{"id":642,"date":"2021-05-30T17:56:43","date_gmt":"2021-05-30T17:56:43","guid":{"rendered":"https:\/\/www.duraanorthodontics.co.za\/eng\/?page_id=642"},"modified":"2021-07-14T06:43:40","modified_gmt":"2021-07-14T06:43:40","slug":"full-health-history-form","status":"publish","type":"page","link":"https:\/\/www.duraanorthodontics.co.za\/eng\/full-health-history-form\/","title":{"rendered":"Full Health History Form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column 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data-config=\"{&quot;form_id&quot;:&quot;557&quot;,&quot;form_post_id&quot;:&quot;557&quot;,&quot;post_id&quot;:642,&quot;form_type&quot;:&quot;database_email&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;field_labels&quot;:{&quot;first_name&quot;:&quot;&quot;,&quot;middle_name&quot;:&quot;&quot;,&quot;last_name&quot;:&quot;&quot;,&quot;nickname&quot;:&quot;&quot;,&quot;birthdate&quot;:&quot;&quot;,&quot;gender&quot;:&quot;&quot;,&quot;address_1&quot;:&quot;&quot;,&quot;address_2&quot;:&quot;&quot;,&quot;city&quot;:&quot;&quot;,&quot;postal_code&quot;:&quot;&quot;,&quot;main_phone&quot;:&quot;&quot;,&quot;second_phone&quot;:&quot;&quot;,&quot;email&quot;:&quot;&quot;,&quot;parent_guardian&quot;:&quot;&quot;,&quot;pasient_residence&quot;:&quot;&quot;,&quot;friends_family&quot;:&quot;&quot;,&quot;sports_hobbies&quot;:&quot;&quot;,&quot;thanks_to&quot;:&quot;&quot;,&quot;patient_financially_responsible&quot;:&quot;&quot;,&quot;first_name_financial&quot;:&quot;&quot;,&quot;last_name_financial&quot;:&quot;&quot;,&quot;marital_status_financial&quot;:&quot;&quot;,&quot;relation_to_patient&quot;:&quot;&quot;,&quot;birthdate_financial&quot;:&quot;&quot;,&quot;address_1_financial&quot;:&quot;&quot;,&quot;address_2_financial&quot;:&quot;&quot;,&quot;city_financial&quot;:&quot;&quot;,&quot;postal_code_financial&quot;:&quot;&quot;,&quot;period_reside&quot;:&quot;&quot;,&quot;previous_address_1&quot;:&quot;If less than 3 years, please provide us with the details of your previous address&quot;,&quot;previous_address_2&quot;:&quot;&quot;,&quot;city_previous-address&quot;:&quot;&quot;,&quot;postal_code_previous_address&quot;:&quot;&quot;,&quot;email_financial&quot;:&quot;&quot;,&quot;main_phone_financial&quot;:&quot;&quot;,&quot;second_phone_financial&quot;:&quot;&quot;,&quot;work_phone_financial&quot;:&quot;&quot;,&quot;ID_number_financial&quot;:&quot;&quot;,&quot;employer_financial&quot;:&quot;&quot;,&quot;occupation_financial&quot;:&quot;&quot;,&quot;occupation_period_financial&quot;:&quot;&quot;,&quot;spouse_first_name_financial&quot;:&quot;&quot;,&quot;spouse_middle_name_financial&quot;:&quot;&quot;,&quot;spouse_last_name_financial&quot;:&quot;&quot;,&quot;spouse_relation_to_patient&quot;:&quot;&quot;,&quot;spouse_ID_number&quot;:&quot;&quot;,&quot;spouse_birthdate_financial&quot;:&quot;&quot;,&quot;spouse_employer&quot;:&quot;&quot;,&quot;spouse_occupation&quot;:&quot;&quot;,&quot;spouse_employment_period&quot;:&quot;&quot;,&quot;spouse_work_phone&quot;:&quot;&quot;,&quot;policy_holder_name&quot;:&quot;&quot;,&quot;policy_holder_relation_to_patient&quot;:&quot;&quot;,&quot;insurance_company&quot;:&quot;&quot;,&quot;subscriber_id&quot;:&quot;&quot;,&quot;insurance_plan&quot;:&quot;&quot;,&quot;insurance_telephone&quot;:&quot;&quot;,&quot;nearest_relative_name&quot;:&quot;&quot;,&quot;nearest_relative_phone&quot;:&quot;&quot;,&quot;relative_address_1&quot;:&quot;&quot;,&quot;relative_address_2&quot;:&quot;&quot;,&quot;relative_address_city&quot;:&quot;&quot;,&quot;relative_address_code&quot;:&quot;&quot;,&quot;relative_relation_to_patient&quot;:&quot;&quot;,&quot;dentist_name&quot;:&quot;&quot;,&quot;check_up_frequency&quot;:&quot;&quot;,&quot;last_dental_visit&quot;:&quot;&quot;,&quot;orthodontic_consultation&quot;:&quot;Has the patient had an orthodontic consultation or treatment?&quot;,&quot;date_of_orthodontic_consultation&quot;:&quot;&quot;,&quot;premedicate_required&quot;:&quot;Does the patient need to premedicate prior to dental visit?&quot;,&quot;main_orthodontic_concern&quot;:&quot;&quot;,&quot;speech_problems&quot;:&quot;Speech problems\\\/therapy&quot;,&quot;clench_grind_teeth&quot;:&quot;Clench or Grind Teeth&quot;,&quot;oral_habits&quot;:&quot;Oral habits (thumb\\\/finger sucking, lip\\\/nail biting)&quot;,&quot;injury&quot;:&quot;Injury to face, jaw, teeth or mouth&quot;,&quot;discomfort &quot;:&quot;Discomfort from teeth or gums&quot;,&quot;pain_tenderness&quot;:&quot;Pain, tenderness or noise in either jaw&quot;,&quot;frequent_headaches&quot;:&quot;Frequent headaches&quot;,&quot;neck_shoulder_pain&quot;:&quot;Neck \\\/ Shoulder Pain&quot;,&quot;frequent_sore_throats&quot;:&quot;Frequent sore throats&quot;,&quot;injured_permanent_teeth&quot;:&quot;Chipped or injured permanent teeth&quot;,&quot;sensitive_hot_cold&quot;:&quot;Teeth sensitive to hot or cold&quot;,&quot;previous_root_canal&quot;:&quot;Previous root canal therapy&quot;,&quot;bad_taste_mouth_odor&quot;:&quot;Bad taste \\\/ mouth odor&quot;,&quot;periodontal_treatment&quot;:&quot;Previous periodontal (gum) treatment&quot;,&quot;abnormal_swallowing&quot;:&quot;Abnormal swallowing (tongue thrust)&quot;,&quot;teeth_that_irritate&quot;:&quot;Teeth that irritate tongue, cheek, lip, etc.&quot;,&quot;numerous_fillings&quot;:&quot;Numerous fillings&quot;,&quot;brush_teeth_daily&quot;:&quot;Brush teeth daily&quot;,&quot;floss_teeth_daily&quot;:&quot;Floss teeth daily&quot;,&quot;fluoride_treatments&quot;:&quot;Fluoride treatments&quot;,&quot;mouth_breathing&quot;:&quot;Mouth breathing&quot;,&quot;snores_during_sleep&quot;:&quot;Snores during sleep&quot;,&quot;missing_extra_permanent_teeth&quot;:&quot;Any missing or extra permanent teeth&quot;,&quot;apprehensive_dental_care&quot;:&quot;Apprehensive about dental care&quot;,&quot;frequently_chew_gum&quot;:&quot;Frequently Chew Gum&quot;,&quot;thumb_habit_as_child&quot;:&quot;Thumb or finger habit as a child&quot;,&quot;jaw_fractures_cysts_infections&quot;:&quot;Jaw fractures, cysts, mouth infections&quot;,&quot;bleeding_gums&quot;:&quot;Bleeding gums&quot;,&quot;other_periodontal_problems&quot;:&quot;Other periodontal (gum) problems&quot;,&quot;canker_sores_cold_sores&quot;:&quot;Frequent canker sores or cold sores&quot;,&quot;wisdom_teeth_removed&quot;:&quot;Have wisdom teeth been removed?&quot;,&quot;food_trapped_between_teeth&quot;:&quot;Problems with food trapped between teeth&quot;,&quot;dental_work_completed&quot;:&quot;Is all dental work completed?&quot;,&quot;answers_explained&quot;:&quot;If any of the above dental questions were answered &#039;Yes&#039;, please explain:&quot;,&quot;TMJ_screening&quot;:&quot;Have you had a TMJ screening?&quot;,&quot;jaw_joint_problems&quot;:&quot;Do you have a history of jaw joint problems&quot;,&quot;treated_for_TMJ&quot;:&quot;Have you been treated for TMJ?&quot;,&quot;jaw_joint_popping &quot;:&quot;Do you notice clicking or popping in your jaw joint?&quot;,&quot;clench_teeth&quot;:&quot;Do you clench your teeth?&quot;,&quot;jaw_ever_locked&quot;:&quot;Has your jaw ever locked?&quot;,&quot;difficulty_chewing_opening_mouth&quot;:&quot;Do you have difficulty chewing or opening your mouth?&quot;,&quot;bite_feel_uncomfortable&quot;:&quot;Does your bite feel uncomfortable or unusual&quot;,&quot;soreness_muscles_face_around_ears&quot;:&quot;Do you experience soreness in the muscles of your face or around your ears?&quot;,&quot;TMJ_answers_explained&quot;:&quot;If any of the above TMJ questions were answered &#039;Yes&#039; please explain:&quot;,&quot;physician_name&quot;:&quot;&quot;,&quot;physician_number&quot;:&quot;&quot;,&quot;last_physical&quot;:&quot;&quot;,&quot;patient_health_conditions&quot;:&quot;Patient Health conditions&quot;,&quot;change_in_health&quot;:&quot;Has there been any change in the patient&#039;s general health within the last year?&quot;,&quot;under_physician_care&quot;:&quot;Is the patient now under the care of a physician (other than routine)?&quot;,&quot;treatment&quot;:&quot;If so, what is being treated?&quot;,&quot;illness_hospitalisation &quot;:&quot;Has the patient had a serious illness\\\/hospitalisation in the past 5 years? &quot;,&quot;hospitalisation_reason&quot;:&quot;If so, what for?&quot;,&quot;medications&quot;:&quot;List any medications currently being taken by the patient (include non-prescription):&quot;,&quot;latex&quot;:&quot;Latex&quot;,&quot;Penicillin_antibiotics &quot;:&quot;Penicillin or other antibiotics&quot;,&quot;sulfa_drugs&quot;:&quot;Sulfa drugs&quot;,&quot;Aspirin_Ibuprofen_Tylenol &quot;:&quot;Aspirin, Ibuprofen, Tylenol &quot;,&quot;Local_anesthetics&quot;:&quot;Local anesthetics&quot;,&quot;Codeine_narcotics &quot;:&quot;Codeine or other narcotics &quot;,&quot;Latex_Metal_Allergy&quot;:&quot;Latex \\\/ Metal Allergy&quot;,&quot;other_allergies&quot;:&quot;Other&quot;,&quot;drug_allergies_sensitivities &quot;:&quot;List any drug allergies or sensitivities (not listed above) that the patient may have:&quot;,&quot;Heart_Murmur&quot;:&quot;Heart Murmur&quot;,&quot;Damaged_artificial_heart_valves &quot;:&quot;Damaged or artificial heart valves &quot;,&quot;Congenital_Heart_Defect &quot;:&quot;Congenital Heart Defect &quot;,&quot;Heart_Disease&quot;:&quot;Heart Disease&quot;,&quot;Rheumatic_Fever&quot;:&quot;Rheumatic Fever&quot;,&quot;Angina&quot;:&quot;Angina&quot;,&quot;Liver_Disease_Jaundice_Hepatitis &quot;:&quot;Liver Disease \\\/ Jaundice \\\/ Hepatitis &quot;,&quot;Kidney_Disease&quot;:&quot;Kidney Disease&quot;,&quot;Heart_Attack_Stroke&quot;:&quot;Heart Attack \\\/ Stroke&quot;,&quot;Hemophilia&quot;:&quot;Hemophilia&quot;,&quot;Hypertension&quot;:&quot;Hypertension \\\/ High Blood Pressure &quot;,&quot;Prolonged_Bleeding_Transfusion &quot;:&quot;Prolonged Bleeding \\\/ Transfusion &quot;,&quot;Anemia_Blood_Disorder &quot;:&quot;Anemia \\\/ Blood Disorder &quot;,&quot;HIV_AIDS&quot;:&quot;HIV \\\/ AIDS&quot;,&quot;Tonsils_Adenoids_Removed &quot;:&quot;Tonsils \\\/ Adenoids Removed &quot;,&quot;Handicaps_Disabilities&quot;:&quot;Handicaps \\\/ Disabilities&quot;,&quot;Arthritis_joint_problems &quot;:&quot;Arthritis \\\/ Joint problems &quot;,&quot;Large_Tonsils&quot;:&quot;Large Tonsils&quot;,&quot;Sinus_Trouble&quot;:&quot;Sinus_Trouble&quot;,&quot;Bed_Wetting&quot;:&quot;Bed_Wetting&quot;,&quot;Substance_abuse&quot;:&quot;Substance abuse problems (past or present) &quot;,&quot;Bone_fractures_Trauma_face_Jaw &quot;:&quot;Bone fractures \\\/ Trauma to face \\\/ Jaw &quot;,&quot;Prosthetic_Joints&quot;:&quot;Prosthetic Joints&quot;,&quot;Chronic_Fatigue&quot;:&quot;Chronic Fatigue&quot;,&quot;Diabetes&quot;:&quot;Diabetes&quot;,&quot;Growth_Problems&quot;:&quot;Growth Problems&quot;,&quot;Tuberculosis_Lung_Disease &quot;:&quot;Tuberculosis or Lung Disease &quot;,&quot;Pneumonia&quot;:&quot;Pneumonia&quot;,&quot;Cancer&quot;:&quot;Cancer&quot;,&quot;Family_History_Cancer &quot;:&quot;Family History of Cancer &quot;,&quot;Received_Radiation_Treatment &quot;:&quot;Received Radiation Treatment &quot;,&quot;Arteriosclerosis&quot;:&quot;Arteriosclerosis&quot;,&quot;Thyroid_Endocrine_Problems &quot;:&quot;Thyroid \\\/ Endocrine Problems &quot;,&quot;Stomach_Ulcer_Hyperacidity &quot;:&quot;Stomach Ulcer or Hyperacidity &quot;,&quot;Hormone_Therapy&quot;:&quot;Hormone Therapy&quot;,&quot;Nervous_Disorders&quot;:&quot;Nervous Disorders&quot;,&quot;Bone_Disorders_Bone_Loss &quot;:&quot;Bone Disorders\\\/Bone Loss &quot;,&quot;Seizures_Epilepsy_Neurological_Disease &quot;:&quot;Seizures \\\/ Epilepsy \\\/ Neurological Disease &quot;,&quot;Treated_Emotional_Problems &quot;:&quot;Treated for Emotional Problems &quot;,&quot;Asthma&quot;:&quot;Asthma&quot;,&quot;Respiratory_Problems_Emphysema &quot;:&quot;Respiratory Problems \\\/ Emphysema &quot;,&quot;Persistent_swollen_neck_glands &quot;:&quot;Persistent swollen neck glands &quot;,&quot;Sexually_Transmitted_Disease &quot;:&quot;Sexually Transmitted Disease &quot;,&quot;Low_Blood_Pressure&quot;:&quot;Low Blood Pressure&quot;,&quot;Persistent_Cough&quot;:&quot;Persistent Cough&quot;,&quot;FEMALES_Are_you_pregnant?&quot;:&quot;FEMALES: Are you pregnant?&quot;,&quot;Take_Bisphosphonates_Fosamax_Boniva&quot;:&quot;Take Bisphosphonates (Fosamax, Boniva)&quot;,&quot;If_any_of_the_above_medical_questions_were_answered_Yes_please_explain&quot;:&quot;If any of the above medical questions were answered &#039;Yes&#039; , please explain:&quot;,&quot;straighten_front_teeth&quot;:&quot;&quot;,&quot;front_teeth_position&quot;:&quot;&quot;,&quot;straighten_back_teeth&quot;:&quot;&quot;,&quot;back_teeth_position&quot;:&quot;&quot;,&quot;move_upper_teeth&quot;:&quot;&quot;,&quot;upper_teeth_position&quot;:&quot;&quot;,&quot;move_lower_teeth&quot;:&quot;&quot;,&quot;lower_teeth_position&quot;:&quot;&quot;,&quot;eliminate_spaces&quot;:&quot;&quot;,&quot;eliminate_spaces_position&quot;:&quot;&quot;,&quot;eliminate_crowding&quot;:&quot;&quot;,&quot;eliminate_crowding_position&quot;:&quot;&quot;,&quot;upper_teeth_level&quot;:&quot;&quot;,&quot;other&quot;:&quot;&quot;,&quot;other_details&quot;:&quot;&quot;,&quot;Move_Upper_Lip&quot;:&quot;&quot;,&quot;Move_Upper_Lip_position&quot;:&quot;&quot;,&quot;Move_Lower_Lip&quot;:&quot;&quot;,&quot;Move_Lower_Lip_position&quot;:&quot;&quot;,&quot;Show_teeth_when_smile &quot;:&quot;&quot;,&quot;Show_teeth_when_smile_position&quot;:&quot;&quot;,&quot;Show_gums_when_smile &quot;:&quot;&quot;,&quot;Show_gums_when_smile_position&quot;:&quot;&quot;,&quot;make_my_nose&quot;:&quot;&quot;,&quot;make_my_nose_position&quot;:&quot;&quot;,&quot;move_chin&quot;:&quot;&quot;,&quot;move_chin_position&quot;:&quot;&quot;,&quot;reduce_strain&quot;:&quot;&quot;,&quot;reduce_strain_position&quot;:&quot;&quot;,&quot;teeth_touch_lips&quot;:&quot;&quot;,&quot;teeth_touch_lips_position&quot;:&quot;&quot;,&quot;Height&quot;:&quot;&quot;,&quot;Weight&quot;:&quot;&quot;,&quot;School&quot;:&quot;&quot;,&quot;Grade&quot;:&quot;&quot;,&quot;begun_puberty&quot;:&quot;Has patient begun puberty: &quot;,&quot;menstruation_begun&quot;:&quot;If patient is a girl, has menstruation begun: &quot;,&quot;boy_voice_changed&quot;:&quot;If patient is a boy, has their voice changed or have facial hair: &quot;,&quot;patient_grown_shoe_size_changed&quot;:&quot;Has the patient grown in the past year or has their shoe size changed recently: &quot;,&quot;biological_parent_orthodontics&quot;:&quot;Has either biological parent ever had orthodontic treatment: &quot;,&quot;Certify&quot;:&quot;&quot;,&quot;Credit_Reports&quot;:&quot;&quot;},&quot;field_logics&quot;:{&quot;first_name&quot;:&quot;&quot;,&quot;middle_name&quot;:&quot;&quot;,&quot;last_name&quot;:&quot;&quot;,&quot;nickname&quot;:&quot;&quot;,&quot;birthdate&quot;:&quot;&quot;,&quot;gender&quot;:&quot;&quot;,&quot;address_1&quot;:&quot;&quot;,&quot;address_2&quot;:&quot;&quot;,&quot;city&quot;:&quot;&quot;,&quot;postal_code&quot;:&quot;&quot;,&quot;main_phone&quot;:&quot;&quot;,&quot;second_phone&quot;:&quot;&quot;,&quot;email&quot;:&quot;&quot;,&quot;parent_guardian&quot;:&quot;&quot;,&quot;pasient_residence&quot;:&quot;&quot;,&quot;friends_family&quot;:&quot;&quot;,&quot;sports_hobbies&quot;:&quot;&quot;,&quot;thanks_to&quot;:&quot;&quot;,&quot;patient_financially_responsible&quot;:&quot;&quot;,&quot;first_name_financial&quot;:&quot;&quot;,&quot;last_name_financial&quot;:&quot;&quot;,&quot;marital_status_financial&quot;:&quot;&quot;,&quot;relation_to_patient&quot;:&quot;&quot;,&quot;birthdate_financial&quot;:&quot;&quot;,&quot;address_1_financial&quot;:&quot;&quot;,&quot;address_2_financial&quot;:&quot;&quot;,&quot;city_financial&quot;:&quot;&quot;,&quot;postal_code_financial&quot;:&quot;&quot;,&quot;period_reside&quot;:&quot;&quot;,&quot;previous_address_1&quot;:&quot;&quot;,&quot;previous_address_2&quot;:&quot;&quot;,&quot;city_previous-address&quot;:&quot;&quot;,&quot;postal_code_previous_address&quot;:&quot;&quot;,&quot;email_financial&quot;:&quot;&quot;,&quot;main_phone_financial&quot;:&quot;&quot;,&quot;second_phone_financial&quot;:&quot;&quot;,&quot;work_phone_financial&quot;:&quot;&quot;,&quot;ID_number_financial&quot;:&quot;&quot;,&quot;employer_financial&quot;:&quot;&quot;,&quot;occupation_financial&quot;:&quot;&quot;,&quot;occupation_period_financial&quot;:&quot;&quot;,&quot;spouse_first_name_financial&quot;:&quot;&quot;,&quot;spouse_middle_name_financial&quot;:&quot;&quot;,&quot;spouse_last_name_financial&quot;:&quot;&quot;,&quot;spouse_relation_to_patient&quot;:&quot;&quot;,&quot;spouse_ID_number&quot;:&quot;&quot;,&quot;spouse_birthdate_financial&quot;:&quot;&quot;,&quot;spouse_employer&quot;:&quot;&quot;,&quot;spouse_occupation&quot;:&quot;&quot;,&quot;spouse_employment_period&quot;:&quot;&quot;,&quot;spouse_work_phone&quot;:&quot;&quot;,&quot;policy_holder_name&quot;:&quot;&quot;,&quot;policy_holder_relation_to_patient&quot;:&quot;&quot;,&quot;insurance_company&quot;:&quot;&quot;,&quot;subscriber_id&quot;:&quot;&quot;,&quot;insurance_plan&quot;:&quot;&quot;,&quot;insurance_telephone&quot;:&quot;&quot;,&quot;nearest_relative_name&quot;:&quot;&quot;,&quot;nearest_relative_phone&quot;:&quot;&quot;,&quot;relative_address_1&quot;:&quot;&quot;,&quot;relative_address_2&quot;:&quot;&quot;,&quot;relative_address_city&quot;:&quot;&quot;,&quot;relative_address_code&quot;:&quot;&quot;,&quot;relative_relation_to_patient&quot;:&quot;&quot;,&quot;dentist_name&quot;:&quot;&quot;,&quot;check_up_frequency&quot;:&quot;&quot;,&quot;last_dental_visit&quot;:&quot;&quot;,&quot;orthodontic_consultation&quot;:&quot;&quot;,&quot;date_of_orthodontic_consultation&quot;:&quot;&quot;,&quot;premedicate_required&quot;:&quot;&quot;,&quot;main_orthodontic_concern&quot;:&quot;&quot;,&quot;speech_problems&quot;:&quot;&quot;,&quot;clench_grind_teeth&quot;:&quot;&quot;,&quot;oral_habits&quot;:&quot;&quot;,&quot;injury&quot;:&quot;&quot;,&quot;discomfort &quot;:&quot;&quot;,&quot;pain_tenderness&quot;:&quot;&quot;,&quot;frequent_headaches&quot;:&quot;&quot;,&quot;neck_shoulder_pain&quot;:&quot;&quot;,&quot;frequent_sore_throats&quot;:&quot;&quot;,&quot;injured_permanent_teeth&quot;:&quot;&quot;,&quot;sensitive_hot_cold&quot;:&quot;&quot;,&quot;previous_root_canal&quot;:&quot;&quot;,&quot;bad_taste_mouth_odor&quot;:&quot;&quot;,&quot;periodontal_treatment&quot;:&quot;&quot;,&quot;abnormal_swallowing&quot;:&quot;&quot;,&quot;teeth_that_irritate&quot;:&quot;&quot;,&quot;numerous_fillings&quot;:&quot;&quot;,&quot;brush_teeth_daily&quot;:&quot;&quot;,&quot;floss_teeth_daily&quot;:&quot;&quot;,&quot;fluoride_treatments&quot;:&quot;&quot;,&quot;mouth_breathing&quot;:&quot;&quot;,&quot;snores_during_sleep&quot;:&quot;&quot;,&quot;missing_extra_permanent_teeth&quot;:&quot;&quot;,&quot;apprehensive_dental_care&quot;:&quot;&quot;,&quot;frequently_chew_gum&quot;:&quot;&quot;,&quot;thumb_habit_as_child&quot;:&quot;&quot;,&quot;jaw_fractures_cysts_infections&quot;:&quot;&quot;,&quot;bleeding_gums&quot;:&quot;&quot;,&quot;other_periodontal_problems&quot;:&quot;&quot;,&quot;canker_sores_cold_sores&quot;:&quot;&quot;,&quot;wisdom_teeth_removed&quot;:&quot;&quot;,&quot;food_trapped_between_teeth&quot;:&quot;&quot;,&quot;dental_work_completed&quot;:&quot;&quot;,&quot;answers_explained&quot;:&quot;&quot;,&quot;TMJ_screening&quot;:&quot;&quot;,&quot;jaw_joint_problems&quot;:&quot;&quot;,&quot;treated_for_TMJ&quot;:&quot;&quot;,&quot;jaw_joint_popping &quot;:&quot;&quot;,&quot;clench_teeth&quot;:&quot;&quot;,&quot;jaw_ever_locked&quot;:&quot;&quot;,&quot;difficulty_chewing_opening_mouth&quot;:&quot;&quot;,&quot;bite_feel_uncomfortable&quot;:&quot;&quot;,&quot;soreness_muscles_face_around_ears&quot;:&quot;&quot;,&quot;TMJ_answers_explained&quot;:&quot;&quot;,&quot;physician_name&quot;:&quot;&quot;,&quot;physician_number&quot;:&quot;&quot;,&quot;last_physical&quot;:&quot;&quot;,&quot;patient_health_conditions&quot;:&quot;&quot;,&quot;change_in_health&quot;:&quot;&quot;,&quot;under_physician_care&quot;:&quot;&quot;,&quot;treatment&quot;:&quot;&quot;,&quot;illness_hospitalisation &quot;:&quot;&quot;,&quot;hospitalisation_reason&quot;:&quot;&quot;,&quot;medications&quot;:&quot;&quot;,&quot;latex&quot;:&quot;&quot;,&quot;Penicillin_antibiotics &quot;:&quot;&quot;,&quot;sulfa_drugs&quot;:&quot;&quot;,&quot;Aspirin_Ibuprofen_Tylenol &quot;:&quot;&quot;,&quot;Local_anesthetics&quot;:&quot;&quot;,&quot;Codeine_narcotics &quot;:&quot;&quot;,&quot;Latex_Metal_Allergy&quot;:&quot;&quot;,&quot;other_allergies&quot;:&quot;&quot;,&quot;drug_allergies_sensitivities &quot;:&quot;&quot;,&quot;Heart_Murmur&quot;:&quot;&quot;,&quot;Damaged_artificial_heart_valves &quot;:&quot;&quot;,&quot;Congenital_Heart_Defect &quot;:&quot;&quot;,&quot;Heart_Disease&quot;:&quot;&quot;,&quot;Rheumatic_Fever&quot;:&quot;&quot;,&quot;Angina&quot;:&quot;&quot;,&quot;Liver_Disease_Jaundice_Hepatitis &quot;:&quot;&quot;,&quot;Kidney_Disease&quot;:&quot;&quot;,&quot;Heart_Attack_Stroke&quot;:&quot;&quot;,&quot;Hemophilia&quot;:&quot;&quot;,&quot;Hypertension&quot;:&quot;&quot;,&quot;Prolonged_Bleeding_Transfusion &quot;:&quot;&quot;,&quot;Anemia_Blood_Disorder &quot;:&quot;&quot;,&quot;HIV_AIDS&quot;:&quot;&quot;,&quot;Tonsils_Adenoids_Removed &quot;:&quot;&quot;,&quot;Handicaps_Disabilities&quot;:&quot;&quot;,&quot;Arthritis_joint_problems &quot;:&quot;&quot;,&quot;Large_Tonsils&quot;:&quot;&quot;,&quot;Sinus_Trouble&quot;:&quot;&quot;,&quot;Bed_Wetting&quot;:&quot;&quot;,&quot;Substance_abuse&quot;:&quot;&quot;,&quot;Bone_fractures_Trauma_face_Jaw &quot;:&quot;&quot;,&quot;Prosthetic_Joints&quot;:&quot;&quot;,&quot;Chronic_Fatigue&quot;:&quot;&quot;,&quot;Diabetes&quot;:&quot;&quot;,&quot;Growth_Problems&quot;:&quot;&quot;,&quot;Tuberculosis_Lung_Disease &quot;:&quot;&quot;,&quot;Pneumonia&quot;:&quot;&quot;,&quot;Cancer&quot;:&quot;&quot;,&quot;Family_History_Cancer &quot;:&quot;&quot;,&quot;Received_Radiation_Treatment &quot;:&quot;&quot;,&quot;Arteriosclerosis&quot;:&quot;&quot;,&quot;Thyroid_Endocrine_Problems &quot;:&quot;&quot;,&quot;Stomach_Ulcer_Hyperacidity &quot;:&quot;&quot;,&quot;Hormone_Therapy&quot;:&quot;&quot;,&quot;Nervous_Disorders&quot;:&quot;&quot;,&quot;Bone_Disorders_Bone_Loss &quot;:&quot;&quot;,&quot;Seizures_Epilepsy_Neurological_Disease &quot;:&quot;&quot;,&quot;Treated_Emotional_Problems &quot;:&quot;&quot;,&quot;Asthma&quot;:&quot;&quot;,&quot;Respiratory_Problems_Emphysema &quot;:&quot;&quot;,&quot;Persistent_swollen_neck_glands &quot;:&quot;&quot;,&quot;Sexually_Transmitted_Disease &quot;:&quot;&quot;,&quot;Low_Blood_Pressure&quot;:&quot;&quot;,&quot;Persistent_Cough&quot;:&quot;&quot;,&quot;FEMALES_Are_you_pregnant?