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_74_0' id='label_6_74_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_6_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_74_1' id='label_6_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_76\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_76'>If yes, when?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_76' id='input_6_76' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_76_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_76_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_76' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_87\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_87'>Chemotherapy Physician\u2019s Name\/Facility<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_6_87' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_80\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_80'>Chemotherapy Therapy Address<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_6_80' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_17\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Past Surgeries<\/h3><\/div><fieldset id=\"field_6_107\" class=\"gfield gfield--type-list gfield--input-type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please list surgery, year of operation, surgeon and location (if known). Click the &quot;PLUS&quot; symbol to add more rows.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Procedure\/Operation<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Physician<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Location<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_107_cell1 gform-grid-col' data-label='Procedure\/Operation'><input aria-invalid='false'   aria-label='Procedure\/Operation, Fila 1' data-aria-label-template='Procedure\/Operation, Fila {0}' type='text' name='input_107[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_107_cell2 gform-grid-col' data-label='Date'><input aria-invalid='false'   aria-label='Date, Fila 1' data-aria-label-template='Date, Fila {0}' type='text' name='input_107[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_107_cell3 gform-grid-col' data-label='Physician'><input aria-invalid='false'   aria-label='Physician, Fila 1' data-aria-label-template='Physician, Fila {0}' type='text' name='input_107[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_107_cell4 gform-grid-col' data-label='Location'><input aria-invalid='false'   aria-label='Location, Fila 1' data-aria-label-template='Location, Fila {0}' type='text' name='input_107[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 4)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 4)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_96\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have any implanted medical devices such as a PACEMAKER, DEFIBRILLATOR, neurostimulator, drug infusion pumps, etc?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_96'>\n\t\t\t<div class='gchoice gchoice_6_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Yes'  id='choice_6_96_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_96_0' id='label_6_96_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='No'  id='choice_6_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_96_1' id='label_6_96_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_97\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong><em>If yes, please provide copy of your medical device card to front desk.<\/strong><\/em><\/p><\/div><div id=\"field_6_98\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px; text-decoration: underline;\">Allergies<\/h3><\/div><fieldset id=\"field_6_99\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you allergic to any medications?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_99'>\n\t\t\t<div class='gchoice gchoice_6_99_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Yes'  id='choice_6_99_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_99_0' id='label_6_99_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_99_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='No'  id='choice_6_99_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_99_1' id='label_6_99_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_100\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_100'>If yes, medication name\/reaction:<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_6_100' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_104\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you allergic to latex?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_104'>\n\t\t\t<div class='gchoice gchoice_6_104_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='Yes'  id='choice_6_104_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_104_0' id='label_6_104_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_104_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='No'  id='choice_6_104_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_104_1' id='label_6_104_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_105\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_105'>If yes, latex reaction:<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_6_105' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you allergic to IV Contrast?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_103'>\n\t\t\t<div class='gchoice gchoice_6_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='Yes'  id='choice_6_103_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_103_0' id='label_6_103_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='No'  id='choice_6_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_103_1' id='label_6_103_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_102\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_102'>If yes, IV Contrast reaction:<\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_6_102' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_106\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_106'>Others (food, tape, environmental, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_6_106' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_108\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration:underline;\">Medications<\/h3><\/div><div id=\"field_6_109\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_109'>Pharmacy Name<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_6_109' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_110\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_110'>Pharmacy Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_110' id='input_6_110' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_111\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Pharmacy Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_6_111' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_111_1_container' >\n                                        <input type='text' name='input_111.1' id='input_6_111_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_111_1' id='input_6_111_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_111.4' id='input_6_111_4' value=''\/><input type='hidden' class='gform_hidden' name='input_111.6' id='input_6_111_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_6_90\" class=\"gfield gfield--type-list gfield--input-type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please list ALL medications. Click the &quot;PLUS&quot; symbol to add more rows.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Medication<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dose<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Frequency<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Prescribing Physician<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_90_cell1 gform-grid-col' data-label='Medication'><input aria-invalid='false'   aria-label='Medication, Fila 1' data-aria-label-template='Medication, Fila {0}' type='text' name='input_90[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_90_cell2 gform-grid-col' data-label='Dose'><input aria-invalid='false'   aria-label='Dose, Fila 1' data-aria-label-template='Dose, Fila {0}' type='text' name='input_90[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_90_cell3 gform-grid-col' data-label='Frequency'><input aria-invalid='false'   aria-label='Frequency, Fila 1' data-aria-label-template='Frequency, Fila {0}' type='text' name='input_90[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_90_cell4 gform-grid-col' data-label='Prescribing Physician'><input aria-invalid='false'   aria-label='Prescribing Physician, Fila 1' data-aria-label-template='Prescribing Physician, Fila {0}' type='text' name='input_90[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_121' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_121' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_3' class='gform_page' data-js='page-field-id-121' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_371\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top: 50px;\">Consent to Obtain Patient Medication History<\/h3>\n<p>Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. <\/p>\n<p>The collected information is stored in the practice electronic medical record system and becomes part of your personal medical record. Medication history is very important in helping providers treat your symptoms and\/or illness properly and avoid potentially dangerous drug interactions. <\/p>\n<p>It is very important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate. Some pharmacies do not make prescription history information available, and your medication history might not include drugs purchased without using your health insurance.<\/p>\n<p>Also, over\u2010the\u2010counter drugs, supplements, or herbal remedies that you take on your own may not be included.<p><\/div><fieldset id=\"field_6_373\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_373.1' id='input_6_373_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_373_1' >I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers. <strong>Valid for 1 year from date of signature.<\/strong><\/label><input type='hidden' name='input_373.2' value='I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers. &lt;strong&gt;Valid for 1 year from date of signature.&lt;\/strong&gt;' class='gform_hidden' \/><input type='hidden' name='input_373.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_374\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_374'>Patient Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_374' id='input_6_374' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_375\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_375'>Today&#039;s 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_375' id='input_6_375' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_375_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_375_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_375' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_370' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_370' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_4' class='gform_page' data-js='page-field-id-370' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_128\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration:underline;\">Family History<\/h3><\/div><div id=\"field_6_118\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_118'>Father: if living, age<\/label><div class='ginput_container ginput_container_number'><input name='input_118' id='input_6_118' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_119\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_119'>Father: If deceased, age at death<\/label><div class='ginput_container ginput_container_number'><input name='input_119' id='input_6_119' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_120\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_120'>Father Medical Problems<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_120' id='input_6_120' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_122\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_122'>Mother: if living, age<\/label><div class='ginput_container ginput_container_number'><input name='input_122' id='input_6_122' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_116\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_116'>Mother: if deceased, age at death<\/label><div class='ginput_container ginput_container_number'><input name='input_116' id='input_6_116' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_124\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_124'>Mother Medical Problems<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_124' id='input_6_124' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_125\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_125'>Siblings: # of Females<\/label><div class='ginput_container ginput_container_number'><input name='input_125' id='input_6_125' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_126\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_126'>Siblings: # of Males<\/label><div class='ginput_container ginput_container_number'><input name='input_126' id='input_6_126' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_127\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_127'>Siblings: Medical Problems\/Deceased<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_127' id='input_6_127' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_115\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_115'>Children: # of Females<\/label><div class='ginput_container ginput_container_number'><input name='input_115' id='input_6_115' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_123\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_123'>Children: # of Males<\/label><div class='ginput_container ginput_container_number'><input name='input_123' id='input_6_123' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_117\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_117'>Children: Medical Problems\/Deceased<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_117' id='input_6_117' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_165\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px; text-decoration: underline;\">Social History<\/h3><\/div><fieldset id=\"field_6_129\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Marital Status:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_129'>\n\t\t\t<div class='gchoice gchoice_6_129_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Single'  id='choice_6_129_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_129_0' id='label_6_129_0' class='gform-field-label gform-field-label--type-inline'>Single<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_129_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Married'  id='choice_6_129_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_129_1' id='label_6_129_1' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_129_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Divorced'  id='choice_6_129_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_129_2' id='label_6_129_2' class='gform-field-label gform-field-label--type-inline'>Divorced<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_129_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Widowed'  id='choice_6_129_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_129_3' id='label_6_129_3' class='gform-field-label gform-field-label--type-inline'>Widowed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_129_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Separated'  id='choice_6_129_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_129_4' id='label_6_129_4' class='gform-field-label gform-field-label--type-inline'>Separated<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_130\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_130'>Spouse or significant other\u2019s name<\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_6_130' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_137\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Social Geographic History<\/h3><\/div><div id=\"field_6_132\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_132'>Where were you born?<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_6_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_133\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_133'>Where did you live most of your life?<\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_6_133' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_136\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you live in this state all year round?