&quot;:&quot;&quot;,&quot;Take_Bisphosphonates_Fosamax_Boniva&quot;:&quot;&quot;,&quot;If_any_of_the_above_medical_questions_were_answered_Yes_please_explain&quot;:&quot;&quot;,&quot;straighten_front_teeth&quot;:&quot;&quot;,&quot;front_teeth_position&quot;:&quot;&quot;,&quot;straighten_back_teeth&quot;:&quot;&quot;,&quot;back_teeth_position&quot;:&quot;&quot;,&quot;move_upper_teeth&quot;:&quot;&quot;,&quot;upper_teeth_position&quot;:&quot;&quot;,&quot;move_lower_teeth&quot;:&quot;&quot;,&quot;lower_teeth_position&quot;:&quot;&quot;,&quot;eliminate_spaces&quot;:&quot;&quot;,&quot;eliminate_spaces_position&quot;:&quot;&quot;,&quot;eliminate_crowding&quot;:&quot;&quot;,&quot;eliminate_crowding_position&quot;:&quot;&quot;,&quot;upper_teeth_level&quot;:&quot;&quot;,&quot;other&quot;:&quot;&quot;,&quot;other_details&quot;:&quot;&quot;,&quot;Move_Upper_Lip&quot;:&quot;&quot;,&quot;Move_Upper_Lip_position&quot;:&quot;&quot;,&quot;Move_Lower_Lip&quot;:&quot;&quot;,&quot;Move_Lower_Lip_position&quot;:&quot;&quot;,&quot;Show_teeth_when_smile &quot;:&quot;&quot;,&quot;Show_teeth_when_smile_position&quot;:&quot;&quot;,&quot;Show_gums_when_smile &quot;:&quot;&quot;,&quot;Show_gums_when_smile_position&quot;:&quot;&quot;,&quot;make_my_nose&quot;:&quot;&quot;,&quot;make_my_nose_position&quot;:&quot;&quot;,&quot;move_chin&quot;:&quot;&quot;,&quot;move_chin_position&quot;:&quot;&quot;,&quot;reduce_strain&quot;:&quot;&quot;,&quot;reduce_strain_position&quot;:&quot;&quot;,&quot;teeth_touch_lips&quot;:&quot;&quot;,&quot;teeth_touch_lips_position&quot;:&quot;&quot;,&quot;Height&quot;:&quot;&quot;,&quot;Weight&quot;:&quot;&quot;,&quot;School&quot;:&quot;&quot;,&quot;Grade&quot;:&quot;&quot;,&quot;begun_puberty&quot;:&quot;&quot;,&quot;menstruation_begun&quot;:&quot;&quot;,&quot;boy_voice_changed&quot;:&quot;&quot;,&quot;patient_grown_shoe_size_changed&quot;:&quot;&quot;,&quot;biological_parent_orthodontics&quot;:&quot;&quot;,&quot;Certify&quot;:&quot;&quot;,&quot;Credit_Reports&quot;:&quot;&quot;}}\"><form action=\"https:\/\/www.duraanorthodontics.co.za\/eng\/full-health-history-form\/\" method=\"post\" class=\"fusion-form fusion-form-557\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-end\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-1\" style=\"text-align:left;line-height:1;\"><h2>Patient Biographical Information<\/h2>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-2{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-2 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"first_name\" id=\"first_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"First name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-3{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-3 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-3{width:50% !important;order : 0;}.fusion-builder-column-3 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-3{width:100% !important;order : 0;}.fusion-builder-column-3 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"middle_name\" id=\"middle_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Middle name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-4{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-4 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-4{width:50% !important;order : 0;}.fusion-builder-column-4 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-4{width:100% !important;order : 0;}.fusion-builder-column-4 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"last_name\" id=\"last_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Last name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-5{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-5 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-5{width:50% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-5{width:100% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"nickname\" id=\"nickname\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Nickname*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-6{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-6 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-6{width:50% !important;order : 0;}.fusion-builder-column-6 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-6{width:100% !important;order : 0;}.fusion-builder-column-6 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"557\"><input autocomplete=\"no\" type=\"date\" data-format=\"\" tabindex=\"\" id=\"birthdate\" name=\"birthdate\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Birthdate*\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-7{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-7 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-7{width:50% !important;order : 0;}.fusion-builder-column-7 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-7{width:100% !important;order : 0;}.fusion-builder-column-7 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-select-wrapper\"><select tabindex=\"\" id=\"gender\" name=\"gender\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>Gender<\/option><option value=\"Male\" >Male<\/option><option value=\"Female\" >Female<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-8{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-8 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-8{width:50% !important;order : 0;}.fusion-builder-column-8 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-8{width:100% !important;order : 0;}.fusion-builder-column-8 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-1{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: #f4f4f4;background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 4px;border-color:#5745c8;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-end\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"address_1\" id=\"address_1\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Address line 1*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-9{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-9 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-9{width:50% !important;order : 0;}.fusion-builder-column-9 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-9{width:100% !important;order : 0;}.fusion-builder-column-9 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"address_2\" id=\"address_2\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Address line 2\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-10{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-10 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-10{width:50% !important;order : 0;}.fusion-builder-column-10 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-10{width:100% !important;order : 0;}.fusion-builder-column-10 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-11 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"city\" id=\"city\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"City*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-11{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-11 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-11{width:50% !important;order : 0;}.fusion-builder-column-11 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-11{width:100% !important;order : 0;}.fusion-builder-column-11 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-12 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"postal_code\" id=\"postal_code\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Postal code*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-12{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-12 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-12{width:50% !important;order : 0;}.fusion-builder-column-12 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-12{width:100% !important;order : 0;}.fusion-builder-column-12 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-2{ padding-top : 20px;margin-top : 25px;padding-right : 35px;padding-bottom : 20px;margin-bottom : 25px;padding-left : 35px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-3 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-13 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"phone-number\" name=\"main_phone\" id=\"main_phone\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Main phone*\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-13{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-13 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-13{width:50% !important;order : 0;}.fusion-builder-column-13 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-13{width:100% !important;order : 0;}.fusion-builder-column-13 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-14 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"phone-number\" name=\"second_phone\" id=\"second_phone\" value=\"\"  class=\"fusion-form-input\" placeholder=\"2nd\/Cell phone\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-14{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-14 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-14{width:50% !important;order : 0;}.fusion-builder-column-14 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-14{width:100% !important;order : 0;}.fusion-builder-column-14 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-15 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"email\" name=\"email\" id=\"email\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Email*\" data-holds-private-data=\"false\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-15{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-15 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-15{width:100% !important;order : 0;}.fusion-builder-column-15 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-15{width:100% !important;order : 0;}.fusion-builder-column-15 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-16 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"parent_guardian\" id=\"parent_guardian\" value=\"\"  class=\"fusion-form-input\" placeholder=\"If patient is a minor, give parent&#039;s or guardian&#039;s name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"pasient_residence\" id=\"pasient_residence\" value=\"\"  class=\"fusion-form-input\" placeholder=\"If patient is a minor, who does the patient live with?\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"557\"><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"friends_family\" name=\"friends_family\" class=\"fusion-form-input\" placeholder=\"Please list the names of any friends or family in the practice\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"557\"><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"sports_hobbies\" name=\"sports_hobbies\" class=\"fusion-form-input\" placeholder=\"List any sports, hobbies, or musical instruments played:\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"thanks_to\" id=\"thanks_to\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Whom may we thank for referring you to our practice?\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-16{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-16 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-16{width:100% !important;order : 0;}.fusion-builder-column-16 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-16{width:100% !important;order : 0;}.fusion-builder-column-16 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-3{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-4 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-17 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-2\" style=\"text-align:left;line-height:1;\"><h2>Financial Party Information<\/h2>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-17{width:100% !important;margin-top : 20px;margin-bottom : 0px;}.fusion-builder-column-17 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-17{width:100% !important;order : 0;}.fusion-builder-column-17 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-17{width:100% !important;order : 0;}.fusion-builder-column-17 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-18 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-patient_financially_responsible-1-0\" type=\"checkbox\" value=\"Check if the patient is also the person who will be financially responsible for treatment.\" name=\"patient_financially_responsible[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-patient_financially_responsible-1-0\">Check if the patient is also the person who will be financially responsible for treatment.<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-18{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-18 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-18{width:100% !important;order : 0;}.fusion-builder-column-18 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-18{width:100% !important;order : 0;}.fusion-builder-column-18 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-19 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"first_name_financial\" id=\"first_name_financial\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"First name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-19{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-19 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-19{width:50% !important;order : 0;}.fusion-builder-column-19 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-19{width:100% !important;order : 0;}.fusion-builder-column-19 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-20 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"last_name_financial\" id=\"last_name_financial\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Last name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-20{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-20 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-20{width:50% !important;order : 0;}.fusion-builder-column-20 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-20{width:100% !important;order : 0;}.fusion-builder-column-20 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-21 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"marital_status_financial\" id=\"marital_status_financial\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Marital Status\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-21{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-21 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-21{width:50% !important;order : 0;}.fusion-builder-column-21 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-21{width:100% !important;order : 0;}.fusion-builder-column-21 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-22 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"relation_to_patient\" id=\"relation_to_patient\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Relation to patient\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-22{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-22 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-22{width:50% !important;order : 0;}.fusion-builder-column-22 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-22{width:100% !important;order : 0;}.fusion-builder-column-22 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-23 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"557\"><input autocomplete=\"no\" type=\"date\" data-format=\"\" tabindex=\"\" id=\"birthdate_financial\" name=\"birthdate_financial\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Birthdate*\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-23{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-23 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-23{width:50% !important;order : 0;}.fusion-builder-column-23 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-23{width:100% !important;order : 0;}.fusion-builder-column-23 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-4{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-5 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: #f4f4f4;background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 4px;border-color:#5745c8;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-end\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-24 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"address_1_financial\" id=\"address_1_financial\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Address line 1*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-24{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-24 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-24{width:50% !important;order : 0;}.fusion-builder-column-24 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-24{width:100% !important;order : 0;}.fusion-builder-column-24 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-25 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"address_2_financial\" id=\"address_2_financial\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Address line 2\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-25{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-25 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-25{width:50% !important;order : 0;}.fusion-builder-column-25 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-25{width:100% !important;order : 0;}.fusion-builder-column-25 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-26 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"city_financial\" id=\"city_financial\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"City*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-26{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-26 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-26{width:50% !important;order : 0;}.fusion-builder-column-26 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-26{width:100% !important;order : 0;}.fusion-builder-column-26 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-27 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"postal_code_financial\" id=\"postal_code_financial\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Postal code*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-27{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-27 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-27{width:50% !important;order : 0;}.fusion-builder-column-27 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-27{width:100% !important;order : 0;}.fusion-builder-column-27 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-28 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"period_reside\" id=\"period_reside\" value=\"\"  class=\"fusion-form-input\" placeholder=\"How long at this address?\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-28{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-28 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-28{width:50% !important;order : 0;}.fusion-builder-column-28 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-28{width:100% !important;order : 0;}.fusion-builder-column-28 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-29 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-29{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-29 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-29{width:50% !important;order : 0;}.fusion-builder-column-29 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-29{width:100% !important;order : 0;}.fusion-builder-column-29 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-30 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><label for=\"previous_address_1\">If less than 3 years, please provide us with the details of your previous address <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"previous_address_1\" id=\"previous_address_1\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Address line 1*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-30{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-30 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-30{width:50% !important;order : 0;}.fusion-builder-column-30 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-30{width:100% !important;order : 0;}.fusion-builder-column-30 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-31 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"previous_address_2\" id=\"previous_address_2\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Address line 2\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-31{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-31 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-31{width:50% !important;order : 0;}.fusion-builder-column-31 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-31{width:100% !important;order : 0;}.fusion-builder-column-31 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-32 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"city_previous-address\" id=\"city_previous-address\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"City*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-32{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-32 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-32{width:50% !important;order : 0;}.fusion-builder-column-32 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-32{width:100% !important;order : 0;}.fusion-builder-column-32 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-33 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"postal_code_previous_address\" id=\"postal_code_previous_address\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Postal code*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-33{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-33 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-33{width:50% !important;order : 0;}.fusion-builder-column-33 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-33{width:100% !important;order : 0;}.fusion-builder-column-33 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-34 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"email\" name=\"email_financial\" id=\"email_financial\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Email*\" data-holds-private-data=\"false\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-34{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-34 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-34{width:100% !important;order : 0;}.fusion-builder-column-34 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-34{width:100% !important;order : 0;}.fusion-builder-column-34 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-35 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"phone-number\" name=\"main_phone_financial\" id=\"main_phone_financial\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Main phone*\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-35{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-35 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-35{width:50% !important;order : 0;}.fusion-builder-column-35 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-35{width:100% !important;order : 0;}.fusion-builder-column-35 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-36 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"phone-number\" name=\"second_phone_financial\" id=\"second_phone_financial\" value=\"\"  class=\"fusion-form-input\" placeholder=\"2nd\/Cell phone\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-36{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-36 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-36{width:50% !important;order : 0;}.fusion-builder-column-36 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-36{width:100% !important;order : 0;}.fusion-builder-column-36 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-37 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"phone-number\" name=\"work_phone_financial\" id=\"work_phone_financial\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Work phone\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-37{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-37 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-37{width:50% !important;order : 0;}.fusion-builder-column-37 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-37{width:100% !important;order : 0;}.fusion-builder-column-37 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-38 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-38{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-38 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-38{width:50% !important;order : 0;}.fusion-builder-column-38 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-38{width:100% !important;order : 0;}.fusion-builder-column-38 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-39 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"ID_number_financial\" id=\"ID_number_financial\" value=\"\"  class=\"fusion-form-input\" placeholder=\"ID Number\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-39{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-39 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-39{width:50% !important;order : 0;}.fusion-builder-column-39 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-39{width:100% !important;order : 0;}.fusion-builder-column-39 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-40 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"employer_financial\" id=\"employer_financial\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Employer\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-40{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-40 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-40{width:50% !important;order : 0;}.fusion-builder-column-40 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-40{width:100% !important;order : 0;}.fusion-builder-column-40 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-41 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"occupation_financial\" id=\"occupation_financial\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Occupation\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-41{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-41 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-41{width:50% !important;order : 0;}.fusion-builder-column-41 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-41{width:100% !important;order : 0;}.fusion-builder-column-41 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-42 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"occupation_period_financial\" id=\"occupation_period_financial\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Period of Employment\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-42{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-42 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-42{width:50% !important;order : 0;}.fusion-builder-column-42 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-42{width:100% !important;order : 0;}.fusion-builder-column-42 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-5{ padding-top : 20px;margin-top : 25px;padding-right : 35px;padding-bottom : 20px;margin-bottom : 25px;padding-left : 35px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-6 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-43 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"spouse_first_name_financial\" id=\"spouse_first_name_financial\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Spouse or Other Parent&#039;s First Name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-43{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-43 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-43{width:50% !important;order : 0;}.fusion-builder-column-43 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-43{width:100% !important;order : 0;}.fusion-builder-column-43 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-44 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"spouse_middle_name_financial\" id=\"spouse_middle_name_financial\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Middle Name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-44{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-44 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-44{width:50% !important;order : 0;}.fusion-builder-column-44 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-44{width:100% !important;order : 0;}.fusion-builder-column-44 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-45 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"spouse_last_name_financial\" id=\"spouse_last_name_financial\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Last Name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-45{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-45 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-45{width:50% !important;order : 0;}.fusion-builder-column-45 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-45{width:100% !important;order : 0;}.fusion-builder-column-45 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-46 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"spouse_relation_to_patient\" id=\"spouse_relation_to_patient\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Relation to Patient\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-46{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-46 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-46{width:50% !important;order : 0;}.fusion-builder-column-46 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-46{width:100% !important;order : 0;}.fusion-builder-column-46 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-47 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"spouse_ID_number\" id=\"spouse_ID_number\" value=\"\"  class=\"fusion-form-input\" placeholder=\"ID Number\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-47{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-47 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-47{width:50% !important;order : 0;}.fusion-builder-column-47 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-47{width:100% !important;order : 0;}.fusion-builder-column-47 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-48 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"557\"><input autocomplete=\"no\" type=\"date\" data-format=\"\" tabindex=\"\" id=\"spouse_birthdate_financial\" name=\"spouse_birthdate_financial\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" placeholder=\"Birthdate\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-48{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-48 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-48{width:50% !important;order : 0;}.fusion-builder-column-48 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-48{width:100% !important;order : 0;}.fusion-builder-column-48 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-49 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"spouse_employer\" id=\"spouse_employer\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Enployer\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-49{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-49 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-49{width:50% !important;order : 0;}.fusion-builder-column-49 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-49{width:100% !important;order : 0;}.fusion-builder-column-49 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-50 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"spouse_occupation\" id=\"spouse_occupation\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Occupation\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-50{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-50 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-50{width:50% !important;order : 0;}.fusion-builder-column-50 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-50{width:100% !important;order : 0;}.fusion-builder-column-50 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-51 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"spouse_employment_period\" id=\"spouse_employment_period\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Period of Employment\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-51{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-51 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-51{width:50% !important;order : 0;}.fusion-builder-column-51 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-51{width:100% !important;order : 0;}.fusion-builder-column-51 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-52 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"spouse_work_phone\" id=\"spouse_work_phone\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Work Phone Number\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-52{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-52 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-52{width:50% !important;order : 0;}.fusion-builder-column-52 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-52{width:100% !important;order : 0;}.fusion-builder-column-52 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-6{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-7 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-53 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-3\" style=\"text-align:left;line-height:1;\"><h2>Dental Insurance Information<\/h2>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-53{width:100% !important;margin-top : 20px;margin-bottom : 0px;}.fusion-builder-column-53 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-53{width:100% !important;order : 0;}.fusion-builder-column-53 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-53{width:100% !important;order : 0;}.fusion-builder-column-53 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-54 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"policy_holder_name\" id=\"policy_holder_name\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Policy Holder&#039;s Name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-54{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-54 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-54{width:50% !important;order : 0;}.fusion-builder-column-54 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-54{width:100% !important;order : 0;}.fusion-builder-column-54 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-55 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"policy_holder_relation_to_patient\" id=\"policy_holder_relation_to_patient\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Relation to Patient\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-55{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-55 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-55{width:50% !important;order : 0;}.fusion-builder-column-55 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-55{width:100% !important;order : 0;}.fusion-builder-column-55 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-56 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"insurance_company\" id=\"insurance_company\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Insurance Company\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-56{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-56 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-56{width:50% !important;order : 0;}.fusion-builder-column-56 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-56{width:100% !important;order : 0;}.fusion-builder-column-56 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-57 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"subscriber_id\" id=\"subscriber_id\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Subscriber ID #\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-57{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-57 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-57{width:50% !important;order : 0;}.fusion-builder-column-57 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-57{width:100% !important;order : 0;}.fusion-builder-column-57 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-58 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"insurance_plan\" id=\"insurance_plan\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Insurance Plan\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-58{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-58 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-58{width:50% !important;order : 0;}.fusion-builder-column-58 