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_136'>\n\t\t\t<div class='gchoice gchoice_6_136_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Yes'  id='choice_6_136_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_136_0' id='label_6_136_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_136_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='No'  id='choice_6_136_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_136_1' id='label_6_136_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_135\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please provide your alternate address:<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_135' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_135_1_container' >\n                                        <input type='text' name='input_135.1' id='input_6_135_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_135_1' id='input_6_135_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_135_3_container' >\n                                    <input type='text' name='input_135.3' id='input_6_135_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_135_3' id='input_6_135_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_135_4_container' >\n                                        <select name='input_135.4' id='input_6_135_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/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='Guam' >Guam<\/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='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/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='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >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_6_135_4' id='input_6_135_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_135_5_container' >\n                                    <input type='text' name='input_135.5' id='input_6_135_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_135_5' id='input_6_135_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_135.6' id='input_6_135_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_131\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top: 50px; text-decoration: underline;\">Occupation\/Service History<\/h3><\/div><div id=\"field_6_138\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_138'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_6_138' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_141\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_141'>\n\t\t\t<div class='gchoice gchoice_6_141_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Retired'  id='choice_6_141_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_141_0' id='label_6_141_0' class='gform-field-label gform-field-label--type-inline'>Retired<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_141_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Disabled'  id='choice_6_141_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_141_1' id='label_6_141_1' class='gform-field-label gform-field-label--type-inline'>Disabled<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_139\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_139'>Reason for disability?<\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_6_139' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_140\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you served in the military?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_140'>\n\t\t\t<div class='gchoice gchoice_6_140_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='No'  id='choice_6_140_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_140_0' id='label_6_140_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_140_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Yes'  id='choice_6_140_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_140_1' id='label_6_140_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_145\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >To your knowledge, have you ever worked in an occupation that involved exposure to asbestos or other cancerous chemicals, fumes, or carcinogens?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_145'>\n\t\t\t<div class='gchoice gchoice_6_145_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='No'  id='choice_6_145_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_145_0' id='label_6_145_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_145_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='Yes'  id='choice_6_145_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_145_1' id='label_6_145_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_143\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_143'>If yes, describe:<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_6_143' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_144\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top: 50px; text-decoration: underline;\">Substance History<\/h3><\/div><fieldset id=\"field_6_154\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever smoked?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_154'>\n\t\t\t<div class='gchoice gchoice_6_154_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='No'  id='choice_6_154_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_154_0' id='label_6_154_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_154_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Yes'  id='choice_6_154_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_154_1' id='label_6_154_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_150\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If yes, what?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_150'><div class='gchoice gchoice_6_150_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.1' type='checkbox'  value='Cigarettes'  id='choice_6_150_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_150_1' id='label_6_150_1' class='gform-field-label gform-field-label--type-inline'>Cigarettes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_150_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.2' type='checkbox'  value='Cigars'  id='choice_6_150_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_150_2' id='label_6_150_2' class='gform-field-label gform-field-label--type-inline'>Cigars<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_150_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.3' type='checkbox'  value='Pipe'  id='choice_6_150_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_150_3' id='label_6_150_3' class='gform-field-label gform-field-label--type-inline'>Pipe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_153\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_153'>How many years smoking?<\/label><div class='ginput_container ginput_container_number'><input name='input_153' id='input_6_153' type='number' step='any' min='1' max='99' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_6_153\" \/><div class='gfield_description instruction ' id='gfield_instruction_6_153'>Por favor, escribe un n\u00famero entre <strong>1<\/strong> y <strong>99<\/strong>.<\/div><\/div><\/div><div id=\"field_6_155\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_155'>Packs\/number per day?<\/label><div class='ginput_container ginput_container_number'><input name='input_155' id='input_6_155' type='number' step='any' min='1' max='99' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_6_155\" \/><div class='gfield_description instruction ' id='gfield_instruction_6_155'>Por favor, escribe un n\u00famero entre <strong>1<\/strong> y <strong>99<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_6_142\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If yes, have you quit smoking?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_142'>\n\t\t\t<div class='gchoice gchoice_6_142_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='No'  id='choice_6_142_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_142_0' id='label_6_142_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_142_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='Yes'  id='choice_6_142_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_142_1' id='label_6_142_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_159\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_159'>If yes, when did you quit smoking?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_159' id='input_6_159' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_159_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_159_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_159' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_146\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever chewed tobacco?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_146'>\n\t\t\t<div class='gchoice gchoice_6_146_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='No'  id='choice_6_146_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_146_0' id='label_6_146_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_146_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='Yes'  id='choice_6_146_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_146_1' id='label_6_146_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_160\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_160'>How much?<\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_6_160' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_161\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If yes, have you quit chewing tobacco?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_161'>\n\t\t\t<div class='gchoice gchoice_6_161_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_161' type='radio' value='No'  id='choice_6_161_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_161_0' id='label_6_161_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_161_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_161' type='radio' value='Yes'  id='choice_6_161_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_161_1' id='label_6_161_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_162\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_162'>If yes, when did you quit chewing tobacco?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_162' id='input_6_162' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_162_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_162_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_162' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_147\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you drink alcoholic beverages?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_147'>\n\t\t\t<div class='gchoice gchoice_6_147_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='No'  id='choice_6_147_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_147_0' id='label_6_147_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_147_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='Yes'  id='choice_6_147_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_147_1' id='label_6_147_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_157\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_157'>If yes, how often and how much do you drink?<\/label><div class='ginput_container ginput_container_text'><input name='input_157' id='input_6_157' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_158\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If yes, have you quit drinking alcohol?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_158'>\n\t\t\t<div class='gchoice gchoice_6_158_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='No'  id='choice_6_158_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_158_0' id='label_6_158_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_158_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='Yes'  id='choice_6_158_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_158_1' id='label_6_158_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_156\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_156'>If yes, when did you quit drinking alcohol?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_156' id='input_6_156' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_156_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_156_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_156' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_148\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you or do you use street drugs?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_148'>\n\t\t\t<div class='gchoice gchoice_6_148_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='No'  id='choice_6_148_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_148_0' id='label_6_148_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_148_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='Yes'  id='choice_6_148_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_148_1' id='label_6_148_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_163\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_163'>If yes, describe:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_163' id='input_6_163' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_50' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_50' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_5' class='gform_page' data-js='page-field-id-50' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_178\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top: 50px; text-decoration: underline;\">Preventative Health Maintenance<\/h3><\/div><div id=\"field_6_351\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_351'>(Female) Last mammogram:<\/label><div class='ginput_container ginput_container_text'><input name='input_351' id='input_6_351' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_352\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_352'>(Female) Last pap smear:<\/label><div class='ginput_container ginput_container_text'><input name='input_352' id='input_6_352' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_353\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_353'>(Female) Last colonoscopy:<\/label><div class='ginput_container ginput_container_text'><input name='input_353' id='input_6_353' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_354\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_354'>(Female) Last bone density scan:<\/label><div class='ginput_container ginput_container_text'><input name='input_354' id='input_6_354' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_355\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_355'>(Female) Last pneumonia vaccine:<\/label><div class='ginput_container ginput_container_text'><input name='input_355' id='input_6_355' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_356\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_356'>(Female) Last influenza (flu) shot:<\/label><div class='ginput_container ginput_container_text'><input name='input_356' id='input_6_356' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_357\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_357'>(Male) Last PSA screening:<\/label><div class='ginput_container ginput_container_text'><input name='input_357' id='input_6_357' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_358\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_358'>(Male) Last prostate exam:<\/label><div class='ginput_container ginput_container_text'><input name='input_358' id='input_6_358' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_359\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_359'>(Male) Last colonoscopy:<\/label><div class='ginput_container ginput_container_text'><input name='input_359' id='input_6_359' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_360\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_360'>(Male) Last bone density scan:<\/label><div class='ginput_container ginput_container_text'><input name='input_360' id='input_6_360' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_361\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_361'>(Male) Last pneumonia vaccine:<\/label><div class='ginput_container ginput_container_text'><input name='input_361' id='input_6_361' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_362\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_362'>(Male) Last influenza (flu) shot:<\/label><div class='ginput_container ginput_container_text'><input name='input_362' id='input_6_362' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_113\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top: 50px; text-decoration: underline;\">Mobility Risk Assessment<\/h3><\/div><fieldset id=\"field_6_182\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you need assistance walking?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_182'>\n\t\t\t<div class='gchoice gchoice_6_182_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_182' type='radio' value='No'  id='choice_6_182_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_182_0' id='label_6_182_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_182_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_182' type='radio' value='Yes'  id='choice_6_182_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_182_1' id='label_6_182_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_367\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you fallen before or been injured because of a fall?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_367'>\n\t\t\t<div class='gchoice gchoice_6_367_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_367' type='radio' value='No'  id='choice_6_367_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_367_0' id='label_6_367_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_367_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_367' type='radio' value='Yes'  id='choice_6_367_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_367_1' id='label_6_367_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_180\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you use a<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_180'><div class='gchoice gchoice_6_180_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.1' type='checkbox'  value='cane?'  id='choice_6_180_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_180_1' id='label_6_180_1' class='gform-field-label gform-field-label--type-inline'>cane?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_180_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.2' type='checkbox'  value='walker?'  