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-58{width:100% !important;order : 0;}.fusion-builder-column-58 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-59 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"insurance_telephone\" id=\"insurance_telephone\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Insurance Co. Phone Number\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-59{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-59 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-59{width:50% !important;order : 0;}.fusion-builder-column-59 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-59{width:100% !important;order : 0;}.fusion-builder-column-59 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-7{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-8 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-60 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-4\" style=\"text-align:left;line-height:1;\"><h2>Emergency Information<\/h2>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-60{width:100% !important;margin-top : 20px;margin-bottom : 0px;}.fusion-builder-column-60 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-60{width:100% !important;order : 0;}.fusion-builder-column-60 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-60{width:100% !important;order : 0;}.fusion-builder-column-60 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-61 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"nearest_relative_name\" id=\"nearest_relative_name\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Name of nearest relative not living with you\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-61{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-61 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-61{width:50% !important;order : 0;}.fusion-builder-column-61 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-61{width:100% !important;order : 0;}.fusion-builder-column-61 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-62 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"nearest_relative_phone\" id=\"nearest_relative_phone\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Phone Number\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-62{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-62 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-62{width:50% !important;order : 0;}.fusion-builder-column-62 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-62{width:100% !important;order : 0;}.fusion-builder-column-62 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-63 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"relative_address_1\" id=\"relative_address_1\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Address line 1\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-63{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-63 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-63{width:50% !important;order : 0;}.fusion-builder-column-63 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-63{width:100% !important;order : 0;}.fusion-builder-column-63 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-64 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"relative_address_2\" id=\"relative_address_2\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Address line 2\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-64{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-64 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-64{width:50% !important;order : 0;}.fusion-builder-column-64 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-64{width:100% !important;order : 0;}.fusion-builder-column-64 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-65 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"relative_address_city\" id=\"relative_address_city\" value=\"\"  class=\"fusion-form-input\" placeholder=\"City\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-65{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-65 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-65{width:50% !important;order : 0;}.fusion-builder-column-65 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-65{width:100% !important;order : 0;}.fusion-builder-column-65 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-66 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"relative_address_code\" id=\"relative_address_code\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Postal code\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-66{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-66 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-66{width:50% !important;order : 0;}.fusion-builder-column-66 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-66{width:100% !important;order : 0;}.fusion-builder-column-66 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-67 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"relative_relation_to_patient\" id=\"relative_relation_to_patient\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Relation to Patient\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-67{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-67 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-67{width:50% !important;order : 0;}.fusion-builder-column-67 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-67{width:100% !important;order : 0;}.fusion-builder-column-67 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-8{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-9 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-68 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-5\" style=\"text-align:left;line-height:1;\"><h2>Dental History<\/h2>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-68{width:100% !important;margin-top : 20px;margin-bottom : 0px;}.fusion-builder-column-68 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-68{width:100% !important;order : 0;}.fusion-builder-column-68 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-68{width:100% !important;order : 0;}.fusion-builder-column-68 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-69 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"dentist_name\" id=\"dentist_name\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Dentist Name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-69{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-69 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-69{width:50% !important;order : 0;}.fusion-builder-column-69 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-69{width:100% !important;order : 0;}.fusion-builder-column-69 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-70 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-select-wrapper\"><select tabindex=\"\" id=\"check_up_frequency\" name=\"check_up_frequency\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>Check-up Frequency<\/option><option value=\"6 months\" >6 months<\/option><option value=\"12 months\" >12 months<\/option><option value=\"18 months\" >18 months<\/option><option value=\"24 months\" >24 months<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-70{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-70 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-70{width:50% !important;order : 0;}.fusion-builder-column-70 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-70{width:100% !important;order : 0;}.fusion-builder-column-70 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-71 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"557\"><input autocomplete=\"no\" type=\"date\" data-format=\"\" tabindex=\"\" id=\"last_dental_visit\" name=\"last_dental_visit\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" placeholder=\"Last Dental Visit\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-71{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-71 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-71{width:50% !important;order : 0;}.fusion-builder-column-71 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-71{width:100% !important;order : 0;}.fusion-builder-column-71 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-72 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Has the patient had an orthodontic consultation or treatment?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-orthodontic_consultation-1-0\" type=\"radio\" value=\"Yes\" name=\"orthodontic_consultation\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-orthodontic_consultation-1-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-orthodontic_consultation-1-1\" type=\"radio\" value=\"No\" name=\"orthodontic_consultation\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-orthodontic_consultation-1-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"557\"><input autocomplete=\"no\" type=\"date\" data-format=\"\" tabindex=\"\" id=\"date_of_orthodontic_consultation\" name=\"date_of_orthodontic_consultation\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" placeholder=\"If so, when?\"autocomplete=\"no\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Does the patient need to premedicate prior to dental visit?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-premedicate_required-2-0\" type=\"radio\" value=\"Yes\" name=\"premedicate_required\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-premedicate_required-2-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-premedicate_required-2-1\" type=\"radio\" value=\"No\" name=\"premedicate_required\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-premedicate_required-2-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"557\"><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"main_orthodontic_concern\" name=\"main_orthodontic_concern\" class=\"fusion-form-input\" placeholder=\"What is the patient&#039;s main orthodontic concern?\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-72{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-72 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-72{width:100% !important;order : 0;}.fusion-builder-column-72 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-72{width:100% !important;order : 0;}.fusion-builder-column-72 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-73 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-6\" style=\"text-align:left;line-height:1;\"><h5><strong>Please select YES if the patient has had any of the conditions listed below either now or in the past.<\/strong><\/h5>\n<\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Speech problems\/therapy<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-speech_problems-3-0\" type=\"radio\" value=\"Yes\" name=\"speech_problems\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-speech_problems-3-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-speech_problems-3-1\" type=\"radio\" value=\"No\" name=\"speech_problems\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-speech_problems-3-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Clench or Grind Teeth<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-clench_grind_teeth-4-0\" type=\"radio\" value=\"Yes\" name=\"clench_grind_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-clench_grind_teeth-4-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-clench_grind_teeth-4-1\" type=\"radio\" value=\"No\" name=\"clench_grind_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-clench_grind_teeth-4-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Oral habits (thumb\/finger sucking, lip\/nail biting)<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-oral_habits-5-0\" type=\"radio\" value=\"Yes\" name=\"oral_habits\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-oral_habits-5-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-oral_habits-5-1\" type=\"radio\" value=\"No\" name=\"oral_habits\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-oral_habits-5-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Injury to face, jaw, teeth or mouth<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-injury-6-0\" type=\"radio\" value=\"Yes\" name=\"injury\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-injury-6-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-injury-6-1\" type=\"radio\" value=\"No\" name=\"injury\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-injury-6-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Discomfort from teeth or gums<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-discomfort--7-0\" type=\"radio\" value=\"Yes\" name=\"discomfort \" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-discomfort--7-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-discomfort--7-1\" type=\"radio\" value=\"No\" name=\"discomfort \" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-discomfort--7-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Pain, tenderness or noise in either jaw<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-pain_tenderness-8-0\" type=\"radio\" value=\"Yes\" name=\"pain_tenderness\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-pain_tenderness-8-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-pain_tenderness-8-1\" type=\"radio\" value=\"No\" name=\"pain_tenderness\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-pain_tenderness-8-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Frequent headaches<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-frequent_headaches-9-0\" type=\"radio\" value=\"Yes\" name=\"frequent_headaches\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-frequent_headaches-9-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-frequent_headaches-9-1\" type=\"radio\" value=\"No\" name=\"frequent_headaches\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-frequent_headaches-9-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Neck \/ Shoulder Pain<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-neck_shoulder_pain-10-0\" type=\"radio\" value=\"Yes\" name=\"neck_shoulder_pain\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-neck_shoulder_pain-10-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-neck_shoulder_pain-10-1\" type=\"radio\" value=\"No\" name=\"neck_shoulder_pain\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-neck_shoulder_pain-10-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Frequent sore throats<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-frequent_sore_throats-11-0\" type=\"radio\" value=\"Yes\" name=\"frequent_sore_throats\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-frequent_sore_throats-11-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-frequent_sore_throats-11-1\" type=\"radio\" value=\"No\" name=\"frequent_sore_throats\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-frequent_sore_throats-11-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Chipped or injured permanent teeth<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-injured_permanent_teeth-12-0\" type=\"radio\" value=\"Yes\" name=\"injured_permanent_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-injured_permanent_teeth-12-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-injured_permanent_teeth-12-1\" type=\"radio\" value=\"No\" name=\"injured_permanent_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-injured_permanent_teeth-12-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Teeth sensitive to hot or cold<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-sensitive_hot_cold-13-0\" type=\"radio\" value=\"Yes\" name=\"sensitive_hot_cold\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-sensitive_hot_cold-13-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-sensitive_hot_cold-13-1\" type=\"radio\" value=\"No\" name=\"sensitive_hot_cold\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-sensitive_hot_cold-13-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Previous root canal therapy<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-previous_root_canal-14-0\" type=\"radio\" value=\"Yes\" name=\"previous_root_canal\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-previous_root_canal-14-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-previous_root_canal-14-1\" type=\"radio\" value=\"No\" name=\"previous_root_canal\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-previous_root_canal-14-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Bad taste \/ mouth odor<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-bad_taste_mouth_odor-15-0\" type=\"radio\" value=\"Yes\" name=\"bad_taste_mouth_odor\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-bad_taste_mouth_odor-15-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-bad_taste_mouth_odor-15-1\" type=\"radio\" value=\"No\" name=\"bad_taste_mouth_odor\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-bad_taste_mouth_odor-15-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Previous periodontal (gum) treatment<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-periodontal_treatment-16-0\" type=\"radio\" value=\"Yes\" name=\"periodontal_treatment\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-periodontal_treatment-16-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-periodontal_treatment-16-1\" type=\"radio\" value=\"No\" name=\"periodontal_treatment\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-periodontal_treatment-16-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Abnormal swallowing (tongue thrust)<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-abnormal_swallowing-17-0\" type=\"radio\" value=\"Yes\" name=\"abnormal_swallowing\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-abnormal_swallowing-17-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-abnormal_swallowing-17-1\" type=\"radio\" value=\"No\" name=\"abnormal_swallowing\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-abnormal_swallowing-17-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Teeth that irritate tongue, cheek, lip, etc.<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-teeth_that_irritate-18-0\" type=\"radio\" value=\"Yes\" name=\"teeth_that_irritate\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-teeth_that_irritate-18-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-teeth_that_irritate-18-1\" type=\"radio\" value=\"No\" name=\"teeth_that_irritate\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-teeth_that_irritate-18-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Numerous fillings<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-numerous_fillings-19-0\" type=\"radio\" value=\"Yes\" name=\"numerous_fillings\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-numerous_fillings-19-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-numerous_fillings-19-1\" type=\"radio\" value=\"No\" name=\"numerous_fillings\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-numerous_fillings-19-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Brush teeth daily<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-brush_teeth_daily-20-0\" type=\"radio\" value=\"Yes\" name=\"brush_teeth_daily\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-brush_teeth_daily-20-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-brush_teeth_daily-20-1\" type=\"radio\" value=\"No\" name=\"brush_teeth_daily\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-brush_teeth_daily-20-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Floss teeth daily<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-floss_teeth_daily-21-0\" type=\"radio\" value=\"Yes\" name=\"floss_teeth_daily\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-floss_teeth_daily-21-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-floss_teeth_daily-21-1\" type=\"radio\" value=\"No\" name=\"floss_teeth_daily\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-floss_teeth_daily-21-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Fluoride treatments<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-fluoride_treatments-22-0\" type=\"radio\" value=\"Yes\" name=\"fluoride_treatments\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-fluoride_treatments-22-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-fluoride_treatments-22-1\" type=\"radio\" value=\"No\" name=\"fluoride_treatments\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-fluoride_treatments-22-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Mouth breathing<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-mouth_breathing-23-0\" type=\"radio\" value=\"Yes\" name=\"mouth_breathing\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-mouth_breathing-23-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-mouth_breathing-23-1\" type=\"radio\" value=\"No\" name=\"mouth_breathing\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-mouth_breathing-23-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Snores during sleep<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-snores_during_sleep-24-0\" type=\"radio\" value=\"Yes\" name=\"snores_during_sleep\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-snores_during_sleep-24-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-snores_during_sleep-24-1\" type=\"radio\" value=\"No\" name=\"snores_during_sleep\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-snores_during_sleep-24-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Any missing or extra permanent teeth<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-missing_extra_permanent_teeth-25-0\" type=\"radio\" value=\"Yes\" name=\"missing_extra_permanent_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-missing_extra_permanent_teeth-25-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-missing_extra_permanent_teeth-25-1\" type=\"radio\" value=\"No\" name=\"missing_extra_permanent_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-missing_extra_permanent_teeth-25-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Apprehensive about dental care<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-apprehensive_dental_care-26-0\" type=\"radio\" value=\"Yes\" name=\"apprehensive_dental_care\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-apprehensive_dental_care-26-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-apprehensive_dental_care-26-1\" type=\"radio\" value=\"No\" name=\"apprehensive_dental_care\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-apprehensive_dental_care-26-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Frequently Chew Gum<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-frequently_chew_gum-27-0\" type=\"radio\" value=\"Yes\" name=\"frequently_chew_gum\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-frequently_chew_gum-27-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-frequently_chew_gum-27-1\" type=\"radio\" value=\"No\" name=\"frequently_chew_gum\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-frequently_chew_gum-27-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Thumb or finger habit as a child<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-thumb_habit_as_child-28-0\" type=\"radio\" value=\"Yes\" name=\"thumb_habit_as_child\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-thumb_habit_as_child-28-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-thumb_habit_as_child-28-1\" type=\"radio\" value=\"No\" name=\"thumb_habit_as_child\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-thumb_habit_as_child-28-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Jaw fractures, cysts, mouth infections<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-jaw_fractures_cysts_infections-29-0\" type=\"radio\" value=\"Yes\" name=\"jaw_fractures_cysts_infections\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-jaw_fractures_cysts_infections-29-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-jaw_fractures_cysts_infections-29-1\" type=\"radio\" value=\"No\" name=\"jaw_fractures_cysts_infections\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-jaw_fractures_cysts_infections-29-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Bleeding gums<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-bleeding_gums-30-0\" type=\"radio\" value=\"Yes\" name=\"bleeding_gums\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-bleeding_gums-30-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-bleeding_gums-30-1\" type=\"radio\" value=\"No\" name=\"bleeding_gums\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-bleeding_gums-30-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Other periodontal (gum) problems<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-other_periodontal_problems-31-0\" type=\"radio\" value=\"Yes\" name=\"other_periodontal_problems\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-other_periodontal_problems-31-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-other_periodontal_problems-31-1\" type=\"radio\" value=\"No\" name=\"other_periodontal_problems\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-other_periodontal_problems-31-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Frequent canker sores or cold sores<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-canker_sores_cold_sores-32-0\" type=\"radio\" value=\"Yes\" name=\"canker_sores_cold_sores\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-canker_sores_cold_sores-32-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-canker_sores_cold_sores-32-1\" type=\"radio\" value=\"No\" name=\"canker_sores_cold_sores\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-canker_sores_cold_sores-32-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have wisdom teeth been removed?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-wisdom_teeth_removed-33-0\" type=\"radio\" value=\"Yes\" name=\"wisdom_teeth_removed\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-wisdom_teeth_removed-33-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-wisdom_teeth_removed-33-1\" type=\"radio\" value=\"No\" name=\"wisdom_teeth_removed\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-wisdom_teeth_removed-33-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Problems with food trapped between teeth<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-food_trapped_between_teeth-34-0\" type=\"radio\" value=\"Yes\" name=\"food_trapped_between_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-food_trapped_between_teeth-34-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-food_trapped_between_teeth-34-1\" type=\"radio\" value=\"No\" name=\"food_trapped_between_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-food_trapped_between_teeth-34-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Is all dental work completed?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-dental_work_completed-35-0\" type=\"radio\" value=\"Yes\" name=\"dental_work_completed\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-dental_work_completed-35-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-dental_work_completed-35-1\" type=\"radio\" value=\"No\" name=\"dental_work_completed\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-dental_work_completed-35-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"557\"><label for=\"answers_explained\">If any of the above dental questions were answered &#039;Yes&#039;, please explain:<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"answers_explained\" name=\"answers_explained\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you had a TMJ screening?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-tmj_screening-36-0\" type=\"radio\" value=\"Yes\" name=\"TMJ_screening\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-tmj_screening-36-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-tmj_screening-36-1\" type=\"radio\" value=\"No\" name=\"TMJ_screening\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-tmj_screening-36-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have a history of jaw joint problems<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-jaw_joint_problems-37-0\" type=\"radio\" value=\"Yes\" name=\"jaw_joint_problems\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-jaw_joint_problems-37-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-jaw_joint_problems-37-1\" type=\"radio\" value=\"No\" name=\"jaw_joint_problems\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-jaw_joint_problems-37-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Have you been treated for TMJ?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-treated_for_tmj-38-0\" type=\"radio\" value=\"Yes\" name=\"treated_for_TMJ\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-treated_for_tmj-38-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-treated_for_tmj-38-1\" type=\"radio\" value=\"No\" name=\"treated_for_TMJ\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-treated_for_tmj-38-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you notice clicking or popping in your jaw joint?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-jaw_joint_popping--39-0\" type=\"radio\" value=\"Yes\" name=\"jaw_joint_popping \" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-jaw_joint_popping--39-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-jaw_joint_popping--39-1\" type=\"radio\" value=\"No\" name=\"jaw_joint_popping \" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-jaw_joint_popping--39-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you clench your teeth?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-clench_teeth-40-0\" type=\"radio\" value=\"Yes\" name=\"clench_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-clench_teeth-40-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-clench_teeth-40-1\" type=\"radio\" value=\"No\" name=\"clench_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-clench_teeth-40-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Has your jaw ever locked?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-jaw_ever_locked-41-0\" type=\"radio\" value=\"Yes\" name=\"jaw_ever_locked\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-jaw_ever_locked-41-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-jaw_ever_locked-41-1\" type=\"radio\" value=\"No\" name=\"jaw_ever_locked\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-jaw_ever_locked-41-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you have difficulty chewing or opening your mouth?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-difficulty_chewing_opening_mouth-42-0\" type=\"radio\" value=\"Yes\" name=\"difficulty_chewing_opening_mouth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-difficulty_chewing_opening_mouth-42-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-difficulty_chewing_opening_mouth-42-1\" type=\"radio\" value=\"No\" name=\"difficulty_chewing_opening_mouth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-difficulty_chewing_opening_mouth-42-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Does your bite feel uncomfortable or unusual<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-bite_feel_uncomfortable-43-0\" type=\"radio\" value=\"Yes\" name=\"bite_feel_uncomfortable\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-bite_feel_uncomfortable-43-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-bite_feel_uncomfortable-43-1\" type=\"radio\" value=\"No\" name=\"bite_feel_uncomfortable\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-bite_feel_uncomfortable-43-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you experience soreness in the muscles of your face or around your ears?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-soreness_muscles_face_around_ears-44-0\" type=\"radio\" value=\"Yes\" name=\"soreness_muscles_face_around_ears\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-soreness_muscles_face_around_ears-44-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-soreness_muscles_face_around_ears-44-1\" type=\"radio\" value=\"No\" name=\"soreness_muscles_face_around_ears\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-soreness_muscles_face_around_ears-44-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"557\"><label for=\"TMJ_answers_explained\">If any of the above TMJ questions were answered &#039;Yes&#039; please explain:<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"TMJ_answers_explained\" name=\"TMJ_answers_explained\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-73{width:100% !important;margin-top : 20px;margin-bottom : 0px;}.fusion-builder-column-73 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-73{width:100% !important;order : 0;}.fusion-builder-column-73 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-73{width:100% !important;order : 0;}.fusion-builder-column-73 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-9{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-10 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-74 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-7\" style=\"text-align:left;line-height:1;\"><h2>Medical History<\/h2>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-74{width:100% !important;margin-top : 20px;margin-bottom : 0px;}.fusion-builder-column-74 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-74{width:100% !important;order : 0;}.fusion-builder-column-74 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-74{width:100% !important;order : 0;}.fusion-builder-column-74 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-75 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"physician_name\" id=\"physician_name\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Physician Name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-75{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-75 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-75{width:50% !important;order : 0;}.fusion-builder-column-75 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-75{width:100% !important;order : 0;}.fusion-builder-column-75 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-76 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"physician_number\" id=\"physician_number\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Physician Telephone number\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-76{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-76 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-76{width:50% !important;order : 0;}.fusion-builder-column-76 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-76{width:100% !important;order : 0;}.fusion-builder-column-76 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-77 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"557\"><input autocomplete=\"no\" type=\"date\" data-format=\"\" tabindex=\"\" id=\"last_physical\" name=\"last_physical\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" placeholder=\"Date of Last Physical\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-77{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-77 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-77{width:50% !important;order : 0;}.fusion-builder-column-77 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-77{width:100% !important;order : 0;}.fusion-builder-column-77 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-78 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"557\"><label for=\"patient_health_conditions\">Patient Health conditions<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"patient_health_conditions\" name=\"patient_health_conditions\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Has there been any change in the patient&#039;s general health within the last year?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-change_in_health-45-0\" type=\"radio\" value=\"Yes\" name=\"change_in_health\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-change_in_health-45-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-change_in_health-45-1\" type=\"radio\" value=\"No\" name=\"change_in_health\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-change_in_health-45-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Is the patient now under the care of a physician (other than routine)?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-under_physician_care-46-0\" type=\"radio\" value=\"Yes\" name=\"under_physician_care\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-under_physician_care-46-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-under_physician_care-46-1\" type=\"radio\" value=\"No\" name=\"under_physician_care\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-under_physician_care-46-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"557\"><label for=\"treatment\">If so, what is being treated?<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"treatment\" name=\"treatment\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Has the patient had a serious illness\/hospitalisation in the past 5 years?  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-illness_hospitalisation--47-0\" type=\"radio\" value=\"Yes\" name=\"illness_hospitalisation \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-illness_hospitalisation--47-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-illness_hospitalisation--47-1\" type=\"radio\" value=\"No\" name=\"illness_hospitalisation \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-illness_hospitalisation--47-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"557\"><label for=\"hospitalisation_reason\">If so, what for?