id='choice_6_180_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_180_2' id='label_6_180_2' class='gform-field-label gform-field-label--type-inline'>walker?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_180_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.3' type='checkbox'  value='wheel chair?'  id='choice_6_180_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_180_3' id='label_6_180_3' class='gform-field-label gform-field-label--type-inline'>wheel chair?<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_183\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you feel weaker than you used to or have less strength in your arms or legs?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_183'>\n\t\t\t<div class='gchoice gchoice_6_183_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='No'  id='choice_6_183_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_183_0' id='label_6_183_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_183_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='Yes'  id='choice_6_183_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_183_1' id='label_6_183_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_184\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you stopped or avoided exercise\/daily activities because of a fear of falling?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_184'>\n\t\t\t<div class='gchoice gchoice_6_184_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_184' type='radio' value='No'  id='choice_6_184_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_184_0' id='label_6_184_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_184_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_184' type='radio' value='Yes'  id='choice_6_184_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_184_1' id='label_6_184_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_185\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have foot ulcers, bunions, hammertoes, or calluses that hurt or cause you to adjust your steps?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_185'>\n\t\t\t<div class='gchoice gchoice_6_185_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='No'  id='choice_6_185_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_185_0' id='label_6_185_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_185_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='Yes'  id='choice_6_185_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_185_1' id='label_6_185_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_186\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you feel dizzy when you stand up?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_186'>\n\t\t\t<div class='gchoice gchoice_6_186_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_186' type='radio' value='No'  id='choice_6_186_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_186_0' id='label_6_186_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_186_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_186' type='radio' value='Yes'  id='choice_6_186_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_186_1' id='label_6_186_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_187\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_187'>How many falls have you had in the last 12 months?<\/label><div class='ginput_container ginput_container_text'><input name='input_187' id='input_6_187' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_188\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you suffer an injury from you falls?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_188'>\n\t\t\t<div class='gchoice gchoice_6_188_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_188' type='radio' value='No'  id='choice_6_188_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_188_0' id='label_6_188_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_188_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_188' type='radio' value='Yes'  id='choice_6_188_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_188_1' id='label_6_188_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_189\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_189'>Please explain:<\/label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_6_189' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_190\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=padding-top: 50px; text-decoration: underline;\">Females Only<\/h3><\/div><div id=\"field_6_191\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_191'>Age at first menstrual period:<\/label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_6_191' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_192\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you still have periods?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_192'>\n\t\t\t<div class='gchoice gchoice_6_192_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_192' type='radio' value='No'  id='choice_6_192_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_192_0' id='label_6_192_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_192_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_192' type='radio' value='Yes'  id='choice_6_192_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_192_1' id='label_6_192_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_193\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_193'>Date or age of last menstrual period:<\/label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_6_193' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_194\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_194'>Age at first pregnancy:<\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_6_194' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_195\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_195'>Number of pregnancies:<\/label><div class='ginput_container ginput_container_text'><input name='input_195' id='input_6_195' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_197\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_197'>Number of births:<\/label><div class='ginput_container ginput_container_text'><input name='input_197' id='input_6_197' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_198\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you breastfeed?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_198'>\n\t\t\t<div class='gchoice gchoice_6_198_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_198' type='radio' value='No'  id='choice_6_198_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_198_0' id='label_6_198_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_198_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_198' type='radio' value='Yes'  id='choice_6_198_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_198_1' id='label_6_198_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_199\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever taken hormone replacement therapy?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_199'>\n\t\t\t<div class='gchoice gchoice_6_199_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_199' type='radio' value='No'  id='choice_6_199_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_199_0' id='label_6_199_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_199_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_199' type='radio' value='Yes'  id='choice_6_199_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_199_1' id='label_6_199_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_200\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_200'>If yes, how many years?<\/label><div class='ginput_container ginput_container_text'><input name='input_200' id='input_6_200' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_201\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Pain Assessment<\/h3><\/div><fieldset id=\"field_6_202\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have pain now?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_202'>\n\t\t\t<div class='gchoice gchoice_6_202_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_202' type='radio' value='No'  id='choice_6_202_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_202_0' id='label_6_202_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_202_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_202' type='radio' value='Yes'  id='choice_6_202_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_202_1' id='label_6_202_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_203\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_203'>Where is your pain located?<\/label><div class='ginput_container ginput_container_text'><input name='input_203' id='input_6_203' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_204\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >On a scale of 1-10, with 1 being very mild and 10 being the worst pain imaginable, what number is your pain?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_204'><div class='gchoice gchoice_6_204_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.1' type='checkbox'  value='1'  id='choice_6_204_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_1' id='label_6_204_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.2' type='checkbox'  value='2'  id='choice_6_204_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_2' id='label_6_204_2' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.3' type='checkbox'  value='3'  id='choice_6_204_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_3' id='label_6_204_3' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.4' type='checkbox'  value='4'  id='choice_6_204_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_4' id='label_6_204_4' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.5' type='checkbox'  value='5'  id='choice_6_204_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_5' id='label_6_204_5' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.6' type='checkbox'  value='6'  id='choice_6_204_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_6' id='label_6_204_6' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.7' type='checkbox'  value='7'  id='choice_6_204_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_7' id='label_6_204_7' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.8' type='checkbox'  value='8'  id='choice_6_204_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_8' id='label_6_204_8' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.9' type='checkbox'  value='9'  id='choice_6_204_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_9' id='label_6_204_9' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.11' type='checkbox'  value='10'  id='choice_6_204_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_11' id='label_6_204_11' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_205\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_205'>How would you describe the pain? (e.g. aching, stabbing, burning, throbbing, sharp, dull)<\/label><div class='ginput_container ginput_container_text'><input name='input_205' id='input_6_205' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_206\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_206'>When did your pain start?<\/label><div class='ginput_container ginput_container_text'><input name='input_206' id='input_6_206' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_207\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_207'>Does anything make it better or worse?<\/label><div class='ginput_container ginput_container_text'><input name='input_207' id='input_6_207' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_208\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you taking pain medications?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_208'>\n\t\t\t<div class='gchoice gchoice_6_208_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_208' type='radio' value='No'  id='choice_6_208_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_208_0' id='label_6_208_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_208_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_208' type='radio' value='Yes'  id='choice_6_208_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_208_1' id='label_6_208_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_209\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_209'>If so, what pain medication?<\/label><div class='ginput_container ginput_container_text'><input name='input_209' id='input_6_209' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_210' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_210' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_6' class='gform_page' data-js='page-field-id-210' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_211\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Review of Systems<\/h3>\n<strong>Have you recently experienced any of these symptoms? Please select all that apply<\/strong><\/div><fieldset id=\"field_6_212\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >General<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_212'><div class='gchoice gchoice_6_212_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_212.1' type='checkbox'  value='Fever\/Chills'  id='choice_6_212_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_212_1' id='label_6_212_1' class='gform-field-label gform-field-label--type-inline'>Fever\/Chills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_212_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_212.2' type='checkbox'  value='Fatigue'  id='choice_6_212_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_212_2' id='label_6_212_2' class='gform-field-label gform-field-label--type-inline'>Fatigue<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_212_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_212.3' type='checkbox'  value='Weight loss\/gain'  id='choice_6_212_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_212_3' id='label_6_212_3' class='gform-field-label gform-field-label--type-inline'>Weight loss\/gain<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_214\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Eyes and Vision<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_214'><div class='gchoice gchoice_6_214_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_214.1' type='checkbox'  value='Glasses\/contacts'  id='choice_6_214_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_214_1' id='label_6_214_1' class='gform-field-label gform-field-label--type-inline'>Glasses\/contacts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_214_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_214.2' type='checkbox'  value='Eye disease or injury'  id='choice_6_214_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_214_2' id='label_6_214_2' class='gform-field-label gform-field-label--type-inline'>Eye disease or injury<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_214_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_214.3' type='checkbox'  value='Eye pain or pressure'  id='choice_6_214_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_214_3' id='label_6_214_3' class='gform-field-label gform-field-label--type-inline'>Eye pain or pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_214_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_214.4' type='checkbox'  value='Blurred or Double vision'  id='choice_6_214_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_214_4' id='label_6_214_4' class='gform-field-label gform-field-label--type-inline'>Blurred or Double vision<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_215\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ears, Nose, Throat<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_215'><div class='gchoice gchoice_6_215_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.1' type='checkbox'  value='Hearing loss'  id='choice_6_215_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_1' id='label_6_215_1' class='gform-field-label gform-field-label--type-inline'>Hearing loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.2' type='checkbox'  value='Ringing in ears'  id='choice_6_215_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_2' id='label_6_215_2' class='gform-field-label gform-field-label--type-inline'>Ringing in ears<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.3' type='checkbox'  value='Ear ache or drainage'  id='choice_6_215_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_3' id='label_6_215_3' class='gform-field-label gform-field-label--type-inline'>Ear ache or drainage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.4' type='checkbox'  value='Sinus problems'  id='choice_6_215_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_4' id='label_6_215_4' class='gform-field-label gform-field-label--type-inline'>Sinus problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.5' type='checkbox'  value='Nose bleeds'  id='choice_6_215_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_5' id='label_6_215_5' class='gform-field-label gform-field-label--type-inline'>Nose bleeds<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.6' type='checkbox'  value='Dental problems'  id='choice_6_215_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_6' id='label_6_215_6' class='gform-field-label gform-field-label--type-inline'>Dental problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.7' type='checkbox'  value='Dentures'  id='choice_6_215_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_7' id='label_6_215_7' class='gform-field-label