<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"hospitalisation_reason\" name=\"hospitalisation_reason\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"557\"><label for=\"medications\">List any medications currently being taken by the patient (include non-prescription):<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"medications\" name=\"medications\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-78{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-78 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-78{width:100% !important;order : 0;}.fusion-builder-column-78 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-78{width:100% !important;order : 0;}.fusion-builder-column-78 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-79 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-8\" style=\"text-align:left;line-height:1;\"><h3>Allergies or drug reaction to:<\/h3>\n<\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Latex <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-latex-48-0\" type=\"radio\" value=\"Yes\" name=\"latex\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-latex-48-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-latex-48-1\" type=\"radio\" value=\"No\" name=\"latex\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-latex-48-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Penicillin or other antibiotics <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-penicillin_antibiotics--49-0\" type=\"radio\" value=\"Yes\" name=\"Penicillin_antibiotics \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-penicillin_antibiotics--49-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-penicillin_antibiotics--49-1\" type=\"radio\" value=\"No\" name=\"Penicillin_antibiotics \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-penicillin_antibiotics--49-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Sulfa drugs <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-sulfa_drugs-50-0\" type=\"radio\" value=\"Yes\" name=\"sulfa_drugs\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-sulfa_drugs-50-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-sulfa_drugs-50-1\" type=\"radio\" value=\"No\" name=\"sulfa_drugs\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-sulfa_drugs-50-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Aspirin, Ibuprofen, Tylenol  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-aspirin_ibuprofen_tylenol--51-0\" type=\"radio\" value=\"Yes\" name=\"Aspirin_Ibuprofen_Tylenol \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-aspirin_ibuprofen_tylenol--51-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-aspirin_ibuprofen_tylenol--51-1\" type=\"radio\" value=\"No\" name=\"Aspirin_Ibuprofen_Tylenol \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-aspirin_ibuprofen_tylenol--51-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Local anesthetics <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-local_anesthetics-52-0\" type=\"radio\" value=\"Yes\" name=\"Local_anesthetics\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-local_anesthetics-52-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-local_anesthetics-52-1\" type=\"radio\" value=\"No\" name=\"Local_anesthetics\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-local_anesthetics-52-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Codeine or other narcotics  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-codeine_narcotics--53-0\" type=\"radio\" value=\"Yes\" name=\"Codeine_narcotics \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-codeine_narcotics--53-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-codeine_narcotics--53-1\" type=\"radio\" value=\"No\" name=\"Codeine_narcotics \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-codeine_narcotics--53-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Latex \/ Metal Allergy <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-latex_metal_allergy-54-0\" type=\"radio\" value=\"Yes\" name=\"Latex_Metal_Allergy\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-latex_metal_allergy-54-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-latex_metal_allergy-54-1\" type=\"radio\" value=\"No\" name=\"Latex_Metal_Allergy\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-latex_metal_allergy-54-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Other <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-other_allergies-55-0\" type=\"radio\" value=\"Yes\" name=\"other_allergies\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-other_allergies-55-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-other_allergies-55-1\" type=\"radio\" value=\"No\" name=\"other_allergies\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-other_allergies-55-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"557\"><label for=\"drug_allergies_sensitivities \">List any drug allergies or sensitivities (not listed above) that the patient may have:<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"drug_allergies_sensitivities \" name=\"drug_allergies_sensitivities \" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-text fusion-text-9\" style=\"text-align:left;line-height:1;\"><h3>Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.<\/h3>\n<\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Heart Murmur <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-heart_murmur-56-0\" type=\"radio\" value=\"Yes\" name=\"Heart_Murmur\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-heart_murmur-56-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-heart_murmur-56-1\" type=\"radio\" value=\"No\" name=\"Heart_Murmur\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-heart_murmur-56-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Damaged or artificial heart valves  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-damaged_artificial_heart_valves--57-0\" type=\"radio\" value=\"Yes\" name=\"Damaged_artificial_heart_valves \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-damaged_artificial_heart_valves--57-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-damaged_artificial_heart_valves--57-1\" type=\"radio\" value=\"No\" name=\"Damaged_artificial_heart_valves \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-damaged_artificial_heart_valves--57-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Congenital Heart Defect  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-congenital_heart_defect--58-0\" type=\"radio\" value=\"Yes\" name=\"Congenital_Heart_Defect \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-congenital_heart_defect--58-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-congenital_heart_defect--58-1\" type=\"radio\" value=\"No\" name=\"Congenital_Heart_Defect \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-congenital_heart_defect--58-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Heart Disease <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-heart_disease-59-0\" type=\"radio\" value=\"Yes\" name=\"Heart_Disease\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-heart_disease-59-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-heart_disease-59-1\" type=\"radio\" value=\"No\" name=\"Heart_Disease\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-heart_disease-59-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Rheumatic Fever <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-rheumatic_fever-60-0\" type=\"radio\" value=\"Yes\" name=\"Rheumatic_Fever\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-rheumatic_fever-60-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-rheumatic_fever-60-1\" type=\"radio\" value=\"No\" name=\"Rheumatic_Fever\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-rheumatic_fever-60-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Angina <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-angina-61-0\" type=\"radio\" value=\"Yes\" name=\"Angina\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-angina-61-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-angina-61-1\" type=\"radio\" value=\"No\" name=\"Angina\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-angina-61-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Liver Disease \/ Jaundice \/ Hepatitis  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-liver_disease_jaundice_hepatitis--62-0\" type=\"radio\" value=\"Yes\" name=\"Liver_Disease_Jaundice_Hepatitis \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-liver_disease_jaundice_hepatitis--62-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-liver_disease_jaundice_hepatitis--62-1\" type=\"radio\" value=\"No\" name=\"Liver_Disease_Jaundice_Hepatitis \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-liver_disease_jaundice_hepatitis--62-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Kidney Disease <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-kidney_disease-63-0\" type=\"radio\" value=\"Yes\" name=\"Kidney_Disease\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-kidney_disease-63-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-kidney_disease-63-1\" type=\"radio\" value=\"No\" name=\"Kidney_Disease\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-kidney_disease-63-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Heart Attack \/ Stroke <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-heart_attack_stroke-64-0\" type=\"radio\" value=\"Yes\" name=\"Heart_Attack_Stroke\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-heart_attack_stroke-64-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-heart_attack_stroke-64-1\" type=\"radio\" value=\"No\" name=\"Heart_Attack_Stroke\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-heart_attack_stroke-64-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Hemophilia <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-hemophilia-65-0\" type=\"radio\" value=\"Yes\" name=\"Hemophilia\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-hemophilia-65-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-hemophilia-65-1\" type=\"radio\" value=\"No\" name=\"Hemophilia\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-hemophilia-65-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Hypertension \/ High Blood Pressure  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-hypertension-66-0\" type=\"radio\" value=\"Yes\" name=\"Hypertension\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-hypertension-66-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-hypertension-66-1\" type=\"radio\" value=\"No\" name=\"Hypertension\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-hypertension-66-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Prolonged Bleeding \/ Transfusion  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-prolonged_bleeding_transfusion--67-0\" type=\"radio\" value=\"Yes\" name=\"Prolonged_Bleeding_Transfusion \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-prolonged_bleeding_transfusion--67-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-prolonged_bleeding_transfusion--67-1\" type=\"radio\" value=\"No\" name=\"Prolonged_Bleeding_Transfusion \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-prolonged_bleeding_transfusion--67-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Anemia \/ Blood Disorder  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-anemia_blood_disorder--68-0\" type=\"radio\" value=\"Yes\" name=\"Anemia_Blood_Disorder \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-anemia_blood_disorder--68-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-anemia_blood_disorder--68-1\" type=\"radio\" value=\"No\" name=\"Anemia_Blood_Disorder \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-anemia_blood_disorder--68-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">HIV \/ AIDS <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-hiv_aids-69-0\" type=\"radio\" value=\"Yes\" name=\"HIV_AIDS\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-hiv_aids-69-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-hiv_aids-69-1\" type=\"radio\" value=\"No\" name=\"HIV_AIDS\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-hiv_aids-69-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Tonsils \/ Adenoids Removed  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-tonsils_adenoids_removed--70-0\" type=\"radio\" value=\"Yes\" name=\"Tonsils_Adenoids_Removed \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-tonsils_adenoids_removed--70-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-tonsils_adenoids_removed--70-1\" type=\"radio\" value=\"No\" name=\"Tonsils_Adenoids_Removed \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-tonsils_adenoids_removed--70-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Handicaps \/ Disabilities <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-handicaps_disabilities-71-0\" type=\"radio\" value=\"Yes\" name=\"Handicaps_Disabilities\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-handicaps_disabilities-71-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-handicaps_disabilities-71-1\" type=\"radio\" value=\"No\" name=\"Handicaps_Disabilities\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-handicaps_disabilities-71-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Arthritis \/ Joint problems  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-arthritis_joint_problems--72-0\" type=\"radio\" value=\"Yes\" name=\"Arthritis_joint_problems \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-arthritis_joint_problems--72-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-arthritis_joint_problems--72-1\" type=\"radio\" value=\"No\" name=\"Arthritis_joint_problems \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-arthritis_joint_problems--72-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Large Tonsils <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-large_tonsils-73-0\" type=\"radio\" value=\"Yes\" name=\"Large_Tonsils\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-large_tonsils-73-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-large_tonsils-73-1\" type=\"radio\" value=\"No\" name=\"Large_Tonsils\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-large_tonsils-73-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Sinus_Trouble <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-sinus_trouble-74-0\" type=\"radio\" value=\"Yes\" name=\"Sinus_Trouble\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-sinus_trouble-74-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-sinus_trouble-74-1\" type=\"radio\" value=\"No\" name=\"Sinus_Trouble\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-sinus_trouble-74-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Bed_Wetting <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-bed_wetting-75-0\" type=\"radio\" value=\"Yes\" name=\"Bed_Wetting\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-bed_wetting-75-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-bed_wetting-75-1\" type=\"radio\" value=\"No\" name=\"Bed_Wetting\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-bed_wetting-75-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Substance abuse problems (past or present)  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-substance_abuse-76-0\" type=\"radio\" value=\"Yes\" name=\"Substance_abuse\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-substance_abuse-76-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-substance_abuse-76-1\" type=\"radio\" value=\"No\" name=\"Substance_abuse\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-substance_abuse-76-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Bone fractures \/ Trauma to face \/ Jaw  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-bone_fractures_trauma_face_jaw--77-0\" type=\"radio\" value=\"Yes\" name=\"Bone_fractures_Trauma_face_Jaw \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-bone_fractures_trauma_face_jaw--77-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-bone_fractures_trauma_face_jaw--77-1\" type=\"radio\" value=\"No\" name=\"Bone_fractures_Trauma_face_Jaw \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-bone_fractures_trauma_face_jaw--77-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Prosthetic Joints <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-prosthetic_joints-78-0\" type=\"radio\" value=\"Yes\" name=\"Prosthetic_Joints\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-prosthetic_joints-78-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-prosthetic_joints-78-1\" type=\"radio\" value=\"No\" name=\"Prosthetic_Joints\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-prosthetic_joints-78-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Chronic Fatigue <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-chronic_fatigue-79-0\" type=\"radio\" value=\"Yes\" name=\"Chronic_Fatigue\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-chronic_fatigue-79-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-chronic_fatigue-79-1\" type=\"radio\" value=\"No\" name=\"Chronic_Fatigue\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-chronic_fatigue-79-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Diabetes <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-diabetes-80-0\" type=\"radio\" value=\"Yes\" name=\"Diabetes\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-diabetes-80-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-diabetes-80-1\" type=\"radio\" value=\"No\" name=\"Diabetes\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-diabetes-80-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Diabetes <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-diabetes-81-0\" type=\"radio\" value=\"Yes\" name=\"Diabetes\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-diabetes-81-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-diabetes-81-1\" type=\"radio\" value=\"No\" name=\"Diabetes\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-diabetes-81-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Growth Problems <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-growth_problems-82-0\" type=\"radio\" value=\"Yes\" name=\"Growth_Problems\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-growth_problems-82-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-growth_problems-82-1\" type=\"radio\" value=\"No\" name=\"Growth_Problems\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-growth_problems-82-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Tuberculosis or Lung Disease  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-tuberculosis_lung_disease--83-0\" type=\"radio\" value=\"Yes\" name=\"Tuberculosis_Lung_Disease \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-tuberculosis_lung_disease--83-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-tuberculosis_lung_disease--83-1\" type=\"radio\" value=\"No\" name=\"Tuberculosis_Lung_Disease \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-tuberculosis_lung_disease--83-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Pneumonia <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-pneumonia-84-0\" type=\"radio\" value=\"Yes\" name=\"Pneumonia\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-pneumonia-84-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-pneumonia-84-1\" type=\"radio\" value=\"No\" name=\"Pneumonia\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-pneumonia-84-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Cancer <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-cancer-85-0\" type=\"radio\" value=\"Yes\" name=\"Cancer\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-cancer-85-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-cancer-85-1\" type=\"radio\" value=\"No\" name=\"Cancer\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-cancer-85-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Family History of Cancer  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-family_history_cancer--86-0\" type=\"radio\" value=\"Yes\" name=\"Family_History_Cancer \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-family_history_cancer--86-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-family_history_cancer--86-1\" type=\"radio\" value=\"No\" name=\"Family_History_Cancer \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-family_history_cancer--86-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Received Radiation Treatment  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-received_radiation_treatment--87-0\" type=\"radio\" value=\"Yes\" name=\"Received_Radiation_Treatment \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-received_radiation_treatment--87-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-received_radiation_treatment--87-1\" type=\"radio\" value=\"No\" name=\"Received_Radiation_Treatment \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-received_radiation_treatment--87-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Arteriosclerosis <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-arteriosclerosis-88-0\" type=\"radio\" value=\"Yes\" name=\"Arteriosclerosis\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-arteriosclerosis-88-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-arteriosclerosis-88-1\" type=\"radio\" value=\"No\" name=\"Arteriosclerosis\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-arteriosclerosis-88-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Thyroid \/ Endocrine Problems  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-thyroid_endocrine_problems--89-0\" type=\"radio\" value=\"Yes\" name=\"Thyroid_Endocrine_Problems \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-thyroid_endocrine_problems--89-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-thyroid_endocrine_problems--89-1\" type=\"radio\" value=\"No\" name=\"Thyroid_Endocrine_Problems \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-thyroid_endocrine_problems--89-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Stomach Ulcer or Hyperacidity  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-stomach_ulcer_hyperacidity--90-0\" type=\"radio\" value=\"Yes\" name=\"Stomach_Ulcer_Hyperacidity \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-stomach_ulcer_hyperacidity--90-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-stomach_ulcer_hyperacidity--90-1\" type=\"radio\" value=\"No\" name=\"Stomach_Ulcer_Hyperacidity \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-stomach_ulcer_hyperacidity--90-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Hormone Therapy <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-hormone_therapy-91-0\" type=\"radio\" value=\"Yes\" name=\"Hormone_Therapy\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-hormone_therapy-91-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-hormone_therapy-91-1\" type=\"radio\" value=\"No\" name=\"Hormone_Therapy\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-hormone_therapy-91-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Nervous Disorders <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-nervous_disorders-92-0\" type=\"radio\" value=\"Yes\" name=\"Nervous_Disorders\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-nervous_disorders-92-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-nervous_disorders-92-1\" type=\"radio\" value=\"No\" name=\"Nervous_Disorders\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-nervous_disorders-92-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Bone Disorders\/Bone Loss  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-bone_disorders_bone_loss--93-0\" type=\"radio\" value=\"Yes\" name=\"Bone_Disorders_Bone_Loss \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-bone_disorders_bone_loss--93-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-bone_disorders_bone_loss--93-1\" type=\"radio\" value=\"No\" name=\"Bone_Disorders_Bone_Loss \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-bone_disorders_bone_loss--93-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Seizures \/ Epilepsy \/ Neurological Disease  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-seizures_epilepsy_neurological_disease--94-0\" type=\"radio\" value=\"Yes\" name=\"Seizures_Epilepsy_Neurological_Disease \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-seizures_epilepsy_neurological_disease--94-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-seizures_epilepsy_neurological_disease--94-1\" type=\"radio\" value=\"No\" name=\"Seizures_Epilepsy_Neurological_Disease \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-seizures_epilepsy_neurological_disease--94-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Treated for Emotional Problems  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-treated_emotional_problems--95-0\" type=\"radio\" value=\"Yes\" name=\"Treated_Emotional_Problems \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-treated_emotional_problems--95-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-treated_emotional_problems--95-1\" type=\"radio\" value=\"No\" name=\"Treated_Emotional_Problems \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-treated_emotional_problems--95-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Asthma <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-asthma-96-0\" type=\"radio\" value=\"Yes\" name=\"Asthma\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-asthma-96-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-asthma-96-1\" type=\"radio\" value=\"No\" name=\"Asthma\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-asthma-96-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Respiratory Problems \/ Emphysema  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-respiratory_problems_emphysema--97-0\" type=\"radio\" value=\"Yes\" name=\"Respiratory_Problems_Emphysema \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-respiratory_problems_emphysema--97-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-respiratory_problems_emphysema--97-1\" type=\"radio\" value=\"No\" name=\"Respiratory_Problems_Emphysema \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-respiratory_problems_emphysema--97-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Persistent swollen neck glands  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-persistent_swollen_neck_glands--98-0\" type=\"radio\" value=\"Yes\" name=\"Persistent_swollen_neck_glands \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-persistent_swollen_neck_glands--98-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-persistent_swollen_neck_glands--98-1\" type=\"radio\" value=\"No\" name=\"Persistent_swollen_neck_glands \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-persistent_swollen_neck_glands--98-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Sexually Transmitted Disease  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-sexually_transmitted_disease--99-0\" type=\"radio\" value=\"Yes\" name=\"Sexually_Transmitted_Disease \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-sexually_transmitted_disease--99-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-sexually_transmitted_disease--99-1\" type=\"radio\" value=\"No\" name=\"Sexually_Transmitted_Disease \" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-sexually_transmitted_disease--99-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Low Blood Pressure <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-low_blood_pressure-100-0\" type=\"radio\" value=\"Yes\" name=\"Low_Blood_Pressure\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-low_blood_pressure-100-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-low_blood_pressure-100-1\" type=\"radio\" value=\"No\" name=\"Low_Blood_Pressure\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-low_blood_pressure-100-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Persistent Cough <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-persistent_cough-101-0\" type=\"radio\" value=\"Yes\" name=\"Persistent_Cough\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-persistent_cough-101-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-persistent_cough-101-1\" type=\"radio\" value=\"No\" name=\"Persistent_Cough\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-persistent_cough-101-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">FEMALES: Are you pregnant? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-females_are_you_pregnant?-102-0\" type=\"radio\" value=\"Yes\" name=\"FEMALES_Are_you_pregnant?\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-females_are_you_pregnant?-102-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-females_are_you_pregnant?-102-1\" type=\"radio\" value=\"No\" name=\"FEMALES_Are_you_pregnant?\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-females_are_you_pregnant?-102-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Take Bisphosphonates (Fosamax, Boniva) <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-take_bisphosphonates_fosamax_boniva-103-0\" type=\"radio\" value=\"Yes\" name=\"Take_Bisphosphonates_Fosamax_Boniva\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-take_bisphosphonates_fosamax_boniva-103-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-take_bisphosphonates_fosamax_boniva-103-1\" type=\"radio\" value=\"No\" name=\"Take_Bisphosphonates_Fosamax_Boniva\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-take_bisphosphonates_fosamax_boniva-103-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">If any of the above medical questions were answered &#039;Yes&#039; , please explain: <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-if_any_of_the_above_medical_questions_were_answered_yes_please_explain-104-0\" type=\"radio\" value=\"Yes\" name=\"If_any_of_the_above_medical_questions_were_answered_Yes_please_explain\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-if_any_of_the_above_medical_questions_were_answered_yes_please_explain-104-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-if_any_of_the_above_medical_questions_were_answered_yes_please_explain-104-1\" type=\"radio\" value=\"No\" name=\"If_any_of_the_above_medical_questions_were_answered_Yes_please_explain\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-if_any_of_the_above_medical_questions_were_answered_yes_please_explain-104-1\">No<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-79{width:100% !important;margin-top : 20px;margin-bottom : 0px;}.fusion-builder-column-79 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-79{width:100% !important;order : 0;}.fusion-builder-column-79 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-79{width:100% !important;order : 0;}.fusion-builder-column-79 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-10{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-11 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-80 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-10\" style=\"text-align:left;line-height:1;\"><h2>Patient Motivation for Orthodontic Treatment<\/h2>\n<\/div><div class=\"fusion-text fusion-text-11\" style=\"text-align:left;line-height:1;\"><p>Patients often request changes in their bites or faces and relief from pain or discomfort.<\/p>\n<p>Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.)<\/p>\n<\/div><div class=\"fusion-text fusion-text-12\" style=\"text-align:left;line-height:1;\"><h5><strong>T<\/strong><strong>eeth<\/strong> <strong>- If your teeth could be changed, how would you like them to change?<\/strong><\/h5>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-80{width:100% !important;margin-top : 20px;margin-bottom : 0px;}.fusion-builder-column-80 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-80{width:100% !important;order : 0;}.fusion-builder-column-80 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-80{width:100% !important;order : 0;}.fusion-builder-column-80 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-81 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-straighten_front_teeth-105-0\" type=\"radio\" value=\"Straighten Front Teeth\" name=\"straighten_front_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-straighten_front_teeth-105-0\">Straighten Front Teeth<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-front_teeth_position-106-0\" type=\"radio\" value=\"Upper\" name=\"front_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-front_teeth_position-106-0\">Upper<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-front_teeth_position-106-1\" type=\"radio\" value=\"Lower\" name=\"front_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-front_teeth_position-106-1\">Lower<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-front_teeth_position-106-2\" type=\"radio\" value=\"Both\" name=\"front_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-front_teeth_position-106-2\">Both<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-81{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-81 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-81{width:100% !important;order : 0;}.fusion-builder-column-81 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-81{width:100% !important;order : 0;}.fusion-builder-column-81 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-82 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-straighten_back_teeth-107-0\" type=\"radio\" value=\"Straighten Back Teeth\" name=\"straighten_back_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-straighten_back_teeth-107-0\">Straighten Back Teeth<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-back_teeth_position-108-0\" type=\"radio\" value=\"Upper\" name=\"back_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-back_teeth_position-108-0\">Upper<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-back_teeth_position-108-1\" type=\"radio\" value=\"Lower\" name=\"back_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-back_teeth_position-108-1\">Lower<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-back_teeth_position-108-2\" type=\"radio\" value=\"Both\" name=\"back_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-back_teeth_position-108-2\">Both<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-82{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-82 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-82{width:100% !important;order : 0;}.fusion-builder-column-82 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-82{width:100% !important;order : 0;}.fusion-builder-column-82 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-83 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-move_upper_teeth-109-0\" type=\"radio\" value=\"Move Upper Teeth\" name=\"move_upper_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_upper_teeth-109-0\">Move Upper Teeth<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-upper_teeth_position-110-0\" type=\"radio\" value=\"Forward\" name=\"upper_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-upper_teeth_position-110-0\">Forward<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-upper_teeth_position-110-1\" type=\"radio\" value=\"Backward\" name=\"upper_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-upper_teeth_position-110-1\">Backward<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-83{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-83 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-83{width:100% !important;order : 0;}.fusion-builder-column-83 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-83{width:100% !important;order : 0;}.fusion-builder-column-83 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-84 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-move_lower_teeth-111-0\" type=\"radio\" value=\"Move Lower Teeth\" name=\"move_lower_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_lower_teeth-111-0\">Move Lower Teeth<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-lower_teeth_position-112-0\" type=\"radio\" value=\"Forward\" name=\"lower_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-lower_teeth_position-112-0\">Forward<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-lower_teeth_position-112-1\" type=\"radio\" value=\"Backward\" name=\"lower_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-lower_teeth_position-112-1\">Backward<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-84{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-84 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-84{width:100% !important;order : 0;}.fusion-builder-column-84 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-84{width:100% !important;order : 0;}.fusion-builder-column-84 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-85 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-eliminate_spaces-113-0\" type=\"radio\" value=\"Eliminate Spaces Between Teeth\" name=\"eliminate_spaces\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_spaces-113-0\">Eliminate Spaces Between Teeth<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-eliminate_spaces_position-114-0\" type=\"radio\" value=\"Upper\" name=\"eliminate_spaces_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_spaces_position-114-0\">Upper<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-eliminate_spaces_position-114-1\" type=\"radio\" value=\"Lower\" name=\"eliminate_spaces_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_spaces_position-114-1\">Lower<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-eliminate_spaces_position-114-2\" type=\"radio\" value=\"Both\" name=\"eliminate_spaces_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_spaces_position-114-2\">Both<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-85{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-85 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-85{width:100% !important;order : 0;}.fusion-builder-column-85 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-85{width:100% !important;order : 0;}.fusion-builder-column-85 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-86 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-eliminate_crowding-115-0\" type=\"radio\" value=\"Eliminate Crowding of Teeth\" name=\"eliminate_crowding\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_crowding-115-0\">Eliminate Crowding of Teeth<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-eliminate_crowding_position-116-0\" type=\"radio\" value=\"Upper\" name=\"eliminate_crowding_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_crowding_position-116-0\">Upper<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-eliminate_crowding_position-116-1\" type=\"radio\" value=\"Lower\" name=\"eliminate_crowding_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_crowding_position-116-1\">Lower<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-eliminate_crowding_position-116-2\" type=\"radio\" value=\"Both\" name=\"eliminate_crowding_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_crowding_position-116-2\">Both<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-86{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-86 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-86{width:100% !important;order : 0;}.fusion-builder-column-86 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-86{width:100% !important;order : 0;}.fusion-builder-column-86 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-87 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-upper_teeth_level-117-0\" type=\"radio\" value=\"Make Line of Upper Teeth More Level\" name=\"upper_teeth_level\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-upper_teeth_level-117-0\">Make Line of Upper Teeth More Level<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-87{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-87 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-87{width:100% !important;order : 0;}.fusion-builder-column-87 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-87{width:100% !important;order : 0;}.fusion-builder-column-87 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-88 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-other-118-0\" type=\"radio\" value=\"Other\" name=\"other\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-other-118-0\">Other<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"557\"><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"other_details\" name=\"other_details\" class=\"fusion-form-input\" placeholder=\"Other\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-88{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-88 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-88{width:100% !important;order : 0;}.fusion-builder-column-88 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-88{width:100% !important;order : 0;}.fusion-builder-column-88 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-89 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-13\" style=\"text-align:left;line-height:1;\"><h5><span lang=\"EN-US\" style=\"color: #202429; letter-spacing: -.1pt;\">Face<\/span><span lang=\"EN-US\" style=\"color: #202429;\"> - If <span style=\"letter-spacing: -.05pt;\">your<\/span> facial appearance could be changed, what <span style=\"letter-spacing: -.05pt;\">would<\/span> <span style=\"letter-spacing: -.05pt;\">you<\/span> change?