gform-field-label--type-inline'>Dentures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.8' type='checkbox'  value='Mouth sores'  id='choice_6_215_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_8' id='label_6_215_8' class='gform-field-label gform-field-label--type-inline'>Mouth sores<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.9' type='checkbox'  value='Sore throat'  id='choice_6_215_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_9' id='label_6_215_9' class='gform-field-label gform-field-label--type-inline'>Sore throat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.11' type='checkbox'  value='Difficulty\/painful swallowing'  id='choice_6_215_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_11' id='label_6_215_11' class='gform-field-label gform-field-label--type-inline'>Difficulty\/painful swallowing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.12' type='checkbox'  value='Hoarseness or voice change'  id='choice_6_215_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_12' id='label_6_215_12' class='gform-field-label gform-field-label--type-inline'>Hoarseness or voice change<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.13' type='checkbox'  value='Swollen glands in neck'  id='choice_6_215_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_13' id='label_6_215_13' class='gform-field-label gform-field-label--type-inline'>Swollen glands in neck<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_216\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Heart\/Cardiovascular<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_216'><div class='gchoice gchoice_6_216_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.1' type='checkbox'  value='Chest pain'  id='choice_6_216_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_216_1' id='label_6_216_1' class='gform-field-label gform-field-label--type-inline'>Chest pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_216_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.2' type='checkbox'  value='Heart Palpitations'  id='choice_6_216_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_216_2' id='label_6_216_2' class='gform-field-label gform-field-label--type-inline'>Heart Palpitations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_216_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.3' type='checkbox'  value='Dizziness'  id='choice_6_216_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_216_3' id='label_6_216_3' class='gform-field-label gform-field-label--type-inline'>Dizziness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_216_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.4' type='checkbox'  value='Swollen legs\/ankles'  id='choice_6_216_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_216_4' id='label_6_216_4' class='gform-field-label gform-field-label--type-inline'>Swollen legs\/ankles<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_217\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Respiratory<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_217'><div class='gchoice gchoice_6_217_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.1' type='checkbox'  value='Frequent Coughing'  id='choice_6_217_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_217_1' id='label_6_217_1' class='gform-field-label gform-field-label--type-inline'>Frequent Coughing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_217_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.2' type='checkbox'  value='Spitting up blood'  id='choice_6_217_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_217_2' id='label_6_217_2' class='gform-field-label gform-field-label--type-inline'>Spitting up blood<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_217_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.3' type='checkbox'  value='Wheezing or asthma'  id='choice_6_217_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_217_3' id='label_6_217_3' class='gform-field-label gform-field-label--type-inline'>Wheezing or asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_217_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.4' type='checkbox'  value='Shortness of breath'  id='choice_6_217_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_217_4' id='label_6_217_4' class='gform-field-label gform-field-label--type-inline'>Shortness of breath<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_218\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endocrine<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_218'><div class='gchoice gchoice_6_218_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.1' type='checkbox'  value='Loss of hair\/thinning hair'  id='choice_6_218_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_218_1' id='label_6_218_1' class='gform-field-label gform-field-label--type-inline'>Loss of hair\/thinning hair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_218_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.2' type='checkbox'  value='Heat\/cold intolerance'  id='choice_6_218_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_218_2' id='label_6_218_2' class='gform-field-label gform-field-label--type-inline'>Heat\/cold intolerance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_218_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.3' type='checkbox'  value='Excessive thirst'  id='choice_6_218_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_218_3' id='label_6_218_3' class='gform-field-label gform-field-label--type-inline'>Excessive thirst<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_219\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Gastrointestinal<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_219'><div class='gchoice gchoice_6_219_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.1' type='checkbox'  value='Loss of appetite'  id='choice_6_219_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_219_1' id='label_6_219_1' class='gform-field-label gform-field-label--type-inline'>Loss of appetite<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_219_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.2' type='checkbox'  value='Nausea or Vomiting'  id='choice_6_219_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_219_2' id='label_6_219_2' class='gform-field-label gform-field-label--type-inline'>Nausea or Vomiting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_219_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.3' type='checkbox'  value='Stomach pain'  id='choice_6_219_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_219_3' id='label_6_219_3' class='gform-field-label gform-field-label--type-inline'>Stomach pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_219_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.4' type='checkbox'  value='Frequent diarrhea'  id='choice_6_219_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_219_4' id='label_6_219_4' class='gform-field-label gform-field-label--type-inline'>Frequent diarrhea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_219_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.5' type='checkbox'  value='Constipation'  id='choice_6_219_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_219_5' id='label_6_219_5' class='gform-field-label gform-field-label--type-inline'>Constipation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_219_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.6' type='checkbox'  value='Blood in stool'  id='choice_6_219_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_219_6' id='label_6_219_6' class='gform-field-label gform-field-label--type-inline'>Blood in stool<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_220\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Genitourinary<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_220'><div class='gchoice gchoice_6_220_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.1' type='checkbox'  value='Frequent urination'  id='choice_6_220_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_1' id='label_6_220_1' class='gform-field-label gform-field-label--type-inline'>Frequent urination<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.2' type='checkbox'  value='Burning or painful urination'  id='choice_6_220_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_2' id='label_6_220_2' class='gform-field-label gform-field-label--type-inline'>Burning or painful urination<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.3' type='checkbox'  value='Blood in urine'  id='choice_6_220_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_3' id='label_6_220_3' class='gform-field-label gform-field-label--type-inline'>Blood in urine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.4' type='checkbox'  value='Incontinence or dribbling'  id='choice_6_220_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_4' id='label_6_220_4' class='gform-field-label gform-field-label--type-inline'>Incontinence or dribbling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.5' type='checkbox'  value='Urgency'  id='choice_6_220_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_5' id='label_6_220_5' class='gform-field-label gform-field-label--type-inline'>Urgency<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.6' type='checkbox'  value='Vaginal discharge'  id='choice_6_220_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_6' id='label_6_220_6' class='gform-field-label gform-field-label--type-inline'>Vaginal discharge<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.7' type='checkbox'  value='Painful\/irregular periods'  id='choice_6_220_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_7' id='label_6_220_7' class='gform-field-label gform-field-label--type-inline'>Painful\/irregular periods<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.8' type='checkbox'  value='Sexual difficulty'  id='choice_6_220_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_8' id='label_6_220_8' class='gform-field-label gform-field-label--type-inline'>Sexual difficulty<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_221\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Psychiatric<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_221'><div class='gchoice gchoice_6_221_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.1' type='checkbox'  value='Depression'  id='choice_6_221_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_221_1' id='label_6_221_1' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_221_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.2' type='checkbox'  value='Anxiety\/Nervousness'  id='choice_6_221_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_221_2' id='label_6_221_2' class='gform-field-label gform-field-label--type-inline'>Anxiety\/Nervousness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_221_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.3' type='checkbox'  value='Sleep Disorders'  id='choice_6_221_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_221_3' id='label_6_221_3' class='gform-field-label gform-field-label--type-inline'>Sleep Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_221_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.4' type='checkbox'  value='Suicidal Thoughts'  id='choice_6_221_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_221_4' id='label_6_221_4' class='gform-field-label gform-field-label--type-inline'>Suicidal Thoughts<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_222\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Hematology\/Lymphatic<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_222'><div class='gchoice gchoice_6_222_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.1' type='checkbox'  value='Easily bruise or bleed'  id='choice_6_222_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_222_1' id='label_6_222_1' class='gform-field-label gform-field-label--type-inline'>Easily bruise or bleed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_222_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.2' type='checkbox'  value='Anemia'  id='choice_6_222_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_222_2' id='label_6_222_2' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_222_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.3' type='checkbox'  value='Slow to heal'  id='choice_6_222_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_222_3' id='label_6_222_3' class='gform-field-label gform-field-label--type-inline'>Slow to heal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_222_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.4' type='checkbox'  value='History of transfusion'  id='choice_6_222_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_222_4' id='label_6_222_4' class='gform-field-label gform-field-label--type-inline'>History of transfusion<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_223\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Musculoskeletal<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_223'><div class='gchoice gchoice_6_223_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.1' type='checkbox'  value='Joint pain or stiffness'  id='choice_6_223_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_223_1' id='label_6_223_1' class='gform-field-label gform-field-label--type-inline'>Joint pain or stiffness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_223_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.2' type='checkbox'  value='Back pain'  id='choice_6_223_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_223_2' id='label_6_223_2' class='gform-field-label gform-field-label--type-inline'>Back pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_223_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.3' type='checkbox'  value='Muscle pain or cramps'  id='choice_6_223_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_223_3' id='label_6_223_3' class='gform-field-label gform-field-label--type-inline'>Muscle pain or cramps<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_223_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.4' type='checkbox'  value='Cold arms or legs'  id='choice_6_223_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_223_4' id='label_6_223_4' class='gform-field-label gform-field-label--type-inline'>Cold arms or legs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_223_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.5' type='checkbox'  value='Difficulty walking'  id='choice_6_223_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_223_5' id='label_6_223_5' class='gform-field-label gform-field-label--type-inline'>Difficulty walking<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_224\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Skin and Breast<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_224'><div class='gchoice gchoice_6_224_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.1' type='checkbox'  value='Rash or Itching'  id='choice_6_224_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_224_1' id='label_6_224_1' class='gform-field-label gform-field-label--type-inline'>Rash or Itching<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_224_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.2' type='checkbox'  value='Lesion or change in skin color'  id='choice_6_224_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_224_2' id='label_6_224_2' class='gform-field-label gform-field-label--type-inline'>Lesion or change in skin color<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_224_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.3' type='checkbox'  value='Breast mass\/lump'  id='choice_6_224_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_224_3' id='label_6_224_3' class='gform-field-label gform-field-label--type-inline'>Breast mass\/lump<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_224_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.4' type='checkbox'  value='Nipple discharge \/ retraction'  id='choice_6_224_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_224_4' id='label_6_224_4' class='gform-field-label gform-field-label--type-inline'>Nipple discharge \/ retraction<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_224_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.5' type='checkbox'  value='Open or non-healing wound'  id='choice_6_224_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_224_5' id='label_6_224_5' class='gform-field-label gform-field-label--type-inline'>Open or non-healing wound<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_225\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Neurological<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_225'><div class='gchoice gchoice_6_225_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.1' type='checkbox'  value='Frequent headache'  id='choice_6_225_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_1' id='label_6_225_1' class='gform-field-label gform-field-label--type-inline'>Frequent headache<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_225_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.2' type='checkbox'  value='Lightheaded or dizzy'  id='choice_6_225_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_2' id='label_6_225_2' class='gform-field-label gform-field-label--type-inline'>Lightheaded or dizzy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_225_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.3' type='checkbox'  value='Confusion'  id='choice_6_225_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_3' id='label_6_225_3' class='gform-field-label gform-field-label--type-inline'>Confusion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_225_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.4' type='checkbox'  value='Speech difficulty'  id='choice_6_225_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_4' id='label_6_225_4' class='gform-field-label gform-field-label--type-inline'>Speech difficulty<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_225_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.5' type='checkbox'  value='Seizure activity'  id='choice_6_225_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_5' id='label_6_225_5' class='gform-field-label gform-field-label--type-inline'>Seizure activity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_225_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.6' type='checkbox'  value='Numbness or tingling'  id='choice_6_225_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_6' id='label_6_225_6' class='gform-field-label gform-field-label--type-inline'>Numbness or tingling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_225_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.7' type='checkbox'  value='Weakness in arms or legs'  id='choice_6_225_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_7' id='label_6_225_7' class='gform-field-label gform-field-label--type-inline'>Weakness in arms or legs<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_376' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_376' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_7' class='gform_page' data-js='page-field-id-376' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_227\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Depression Screening<\/h3>\n<p>Over the last 2 weeks, how often have you been bothered by any of the following problems?