<\/span><\/h5>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-89{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-89 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-89{width:100% !important;order : 0;}.fusion-builder-column-89 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-89{width:100% !important;order : 0;}.fusion-builder-column-89 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-90 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-move_upper_lip-119-0\" type=\"radio\" value=\"Move Upper Lip\" name=\"Move_Upper_Lip\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_upper_lip-119-0\">Move Upper Lip<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-move_upper_lip_position-120-0\" type=\"radio\" value=\"Forward\" name=\"Move_Upper_Lip_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_upper_lip_position-120-0\">Forward<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-move_upper_lip_position-120-1\" type=\"radio\" value=\"Backward\" name=\"Move_Upper_Lip_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_upper_lip_position-120-1\">Backward<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-90{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-90 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-90{width:100% !important;order : 0;}.fusion-builder-column-90 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-90{width:100% !important;order : 0;}.fusion-builder-column-90 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-91 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-move_lower_lip-121-0\" type=\"radio\" value=\"Move Lower Lip\" name=\"Move_Lower_Lip\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_lower_lip-121-0\">Move Lower Lip<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-move_lower_lip_position-122-0\" type=\"radio\" value=\"Forward\" name=\"Move_Lower_Lip_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_lower_lip_position-122-0\">Forward<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-move_lower_lip_position-122-1\" type=\"radio\" value=\"Backward\" name=\"Move_Lower_Lip_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_lower_lip_position-122-1\">Backward<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-91{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-91 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-91{width:100% !important;order : 0;}.fusion-builder-column-91 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-91{width:100% !important;order : 0;}.fusion-builder-column-91 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-92 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-show_teeth_when_smile--123-0\" type=\"radio\" value=\"Show my teeth when I smile\" name=\"Show_teeth_when_smile \" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-show_teeth_when_smile--123-0\">Show my teeth when I smile<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-show_teeth_when_smile_position-124-0\" type=\"radio\" value=\"More\" name=\"Show_teeth_when_smile_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-show_teeth_when_smile_position-124-0\">More<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-show_teeth_when_smile_position-124-1\" type=\"radio\" value=\"Less\" name=\"Show_teeth_when_smile_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-show_teeth_when_smile_position-124-1\">Less<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-92{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-92 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-92{width:100% !important;order : 0;}.fusion-builder-column-92 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-92{width:100% !important;order : 0;}.fusion-builder-column-92 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-93 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-show_gums_when_smile--125-0\" type=\"radio\" value=\"Show my gums when I smile\" name=\"Show_gums_when_smile \" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-show_gums_when_smile--125-0\">Show my gums when I smile<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-show_gums_when_smile_position-126-0\" type=\"radio\" value=\"More\" name=\"Show_gums_when_smile_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-show_gums_when_smile_position-126-0\">More<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-show_gums_when_smile_position-126-1\" type=\"radio\" value=\"Less\" name=\"Show_gums_when_smile_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-show_gums_when_smile_position-126-1\">Less<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-93{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-93 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-93{width:100% !important;order : 0;}.fusion-builder-column-93 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-93{width:100% !important;order : 0;}.fusion-builder-column-93 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-94 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-make_my_nose-127-0\" type=\"radio\" value=\"Make my nose\" name=\"make_my_nose\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-make_my_nose-127-0\">Make my nose<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-make_my_nose_position-128-0\" type=\"radio\" value=\"Longer\" name=\"make_my_nose_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-make_my_nose_position-128-0\">Longer<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-make_my_nose_position-128-1\" type=\"radio\" value=\"Shorter\" name=\"make_my_nose_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-make_my_nose_position-128-1\">Shorter<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-94{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-94 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-94{width:100% !important;order : 0;}.fusion-builder-column-94 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-94{width:100% !important;order : 0;}.fusion-builder-column-94 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-95 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-move_chin-129-0\" type=\"radio\" value=\"Move chin\" name=\"move_chin\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_chin-129-0\">Move chin<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-move_chin_position-130-0\" type=\"radio\" value=\"Forward\" name=\"move_chin_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_chin_position-130-0\">Forward<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-move_chin_position-130-1\" type=\"radio\" value=\"Backward\" name=\"move_chin_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_chin_position-130-1\">Backward<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-95{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-95 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-95{width:100% !important;order : 0;}.fusion-builder-column-95 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-95{width:100% !important;order : 0;}.fusion-builder-column-95 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-96 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-move_chin-131-0\" type=\"radio\" value=\"Move chin\" name=\"move_chin\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_chin-131-0\">Move chin<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-move_chin_position-132-0\" type=\"radio\" value=\"Left\" name=\"move_chin_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_chin_position-132-0\">Left<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-move_chin_position-132-1\" type=\"radio\" value=\"Right\" name=\"move_chin_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_chin_position-132-1\">Right<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-96{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-96 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-96{width:100% !important;order : 0;}.fusion-builder-column-96 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-96{width:100% !important;order : 0;}.fusion-builder-column-96 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-97 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-reduce_strain-133-0\" type=\"radio\" value=\"Reduce the strain when I close my lips in my:\" name=\"reduce_strain\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-reduce_strain-133-0\">Reduce the strain when I close my lips in my:<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-reduce_strain_position-134-0\" type=\"radio\" value=\"Chin\" name=\"reduce_strain_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-reduce_strain_position-134-0\">Chin<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-reduce_strain_position-134-1\" type=\"radio\" value=\"Lips\" name=\"reduce_strain_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-reduce_strain_position-134-1\">Lips<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-reduce_strain_position-134-2\" type=\"radio\" value=\"Both\" name=\"reduce_strain_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-reduce_strain_position-134-2\">Both<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-97{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-97 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-97{width:100% !important;order : 0;}.fusion-builder-column-97 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-97{width:100% !important;order : 0;}.fusion-builder-column-97 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-98 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-teeth_touch_lips-135-0\" type=\"radio\" value=\"Close together\" name=\"teeth_touch_lips\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-teeth_touch_lips-135-0\">Close together<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-teeth_touch_lips-135-1\" type=\"radio\" value=\"Farther apart\" name=\"teeth_touch_lips\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-teeth_touch_lips-135-1\">Farther apart<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-teeth_touch_lips_position-136-0\" type=\"radio\" value=\"Close together\" name=\"teeth_touch_lips_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-teeth_touch_lips_position-136-0\">Close together<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-teeth_touch_lips_position-136-1\" type=\"radio\" value=\"Father apart\" name=\"teeth_touch_lips_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-teeth_touch_lips_position-136-1\">Father apart<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-98{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-98 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-98{width:100% !important;order : 0;}.fusion-builder-column-98 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-98{width:100% !important;order : 0;}.fusion-builder-column-98 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-11{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-12 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-99 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-14\" style=\"text-align:left;line-height:1;\"><h2>Patient Motivation for Orthodontic Treatment<\/h2>\n<\/div><div class=\"fusion-text fusion-text-15\" style=\"text-align:left;line-height:1;\"><h5>If patient is under the age of 18, please answer the following questions:<\/h5>\n<\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"Height\" id=\"Height\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Height\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"Weight\" id=\"Weight\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Weight\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"School\" id=\"School\" value=\"\"  class=\"fusion-form-input\" placeholder=\"School\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"557\"><input type=\"text\" name=\"Grade\" id=\"Grade\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Grade\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-99{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-99 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-99{width:100% !important;order : 0;}.fusion-builder-column-99 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-99{width:100% !important;order : 0;}.fusion-builder-column-99 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-100 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Has patient begun puberty: <\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-begun_puberty-137-0\" type=\"radio\" value=\"No\" name=\"begun_puberty\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-begun_puberty-137-0\">No<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-begun_puberty-137-1\" type=\"radio\" value=\"Yes\" name=\"begun_puberty\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-begun_puberty-137-1\">Yes<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">If patient is a girl, has menstruation begun: <\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-menstruation_begun-138-0\" type=\"radio\" value=\"No\" name=\"menstruation_begun\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-menstruation_begun-138-0\">No<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-menstruation_begun-138-1\" type=\"radio\" value=\"Yes\" name=\"menstruation_begun\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-menstruation_begun-138-1\">Yes<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">If patient is a boy, has their voice changed or have facial hair: <\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-boy_voice_changed-139-0\" type=\"radio\" value=\"No\" name=\"boy_voice_changed\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-boy_voice_changed-139-0\">No<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-boy_voice_changed-139-1\" type=\"radio\" value=\"Yes\" name=\"boy_voice_changed\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-boy_voice_changed-139-1\">Yes<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Has the patient grown in the past year or has their shoe size changed recently: <\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-patient_grown_shoe_size_changed-140-0\" type=\"radio\" value=\"No\" name=\"patient_grown_shoe_size_changed\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-patient_grown_shoe_size_changed-140-0\">No<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-patient_grown_shoe_size_changed-140-1\" type=\"radio\" value=\"Yes\" name=\"patient_grown_shoe_size_changed\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-patient_grown_shoe_size_changed-140-1\">Yes<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"557\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Has either biological parent ever had orthodontic treatment: <\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-biological_parent_orthodontics-141-0\" type=\"radio\" value=\"No\" name=\"biological_parent_orthodontics\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-biological_parent_orthodontics-141-0\">No<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-biological_parent_orthodontics-141-1\" type=\"radio\" value=\"Yes\" name=\"biological_parent_orthodontics\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-biological_parent_orthodontics-141-1\">Yes<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-100{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-100 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-100{width:100% !important;order : 0;}.fusion-builder-column-100 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-100{width:100% !important;order : 0;}.fusion-builder-column-100 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-12{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-13 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-101 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-certify-2-0\" type=\"checkbox\" value=\"I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his\/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.\" name=\"Certify[]\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"checkbox-certify-2-0\">I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his\/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"557\"><fieldset><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-credit_reports-3-0\" type=\"checkbox\" value=\"I understand that where appropriate, credit bureau reports may be obtained.\" name=\"Credit_Reports[]\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"checkbox-credit_reports-3-0\">I understand that where appropriate, credit bureau reports may be obtained.<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-101{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-101 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-101{width:100% !important;order : 0;}.fusion-builder-column-101 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-101{width:100% !important;order : 0;}.fusion-builder-column-101 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-13{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-14 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-102 fusion_builder_column_1_5 1_5 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-recaptcha-field fusion-form-label-above\" data-form-id=\"557\">\t\t\t\t\t\t\t\t\t<div class=\"form-creator-recaptcha\" >\n\t\t\t\t\t\t\t\t\t\t\t\t\t<div\n\t\t\t\t\t\t\t\tid=\"g-recaptcha-557\"\n\t\t\t\t\t\t\t\tclass=\"fusion-form-recaptcha-v2\"\n\t\t\t\t\t\t\t\tdata-theme=\"light\"\n\t\t\t\t\t\t\t\tdata-sitekey=\"6Lctpz4bAAAAAOr8oAVuyCTKs76scmxmcPGFUSwi\"\n\t\t\t\t\t\t\t\tdata-tabindex=\"\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-102{width:20% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-102 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 9.6%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 9.6%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-102{width:20% !important;order : 0;}.fusion-builder-column-102 > .fusion-column-wrapper {margin-right : 9.6%;margin-left : 9.6%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-102{width:100% !important;order : 0;}.fusion-builder-column-102 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-103 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"form-submission-notices\" id=\"fusion-notices-1\"><div class=\"fusion-alert alert success alert-success fusion-alert-center fusion-form-response fusion-form-response-success alert-dismissable\" style=\"background-color:rgba(18,184,120,0.1);color:#12b878;border-color:#12b878;border-width:1px;margin-top:20px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa fa-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Thank you for your message. It has been sent.<\/span><\/div><\/div><div class=\"fusion-alert alert error alert-danger fusion-alert-center fusion-form-response fusion-form-response-error alert-dismissable\" style=\"background-color:rgba(219,75,104,0.1);color:#db4b68;border-color:#db4b68;border-width:1px;margin-top:20px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa fa-exclamation-triangle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">There was an error trying to send your message. 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