<\/div><fieldset id=\"field_6_378\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. Little interest or pleasure in doing things<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_378'>\n\t\t\t<div class='gchoice gchoice_6_378_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_378' type='radio' value='Not at all'  id='choice_6_378_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_378_0' id='label_6_378_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_378_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_378' type='radio' value='Several days'  id='choice_6_378_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_378_1' id='label_6_378_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_378_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_378' type='radio' value='More than half the days'  id='choice_6_378_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_378_2' id='label_6_378_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_378_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_378' type='radio' value='Nearly every day'  id='choice_6_378_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_378_3' id='label_6_378_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_379\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Feeling down, depressed, or hopeless<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_379'>\n\t\t\t<div class='gchoice gchoice_6_379_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_379' type='radio' value='Not at all'  id='choice_6_379_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_379_0' id='label_6_379_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_379_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_379' type='radio' value='Several days'  id='choice_6_379_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_379_1' id='label_6_379_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_379_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_379' type='radio' value='More than half the days'  id='choice_6_379_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_379_2' id='label_6_379_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_379_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_379' type='radio' value='Nearly every day'  id='choice_6_379_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_379_3' id='label_6_379_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_380\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Trouble falling or staying asleep, or sleeping too much<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_380'>\n\t\t\t<div class='gchoice gchoice_6_380_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_380' type='radio' value='Not at all'  id='choice_6_380_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_380_0' id='label_6_380_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_380_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_380' type='radio' value='Several days'  id='choice_6_380_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_380_1' id='label_6_380_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_380_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_380' type='radio' value='More than half the days'  id='choice_6_380_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_380_2' id='label_6_380_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_380_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_380' type='radio' value='Nearly every day'  id='choice_6_380_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_380_3' id='label_6_380_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_381\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Feeling tired or having little energy<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_381'>\n\t\t\t<div class='gchoice gchoice_6_381_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_381' type='radio' value='Not at all'  id='choice_6_381_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_381_0' id='label_6_381_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_381_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_381' type='radio' value='Several days'  id='choice_6_381_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_381_1' id='label_6_381_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_381_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_381' type='radio' value='More than half the days'  id='choice_6_381_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_381_2' id='label_6_381_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_381_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_381' type='radio' value='Nearly every day'  id='choice_6_381_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_381_3' id='label_6_381_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_382\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. Poor appetite or overeating<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_382'>\n\t\t\t<div class='gchoice gchoice_6_382_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_382' type='radio' value='Not at all'  id='choice_6_382_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_382_0' id='label_6_382_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_382_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_382' type='radio' value='Several days'  id='choice_6_382_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_382_1' id='label_6_382_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_382_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_382' type='radio' value='More than half the days'  id='choice_6_382_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_382_2' id='label_6_382_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_382_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_382' type='radio' value='Nearly every day'  id='choice_6_382_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_382_3' id='label_6_382_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_383\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_383'>\n\t\t\t<div class='gchoice gchoice_6_383_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_383' type='radio' value='Not at all'  id='choice_6_383_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_383_0' id='label_6_383_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_383_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_383' type='radio' value='Several days'  id='choice_6_383_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_383_1' id='label_6_383_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_383_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_383' type='radio' value='More than half the days'  id='choice_6_383_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_383_2' id='label_6_383_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_383_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_383' type='radio' value='Nearly every day'  id='choice_6_383_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_383_3' id='label_6_383_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_384\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Trouble concentrating on things, such as reading the newspaper or watching television<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_384'>\n\t\t\t<div class='gchoice gchoice_6_384_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_384' type='radio' value='Not at all'  id='choice_6_384_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_384_0' id='label_6_384_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_384_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_384' type='radio' value='Several days'  id='choice_6_384_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_384_1' id='label_6_384_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_384_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_384' type='radio' value='More than half the days'  id='choice_6_384_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_384_2' id='label_6_384_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_384_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_384' type='radio' value='Nearly every day'  id='choice_6_384_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_384_3' id='label_6_384_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_386\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. Moving or speaking o slowly that other people could have noticed? Or the oppoite - being o fidgety or restless that you have been moving around a lot more than usual<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_386'>\n\t\t\t<div class='gchoice gchoice_6_386_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_386' type='radio' value='Not at all'  id='choice_6_386_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_386_0' id='label_6_386_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_386_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_386' type='radio' value='Several days'  id='choice_6_386_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_386_1' id='label_6_386_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_386_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_386' type='radio' value='More than half the days'  id='choice_6_386_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_386_2' id='label_6_386_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_386_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_386' type='radio' value='Nearly every day'  id='choice_6_386_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_386_3' id='label_6_386_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_385\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >9. Thought that you would be better off dead or of hurting yourself in some way<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_385'>\n\t\t\t<div class='gchoice gchoice_6_385_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_385' type='radio' value='Not at all'  id='choice_6_385_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_385_0' id='label_6_385_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_385_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_385' type='radio' value='Several days'  id='choice_6_385_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_385_1' id='label_6_385_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_385_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_385' type='radio' value='More than half the days'  id='choice_6_385_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_385_2' id='label_6_385_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_385_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_385' type='radio' value='Nearly every day'  id='choice_6_385_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_385_3' id='label_6_385_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_226' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_226' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_8' class='gform_page' data-js='page-field-id-226' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_377\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Advance Directives<\/h3><\/div><fieldset id=\"field_6_228\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a medical power of attorney?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_228'>\n\t\t\t<div class='gchoice gchoice_6_228_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_228' type='radio' value='No'  id='choice_6_228_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_228_0' id='label_6_228_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_228_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_228' type='radio' value='Yes'  id='choice_6_228_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_228_1' id='label_6_228_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_229\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have an advance directive?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_229'>\n\t\t\t<div class='gchoice gchoice_6_229_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='No'  id='choice_6_229_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_229_0' id='label_6_229_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_229_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='Yes'  id='choice_6_229_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_229_1' id='label_6_229_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_230\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a living will?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_230'>\n\t\t\t<div class='gchoice gchoice_6_230_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='No'  id='choice_6_230_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_230_0' id='label_6_230_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_230_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='Yes'  id='choice_6_230_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_230_1' id='label_6_230_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_231\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a donor card?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_231'>\n\t\t\t<div class='gchoice gchoice_6_231_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='No'  id='choice_6_231_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_231_0' id='label_6_231_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_231_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='Yes'  id='choice_6_231_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_231_1' id='label_6_231_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_232\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_232'>Please provide a copy of the document:<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='134217728' \/><input name='input_232' id='input_6_232' type='file' class='medium' aria-describedby=\"gfield_upload_rules_6_232\" onchange='javascript:gformValidateFileSize( this, 134217728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_232'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_6_232'><\/div> <\/div><\/div><div id=\"field_6_233\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Please list the names and addresses of Physicians you would like correspondence sent to:<\/strong><\/div><div id=\"field_6_234\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_234'>Physician name and phone<\/label><div class='ginput_container ginput_container_text'><input name='input_234' id='input_6_234' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_237\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_237'>Physician name and phone<\/label><div class='ginput_container ginput_container_text'><input name='input_237' id='input_6_237' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_236\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_236'>Physician name and phone<\/label><div class='ginput_container ginput_container_text'><input name='input_236' id='input_6_236' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_235\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_235'>Physician name and phone<\/label><div class='ginput_container ginput_container_text'><input name='input_235' id='input_6_235' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_238\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>As the patient you acknowledge with the completion of this form it constitutes your complete clinical history summary<\/strong><\/p>\n<p><small>By entering my name I agree that the signature and initials will be the electronic representation of my signature and initials for all purposes when I\nuse them in this form - just the same as a pen-and-paper signature or initial<\/small><\/p><\/div><div id=\"field_6_239\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_239'>Patient \/ Responsible Party Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_239' id='input_6_239' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_242\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_242'>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_242' id='input_6_242' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_242_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_242_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_242' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_337\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you agree to sign electronically?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_337.1' id='input_6_337_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_337_1' >Yes, I agree to sign electronically.<\/label><input type='hidden' name='input_337.2' value='Yes, I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_337.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_243\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_243'>Nurse Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_243' id='input_6_243' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_244\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_244'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_244' id='input_6_244' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_244_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_244_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_244' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_338\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_338.1' id='input_6_338_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_338_1' >Yes, I agree to sign electronically.<\/label><input type='hidden' name='input_338.2' value='Yes, I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_338.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_245\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_245'>Physician Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_245' id='input_6_245' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_340\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_340'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_340' id='input_6_340' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_340_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_340_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_340' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_339\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_339.1' id='input_6_339_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_339_1' >Yes, I agree to sign electronically.<\/label><input type='hidden' name='input_339.2' value='Yes, I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_339.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_247' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_247' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_9' class='gform_page' data-js='page-field-id-247' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_249\" class=\"gfield gfield--type-html gfield--input-type-html pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">GENERAL CONSENT FOR TREATMENT, FINANCIAL AGREEMENT, AND\nCOMMUNICATION AUTHORIZATION<\/h3>\n<h4>Precision Healthcare Specialists, LLC<\/h4>\n<p>We are pleased to share that we are now part of Precision Healthcare Specialists. This transition allows us to expand our resources and continue strengthening the care we provide to our patients and community.<\/p>\n\n<p><strong>What this means for you:<\/strong><\/p>\n\n<ul>\n<li><strong>Your care will not change.<\/strong> You will continue to see the same physicians and care team you know and trust.<\/li>\n\n<li><strong>Your treatment and services remain the same.<\/strong> There is no change to the quality or approach to your care.<\/li>\n\n<li><strong>Billing statements and other administrative forms may reflect a new name.<\/strong> You may see <strong>Precision Healthcare Specialists<\/strong> listed on billing and related communications.<\/li>\n<\/ul>\n\n<p>If you have any questions about this update or your account, please contact our office. We are happy to assist you. Thank you for trusting us with your care.<\/p>\n\n<hr\/>\n\n<h4>Consent for Medical Evaluation and Treatment<\/h4>\n\n<p>I voluntarily consent to receive medical evaluation, diagnostic procedures, and treatment from Precision Healthcare Specialists (\u201cthe Practice\u201d), including its physicians, advanced practice providers, nurses, technicians, students, trainees, and other healthcare personnel involved in my care.<\/p>\n\n<p>My care may include:<\/p>\n\n<ul>\n<li>Medical evaluation and examination<\/li>\n\n<li>Diagnostic testing and procedures<\/li>\n\n<li>Laboratory testing and imaging<\/li>\n\n<li>Administration of medications<\/li>\n\n<li>Routine medical treatment and care<\/li>\n\n<li>Telehealth services when appropriate<\/li>\n<\/ul>\n\n<p>I understand that medications, injections, infusions, or other therapeutic treatments may be prescribed or administered as part of my care. These treatments may involve potential risks or side effects, including but not limited to allergic reactions, medication side effects, infection, bleeding, or other complications. When clinically appropriate, my healthcare provider may discuss the purpose, risks, benefits, and alternatives to these treatments, and I have the opportunity to ask questions before proceeding.<\/p>\n\n<p>My healthcare provider may discuss with me the nature and purpose of proposed treatments, the material risks and benefits, and reasonable alternatives, including the option of no treatment, when clinically appropriate. I have the right to ask questions about my condition, proposed treatment, risks, benefits, and alternatives, and I have the right to refuse treatment to the extent permitted by law. I understand that refusal of recommended care may affect my health outcomes.<\/p>\n\n<p>I am responsible for informing my healthcare provider of my medical history, medications, allergies, and any changes in my condition.<\/p>\n\n<hr\/>\n\n<h4>Care Team Participation and Coordination of Care<\/h4>\n\n<p>I understand that individuals involved in my care may include physicians, advanced practice providers, nurses, medical assistants, technicians, trainees, students, or other authorized healthcare personnel working under appropriate supervision.<\/p>\n\n<p>I authorize the Practice to use and disclose my medical information as necessary for treatment, payment, and healthcare operations, including coordination with other healthcare providers involved in my care, consistent with applicable federal and state privacy laws.<\/p>\n\n<hr\/>\n\n<h4>Photography and Documentation for Treatment Purposes<\/h4>\n\n<p>I understand that photographs, video, or other recordings may be taken for purposes of diagnosis, treatment, medical documentation, quality improvement, or healthcare operations. These images will be handled in accordance with privacy and security standards and applicable law.<\/p>\n\n<hr\/>\n\n<h4>Use of Technology and AI-Assisted Documentation<\/h4>\n\n<p>The Practice may use technology to support high-quality patient care and accurate medical documentation, including voice recognition, ambient listening tools, and artificial intelligence (AI)\u2013assisted documentation systems.<\/p>\n\n<p>Telehealth services and other electronic technologies rely on communication systems that may occasionally experience interruptions, delays, or technical failures that could require rescheduling or an in-person visit.<\/p>\n\n<p>I understand that:<\/p>\n\n<ul>\n<li>Technology may be used during my visit to assist with documentation.<\/li>\n\n<li>Conversations may be electronically processed to create medical records.<\/li>\n\n<li>My healthcare provider reviews and approves all documentation entered into my medical record.<\/li>\n\n<li>These tools support clinical documentation and do not replace medical judgment.<\/li>\n\n<li>Information collected is handled in accordance with applicable privacy and security laws.<\/li>\n<\/ul>\n\n<p>I understand that I may request that these technologies not be used during my visit and that my care will not be affected if I decline.<\/p><\/div><fieldset id=\"field_6_401\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Consent to use of AI or technology-assisted documentation<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_401'>\n\t\t\t<div class='gchoice gchoice_6_401_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_401' type='radio' value='I agree to the use of AI or technology-assisted documentation during my visits.'  id='choice_6_401_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_401_0' id='label_6_401_0' class='gform-field-label gform-field-label--type-inline'>I agree to the use of AI or technology-assisted documentation during my visits.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_401_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_401' type='radio' value='I decline the use of AI or technology-assisted documentation during my visits.'  id='choice_6_401_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_401_1' id='label_6_401_1' class='gform-field-label gform-field-label--type-inline'>I decline the use of AI or technology-assisted documentation during my visits.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_402\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >\n<hr\/>\n\n<h4>Procedural Acknowledgment<\/h4>\n\n<p>I understand that certain procedures, treatments, or interventions may involve additional risks and may require separate informed consent documents. When applicable, these procedures will be explained to me, including risks, benefits, and alternatives, and I will have the opportunity to ask questions before agreeing to proceed.<\/p>\n\n<hr\/>\n\n<h4>Financial Responsibility<\/h4>\n\n<p>I understand and agree that:<\/p>\n\n<ul>\n<li>All professional services rendered are the responsibility of the patient or designated party.<\/li>\n\n<li>Payment is due at the time services are rendered unless other arrangements have been made in advance.<\/li>\n\n<li>I am responsible for any balance not paid by my insurance carrier, including copayments, coinsurance, deductibles, non-covered services, and denied claims.<\/li>\n\n<li>Verification of insurance benefits is not a guarantee of payment. Coverage is determined by my insurance plan.<\/li>\n\n<li>I agree to provide current and accurate insurance information and notify the Practice of any changes.<\/li>\n\n<li>If my account becomes delinquent, it may be referred for collection, and I may be responsible for reasonable collection costs, attorney fees, and court costs where permitted by law.<\/li>\n<\/ul>\n\n<hr\/>\n\n<h4>Assignment of Benefits<\/h4>\n\n<p>I hereby assign and authorize direct payment of all medical and surgical benefits, including major medical benefits, to Precision Healthcare Specialists for services rendered to me or my dependents.<\/p>\n\n<p>I authorize my insurance carrier(s), including Medicare, private insurance, and any other health or medical plan, to issue payment directly to Precision Healthcare Specialists. I understand that I remain financially responsible for any amount not covered by insurance.<\/p>\n\n<p>A photocopy or electronic copy of this authorization shall be considered as valid as the original.<\/p>\n\n<hr\/>\n\n<h4>Authorization to Release Information for Payment<\/h4>\n\n<p>I authorize the Practice to release information necessary to:<\/p>\n\n<ul>\n<li>Process insurance claims<\/li>\n\n<li>Obtain payment<\/li>\n\n<li>Coordinate benefits with payers<\/li>\n<\/ul>\n\n<p>This authorization remains in effect until revoked by me in writing.<\/p>\n\n<hr\/>\n\n<h4>Communication Authorization and Consent to Contact<\/h4>\n\n<p>I authorize Precision Healthcare Specialists, its employees, agents, contractors, and affiliates to contact me using the contact information I have provided regarding my healthcare, appointments, treatment, billing, office policies, updates or changes and related services.<\/p>\n\n<p>Communication methods may include:<\/p>\n\n<ul>\n<li>Telephone calls<\/li>\n\n<li>Text messages (SMS)<\/li>\n\n<li>Voicemail messages<\/li>\n\n<li>Email<\/li>\n\n<li>Patient portal messaging<\/li>\n\n<li>Automated or prerecorded voice messages<\/li>\n\n<li>Other electronic communication methods<\/li>\n<\/ul>\n\n<p>These communications may include appointment reminders, care coordination, test results, billing matters, practice updates, health education, and information about services that may be relevant to my care.<\/p>\n\n<p>I understand that:<\/p>\n\n<ul>\n<li>Calls or messages may be sent using automated dialing systems or prerecorded messages.<\/li>\n\n<li>Messages may be left on voicemail or with another person unless I notify the Practice otherwise.<\/li>\n\n<li>Standard message and data rates may apply depending on my mobile carrier plan.<\/li>\n\n<li>I may opt out of certain communications at any time by notifying the Practice or following opt-out instructions (such as replying STOP to text messages).<\/li>\n<\/ul>\n\n<p>Signing this authorization is voluntary. My treatment will not be conditioned upon providing consent to receive communications.<\/p>\n<\/div><fieldset id=\"field_6_403\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Consent to receive electronic communications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_403'>\n\t\t\t<div class='gchoice gchoice_6_403_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_403' type='radio' value='I agree to receive electronic communications'  id='choice_6_403_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_403_0' id='label_6_403_0' class='gform-field-label gform-field-label--type-inline'>I agree to receive electronic communications<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_403_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_403' type='radio' value='I decline to receive electronic communications'  id='choice_6_403_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_403_1' id='label_6_403_1' class='gform-field-label gform-field-label--type-inline'>I decline to receive electronic communications<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_405\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><hr\/>\n\n<h4>Consent to Contact for Marketing &amp; Communications<\/h4>\n\n<p>By providing my contact information, I consent to receive communications from Precision Healthcare Specialists and its affiliated providers, which may include appointment reminders, follow-up care information, educational content, and information about services, programs, or events that may be of interest to me.<\/p>\n\n<p>These communications may be delivered via phone call, voicemail, text message (SMS), or email, using the contact information I have provided.<\/p>\n\n<p>I understand that:<\/p>\n\n<ul>\n<li>Consent to receive marketing or promotional communications is voluntary and is not a condition of receiving treatment or services<\/li>\n\n<li>Message and data rates may apply for text messages<\/li>\n\n<li>I may opt out at any time by following the unsubscribe instructions included in communications or by contacting the practice directly<\/li>\n<\/ul><\/div><fieldset id=\"field_6_404\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Consent to receive marketing communications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_404'>\n\t\t\t<div class='gchoice gchoice_6_404_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_404' type='radio' value='I agree to receive marketing communications'  id='choice_6_404_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_404_0' id='label_6_404_0' class='gform-field-label gform-field-label--type-inline'>I agree to receive marketing communications<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_404_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_404' type='radio' value='I decline to receive marketing communications'  id='choice_6_404_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_404_1' id='label_6_404_1' class='gform-field-label gform-field-label--type-inline'>I decline to receive marketing communications<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_406\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><hr\/>\n\n<h4>Advance Directives<\/h4>\n\n<p>I understand that I have the right under Florida law to make decisions regarding my medical care, including the right to accept or refuse treatment and the right to formulate advance directives. Information regarding advance directives is available to me upon request.<\/p>\n\n<hr\/>\n\n<h4>Duration of Consent<\/h4>\n\n<p>This consent and authorization will remain in effect for the duration of my treatment with Precision Healthcare Specialists unless revoked by me in writing.<\/p>\n\n<h4>Patient Acknowledgment and Signature<\/h4>\n\n<p>I have read and understand this document. I have had the opportunity to ask questions about my care, and my questions have been answered to my satisfaction. I voluntarily consent to medical evaluation and treatment and agree to the financial and communication terms described above.<\/p>\n<\/div><div id=\"field_6_251\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_251'>Patient \/ Responsible Party Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_251' id='input_6_251' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_407\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_407'>Relationship to Patient<\/label><div class='ginput_container ginput_container_text'><input name='input_407' id='input_6_407' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_250\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_250'>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_250' id='input_6_250' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_250_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_250_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_250' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_341\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent to sign electronically.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_341.1' id='input_6_341_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_341_1' >I agree to sign electronically.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_341.2' value='I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_341.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_252\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_252'>Witness<\/label><div class='ginput_container ginput_container_text'><input name='input_252' id='input_6_252' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_253\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_253'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_253' id='input_6_253' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_253_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_253_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_253' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_342\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent to sign electronically.<\/legend><div class='ginput_container ginput_container_consent'><input name='input_342.1' id='input_6_342_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_342_1' >I agree to sign electronically.<\/label><input type='hidden' name='input_342.2' value='I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_342.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_262' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_262' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_10' class='gform_page' data-js='page-field-id-262' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_315\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">HIPAA Patient Disclosure Form for Health Information<\/h3>\n<\/div><fieldset id=\"field_6_410\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I have read the HIPAA information below.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_410.1' id='input_6_410_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_410_1' ><p>I am a patient of Advocate Radiation Oncology (Precision Healthcare Specialists) and understand that I am required to inform the facility of the persons to whom they may disclose my medical information. These assigned persons may be changed at any time by myself. This disclosure becomes effective on the date it is signed and will continue until it is cancelled, changed, altered or amended by myself or my appointed legal representative.  This facility has notified me that they have a listing of all the persons and agencies or payers to whom my medical information may be disclosed during the course of any medical treatment by this facility.<\/p>  <p>I HAVE READ THE PERMITTED DISCLOSURE FORM AND I UNDERSTAND IT.<\/p>  <p>I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.<\/p>  <p>I understand that uses and disclosures already made based upon my original permission cannot be taken back.<\/p>  <p>I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.<\/p>  <p>I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.<\/p>  <p>I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.<\/p><\/label><input type='hidden' name='input_410.2' value='&lt;p&gt;I am a patient of Advocate Radiation Oncology (Precision Healthcare Specialists) and understand that I am required to inform the facility of the persons to whom they may disclose my medical information. These assigned persons may be changed at any time by myself. This disclosure becomes effective on the date it is signed and will continue until it is cancelled, changed, altered or amended by myself or my appointed legal representative.  This facility has notified me that they have a listing of all the persons and agencies or payers to whom my medical information may be disclosed during the course of any medical treatment by this facility.&lt;\/p&gt;  &lt;p&gt;I HAVE READ THE PERMITTED DISCLOSURE FORM AND I UNDERSTAND IT.&lt;\/p&gt;  &lt;p&gt;I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.&lt;\/p&gt;  &lt;p&gt;I understand that uses and disclosures already made based upon my original permission cannot be taken back.&lt;\/p&gt;  &lt;p&gt;I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.&lt;\/p&gt;  &lt;p&gt;I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.&lt;\/p&gt;  &lt;p&gt;I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.&lt;\/p&gt;' class='gform_hidden' \/><input type='hidden' name='input_410.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_411\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_411'>Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_411' id='input_6_411' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_412\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_412'>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_412' id='input_6_412' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_412_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_412_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_412' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_413\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent to sign electronically<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_413.1' id='input_6_413_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_413_1' >I agree to sign electronically.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_413.2' value='I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_413.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_414\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_414'>Full Name of Witness<\/label><div class='ginput_container ginput_container_text'><input name='input_414' id='input_6_414' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_415\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_415'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_415' id='input_6_415' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_415_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_415_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_415' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_416\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent to sign electronically<\/legend><div class='ginput_container ginput_container_consent'><input name='input_416.1' id='input_6_416_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_416_1' >I agree to sign electronically.<\/label><input type='hidden' name='input_416.2' value='I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_416.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_417\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>If Individual is unable to sign this Authorization, please complete the information below:<\/strong><\/div><div id=\"field_6_418\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_418'>Name of Guardian \/ Representative<\/label><div class='ginput_container ginput_container_text'><input name='input_418' id='input_6_418' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_419\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_419'>Legal Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_419' id='input_6_419' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_420\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_420'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_420' id='input_6_420' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_420_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_420_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_420' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_421\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_421'>Witness<\/label><div class='ginput_container ginput_container_text'><input name='input_421' id='input_6_421' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_422\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>I do hereby authorize the following to access my medical information at any time:<\/strong><\/div><div id=\"field_6_423\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_423'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_423' id='input_6_423' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_434\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_434'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_434' id='input_6_434' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_433\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_433'>Phone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_433' id='input_6_433' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_435\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_6_435' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_435_1_container' >\n                                        <input type='text' name='input_435.1' id='input_6_435_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_435_1' id='input_6_435_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_435_2_container' >\n                                        <input type='text' name='input_435.2' id='input_6_435_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_435_2' id='input_6_435_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_435_3_container' >\n                                    <input type='text' name='input_435.3' id='input_6_435_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_435_3' id='input_6_435_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_435_4_container' >\n                                        <input type='text' name='input_435.4' id='input_6_435_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_435_4' id='input_6_435_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_435_5_container' >\n                                    <input type='text' name='input_435.5' id='input_6_435_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_435_5' id='input_6_435_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_6_435_6_container' >\n                                        <select name='input_435.6' id='input_6_435_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_6_435_6' id='input_6_435_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_439\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br \/><\/div><div id=\"field_6_432\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_432'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_432' id='input_6_432' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_431\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_431'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_431' id='input_6_431' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_430\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_430'>Phone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_430' id='input_6_430' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_438\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_6_438' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_438_1_container' >\n                                        <input type='text' name='input_438.1' id='input_6_438_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_438_1' id='input_6_438_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_438_2_container' >\n                                        <input type='text' name='input_438.2' id='input_6_438_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_438_2' id='input_6_438_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_438_3_container' >\n                                    <input type='text' name='input_438.3' id='input_6_438_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_438_3' id='input_6_438_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_438_4_container' >\n                                        <input type='text' name='input_438.4' id='input_6_438_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_438_4' id='input_6_438_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_438_5_container' >\n                                    <input type='text' name='input_438.5' id='input_6_438_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_438_5' id='input_6_438_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_6_438_6_container' >\n                                        <select name='input_438.6' id='input_6_438_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_6_438_6' id='input_6_438_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_442\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br \/><\/div><div id=\"field_6_429\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_429'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_429' id='input_6_429' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_428\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_428'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_428' id='input_6_428' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_427\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_427'>Phone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_427' id='input_6_427' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_437\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_6_437' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_437_1_container' >\n                                        <input type='text' name='input_437.1' id='input_6_437_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_437_1' id='input_6_437_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_437_2_container' >\n                                        <input type='text' name='input_437.2' id='input_6_437_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_437_2' id='input_6_437_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_437_3_container' >\n                                    <input type='text' name='input_437.3' id='input_6_437_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_437_3' id='input_6_437_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_437_4_container' >\n                                        <input type='text' name='input_437.4' id='input_6_437_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_437_4' id='input_6_437_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_437_5_container' >\n                                    <input type='text' name='input_437.5' id='input_6_437_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_437_5' id='input_6_437_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_6_437_6_container' >\n                                        <select name='input_437.6' id='input_6_437_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_6_437_6' id='input_6_437_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_441\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br \/><\/div><div id=\"field_6_426\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_426'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_426' id='input_6_426' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_425\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_425'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_425' id='input_6_425' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_424\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_424'>Phone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_424' id='input_6_424' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_436\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_6_436' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_436_1_container' >\n                                        <input type='text' name='input_436.1' id='input_6_436_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_436_1' id='input_6_436_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_436_2_container' >\n                                        <input type='text' name='input_436.2' id='input_6_436_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_436_2' id='input_6_436_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_436_3_container' >\n                                    <input type='text' name='input_436.3' id='input_6_436_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_436_3' id='input_6_436_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_436_4_container' >\n                                        <input type='text' name='input_436.4' id='input_6_436_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_436_4' id='input_6_436_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_436_5_container' >\n                                    <input type='text' name='input_436.5' id='input_6_436_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_436_5' id='input_6_436_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_6_436_6_container' >\n                                        <select name='input_436.6' id='input_6_436_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_6_436_6' id='input_6_436_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_440\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br \/><\/div><fieldset id=\"field_6_443\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent to sign electronically<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_443.1' id='input_6_443_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_443_1' >I agree to sign electronically.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_443.2' value='I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_443.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_446\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_446'>Patient Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_446' id='input_6_446' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_447\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_447'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_447' id='input_6_447' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_447_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_447_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_447' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_444\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent to sign electronically<\/legend><div class='ginput_container ginput_container_consent'><input name='input_444.1' id='input_6_444_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_444_1' >I agree to sign electronically.<\/label><input type='hidden' name='input_444.2' value='I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_444.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_445\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_445'>Witness Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_445' id='input_6_445' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_448\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_448'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_448' id='input_6_448' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_448_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_448_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_448' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_408' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_408' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_11' class='gform_page' data-js='page-field-id-408' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_409\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"text-decoration: underline;\">Medical Records Release Form<\/h3>\n<\/div><div id=\"field_6_291\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_291'>Patient Name<\/label><div class='ginput_container ginput_container_text'><input name='input_291' id='input_6_291' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_292\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_292'>Date of Birth<\/label><div class='ginput_container ginput_container_text'><input name='input_292' id='input_6_292' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_293\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_293'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_293' id='input_6_293' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_294\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_294' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_294_1_container' >\n                                        <input type='text' name='input_294.1' id='input_6_294_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_294_1' id='input_6_294_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_294_3_container' >\n                                    <input type='text' name='input_294.3' id='input_6_294_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_294_3' id='input_6_294_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_294_4_container' >\n                                        <input type='text' name='input_294.4' id='input_6_294_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_294_4' id='input_6_294_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_294_5_container' >\n                                    <input type='text' name='input_294.5' id='input_6_294_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_294_5' id='input_6_294_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_294.6' id='input_6_294_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_295\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>1. I authorize the use or disclosure of the above-named individual\u2019s health information as described below:<\/strong><\/p>\n<p><strong>2. The following individual or organization is authorized to make the disclosure: <\/strong><\/p><\/div><div id=\"field_6_296\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_296'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_296' id='input_6_296' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_297\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_297' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_297_1_container' >\n                                        <input type='text' name='input_297.1' id='input_6_297_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_297_1' id='input_6_297_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_297_3_container' >\n                                    <input type='text' name='input_297.3' id='input_6_297_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_297_3' id='input_6_297_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_297_4_container' >\n                                        <input type='text' name='input_297.4' id='input_6_297_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_297_4' id='input_6_297_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_297_5_container' >\n                                    <input type='text' name='input_297.5' id='input_6_297_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_297_5' id='input_6_297_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_297.6' id='input_6_297_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_6_298\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >3. The type and amount of information to be used or disclosed is as follows: (include dates where appropriate).<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_298'><div class='gchoice gchoice_6_298_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.1' type='checkbox'  value='All medical records'  id='choice_6_298_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_1' id='label_6_298_1' class='gform-field-label gform-field-label--type-inline'>All medical records<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_298_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.2' type='checkbox'  value='Consultation Reports'  id='choice_6_298_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_2' id='label_6_298_2' class='gform-field-label gform-field-label--type-inline'>Consultation Reports<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_298_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.3' type='checkbox'  value='Dosimetry \/ Physics'  id='choice_6_298_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_3' id='label_6_298_3' class='gform-field-label gform-field-label--type-inline'>Dosimetry \/ Physics<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_298_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.4' type='checkbox'  value='Lab results\/X\u2010ray reports'  id='choice_6_298_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_4' id='label_6_298_4' class='gform-field-label gform-field-label--type-inline'>Lab results\/X\u2010ray reports<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_298_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.5' type='checkbox'  value='Progress Notes'  id='choice_6_298_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_5' id='label_6_298_5' class='gform-field-label gform-field-label--type-inline'>Progress Notes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_298_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.6' type='checkbox'  value='Follow up'  id='choice_6_298_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_6' id='label_6_298_6' class='gform-field-label gform-field-label--type-inline'>Follow up<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_298_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.7' type='checkbox'  value='Other (Please specify)'  id='choice_6_298_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_7' id='label_6_298_7' class='gform-field-label gform-field-label--type-inline'>Other (Please specify)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_300\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>4. I understand that the information in my health records may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.<\/strong><\/p> \n\n<p><strong>5. This information may be disclosed to and used by the following individual or organization.<\/strong><\/p><\/div><fieldset id=\"field_6_368\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Location | Advocate Radiation Oncology LLC<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_368'>\n\t\t\t<div class='gchoice gchoice_6_368_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Port Charlotte&lt;\/strong&gt; &lt;br&gt;3080 Harbor Blvd. &lt;br&gt;Port Charlotte, FL 33952 &lt;br&gt;Phone: (941) 883-2199 &lt;br&gt;Fax: (941) 979-5041'  id='choice_6_368_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_0' id='label_6_368_0' class='gform-field-label gform-field-label--type-inline'><strong>Port Charlotte<\/strong> <br>3080 Harbor Blvd. <br>Port Charlotte, FL 33952 <br>Phone: (941) 883-2199 <br>Fax: (941) 979-5041<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Port Charlotte 2&lt;\/strong&gt; &lt;br&gt;3175 Harbor Blvd&lt;br&gt;Port Charlotte, FL 33952 &lt;br&gt;Phone: (941) 220-6460 &lt;br&gt;Fax: (941) 220-5284'  id='choice_6_368_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_1' id='label_6_368_1' class='gform-field-label gform-field-label--type-inline'><strong>Port Charlotte 2<\/strong> <br>3175 Harbor Blvd<br>Port Charlotte, FL 33952 <br>Phone: (941) 220-6460 <br>Fax: (941) 220-5284<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Fort Myers&lt;\/strong&gt; &lt;br&gt;15681 New Hampshire Ct. &lt;br&gt;Fort Myers, FL 33908 &lt;br&gt;Phone: (239) 437-1977 &lt;br&gt;Fax: (239) 437-1889'  id='choice_6_368_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_2' id='label_6_368_2' class='gform-field-label gform-field-label--type-inline'><strong>Fort Myers<\/strong> <br>15681 New Hampshire Ct. <br>Fort Myers, FL 33908 <br>Phone: (239) 437-1977 <br>Fax: (239) 437-1889<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Cape Coral&lt;\/strong&gt; &lt;br&gt;909 Del Pra do Blvd. S &lt;br&gt;Cape Coral, FL 33990 &lt;br&gt;Phone: (239) 217-8070 &lt;br&gt;Fax: (239) 217-8069'  id='choice_6_368_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_3' id='label_6_368_3' class='gform-field-label gform-field-label--type-inline'><strong>Cape Coral<\/strong> <br>909 Del Pra do Blvd. S <br>Cape Coral, FL 33990 <br>Phone: (239) 217-8070 <br>Fax: (239) 217-8069<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Bonita Springs&lt;\/strong&gt; &lt;br&gt;25243 Elementary Way&lt;br&gt;Bonita Spings, FL 34135 &lt;br&gt;Phone: (239) 317-2772 &lt;br&gt;Fax: (239) 676-7637'  id='choice_6_368_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_4' id='label_6_368_4' class='gform-field-label gform-field-label--type-inline'><strong>Bonita Springs<\/strong> <br>25243 Elementary Way<br>Bonita Spings, FL 34135 <br>Phone: (239) 317-2772 <br>Fax: (239) 676-7637<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Naples&lt;\/strong&gt; &lt;br&gt;1775 Davis Blvd. &lt;br&gt;Naples, FL 34102 &lt;br&gt;Phone: (239) 372-2838'  id='choice_6_368_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_5' id='label_6_368_5' class='gform-field-label gform-field-label--type-inline'><strong>Naples<\/strong> <br>1775 Davis Blvd. <br>Naples, FL 34102 <br>Phone: (239) 372-2838<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Bradenton&lt;\/strong&gt; &lt;br&gt;5325 E St Road 64&lt;br&gt;Bradenton, FL 34208 &lt;br&gt;Phone: (941) 220-6263 &lt;br&gt;Fax: (386) 490-9100'  id='choice_6_368_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_6' id='label_6_368_6' class='gform-field-label gform-field-label--type-inline'><strong>Bradenton<\/strong> <br>5325 E St Road 64<br>Bradenton, FL 34208 <br>Phone: (941) 220-6263 <br>Fax: (386) 490-9100<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Tamarac&lt;\/strong&gt; &lt;br&gt;7850 N. University Drive&lt;br&gt;Tamarac, FL 33321 &lt;br&gt;Phone: (754) 205-0099 &lt;br&gt;Fax: (954) 388-5849'  id='choice_6_368_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_7' id='label_6_368_7' class='gform-field-label gform-field-label--type-inline'><strong>Tamarac<\/strong> <br>7850 N. University Drive<br>Tamarac, FL 33321 <br>Phone: (754) 205-0099 <br>Fax: (954) 388-5849<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;West Palm Beach&lt;\/strong&gt; &lt;br&gt;4832 Okeechobee Blvd&lt;br&gt;West Palm Beach, FL 33417 &lt;br&gt;Phone: (561) 277-0786 &lt;br&gt;Fax: (561) 277-0831'  id='choice_6_368_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_8' id='label_6_368_8' class='gform-field-label gform-field-label--type-inline'><strong>West Palm Beach<\/strong> <br>4832 Okeechobee Blvd<br>West Palm Beach, FL 33417 <br>Phone: (561) 277-0786 <br>Fax: (561) 277-0831<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Wellen Park - Venice&lt;\/strong&gt; &lt;br&gt; 8020 S Tamiami Trail Suite 101 &lt;br&gt;Venice, FL 34293 &lt;br&gt;Phone: (941) 220-6460 &lt;br&gt;Fax: (941) 220-5284'  id='choice_6_368_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_9' id='label_6_368_9' class='gform-field-label gform-field-label--type-inline'><strong>Wellen Park - Venice<\/strong> <br> 8020 S Tamiami Trail Suite 101 <br>Venice, FL 34293 <br>Phone: (941) 220-6460 <br>Fax: (941) 220-5284<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Proton Center&lt;\/strong&gt; &lt;br&gt;9961 Estero Oaks Dr, 1st Floor &lt;br&gt;Fort Myers, FL 33967'  id='choice_6_368_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_10' id='label_6_368_10' class='gform-field-label gform-field-label--type-inline'><strong>Proton Center<\/strong> <br>9961 Estero Oaks Dr, 1st Floor <br>Fort Myers, FL 33967<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Lakewood Ranch&lt;\/strong&gt; &lt;br&gt;8946 77th Terrace East&lt;br&gt;Lakewood Ranch, FL, 34202-6421'  id='choice_6_368_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_11' id='label_6_368_11' class='gform-field-label gform-field-label--type-inline'><strong>Lakewood Ranch<\/strong> <br>8946 77th Terrace East<br>Lakewood Ranch, FL, 34202-6421<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_302\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_302'>For the purpose of:<\/label><div class='ginput_container ginput_container_text'><input name='input_302' id='input_6_302' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_303\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_303'>6. I understand that I have a right to revoke this authorization at any time. I understand that is I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. UNLESS OTHERWISE REVOKED, THIS AUTHORIZATION WILL EXPIRE ON THE FOLLOWING DATE, EVENT, OR CONDITION:<\/label><div class='ginput_container ginput_container_text'><input name='input_303' id='input_6_303' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_305\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>7. If I fail to specify an expiration date, event or condition, this authorization will expire in one year. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact a clinic representative at any of the Advocate Radiation Oncology locations.<\/strong><\/p><\/div><fieldset id=\"field_6_347\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent to sign electronically<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_347.1' id='input_6_347_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_347_1' >Yes, I agree to sign electronically.<\/label><input type='hidden' name='input_347.2' value='Yes, I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_347.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_306\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_306'>Signature of patient or legal representative<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_306' id='input_6_306' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_309\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_309'>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_309' id='input_6_309' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_309_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_309_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_309' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_307\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_307'>Printed name of Patient or Representative &amp; relationship to patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_307' id='input_6_307' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_387' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_387' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_12' class='gform_page' data-js='page-field-id-387' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_388\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please carefully review your submission. If there are any errors, use the links above to edit that section. <br \/><br \/>\n\n<strong>On page 11, you selected this as your primary office location:<\/strong><br \/><br \/>\n<span style=\"color: #ff0000;\">{Field:368}<\/span>\n\n<br \/><br \/>\n\n{all_fields}<\/div><div id=\"field_6_390\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_390'>Confirmation Number (internal)<\/label><div class='ginput_container ginput_container_text'><input name='input_390' id='input_6_390' type='text' value='' class=''      aria-invalid=\"false\"   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