{"id":439,"date":"2026-05-04T07:17:58","date_gmt":"2026-05-04T07:17:58","guid":{"rendered":"https:\/\/artistryminds.org\/fahad\/?page_id=439"},"modified":"2026-05-16T07:24:14","modified_gmt":"2026-05-16T07:24:14","slug":"new-patient-packet","status":"publish","type":"page","link":"https:\/\/artistryminds.org\/fahad\/es\/new-patient-packet\/","title":{"rendered":"Paquete para nuevos pacientes"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"439\" class=\"elementor elementor-439\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-aace5c7 e-flex e-con-boxed e-con e-parent\" data-id=\"aace5c7\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-09f48ce elementor-widget elementor-widget-heading\" data-id=\"09f48ce\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">New Patient Packet<\/h1>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-7dd7119 e-flex e-con-boxed e-con e-parent\" data-id=\"7dd7119\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-bafb4e2 elementor-widget-divider--view-line_text elementor-widget-divider--element-align-center elementor-widget elementor-widget-divider\" data-id=\"bafb4e2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t\t<span class=\"elementor-divider__text elementor-divider__element\">\n\t\t\t\tWelcome to\t\t\t\t<\/span>\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0126b36 elementor-widget elementor-widget-heading\" data-id=\"0126b36\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Caceres Medical Group<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-ec2e8cc elementor-widget__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"ec2e8cc\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\tComprehensive Healthcare with Compassion and Excellence \t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bfcb2ed elementor-button-align-start elementor-widget elementor-widget-form\" data-id=\"bfcb2ed\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\" aria-label=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"439\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"bfcb2ed\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_7747d9c elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Personal Information\" data-previousButton=\"\" data-nextButton=\"Medical Questionnaire\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFull Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_d611cce elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d611cce\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_d611cce]\" id=\"form-field-field_d611cce\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_df1a0ac elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_df1a0ac\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_df1a0ac]\" id=\"form-field-field_df1a0ac\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_ba6eca6 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ba6eca6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAppointment Date\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_ba6eca6]\" id=\"form-field-field_ba6eca6\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-time elementor-field-group elementor-column elementor-field-group-field_0faf76b elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0faf76b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAppointment Time\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"time\" name=\"form_fields[field_0faf76b]\" id=\"form-field-field_0faf76b\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-time-field\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6e72190 elementor-col-100\">\n\t\t\t\t\t<div>\n  <p><strong>Dear New Patient,<\/strong><\/p>\n\n  <p>\n    PLEASE BRING A VALID PHOTO ID AND YOUR HEALTH INSURANCE CARD, IF ANY.\n    WE NEED THIS INFORMATION TO CHECK YOUR HEALTH INSURANCE COVERAGE, IF THAT IS THE CASE.\n  <\/p>\n\n  <p>\n    We are sending you a medical questionnaire to complete at home. Please bring the completed packet to your appointment.\n  <\/p>\n\n  <p>\n    PLEASE BRING ALL YOUR CURRENT MEDICATIONS WITH YOU TO YOUR APPOINTMENT (including vitamins and supplements).\n  <\/p>\n\n  <p>\n    It is very important that we have pertinent records from your referring physician including laboratory reports,\n    EKGs, treadmill tests, Holter monitors, or echocardiogram copies. You may bring copies with you or request that\n    they be forwarded directly to this office. (See Authorization to Release Records form.)\n  <\/p>\n\n  <p>\n    We do insurance billing. We are happy to bill other group insurance plans provided the visit is paid at the time of service and current billing information is supplied. Please bring your physical insurance cards (no electronic-only cards). Deductibles and copayments are due at the time of service according to your plan.\n  <\/p>\n\n  <p>\n    Our schedule is heavily booked. Please arrive 15 minutes prior to your appointment with all forms completed.\n    Notify us right away if you are unable to keep this appointment.\n  <\/p>\n\n <p>\n  If you have any questions, please call \n  <a href=\"tel:+17148218588\" style=\"background-color: #fff59d; padding: 2px 4px; font-weight: bold; color: inherit; text-decoration: none;\">\n    (714) 821-8588\n  <\/a>\n<\/p>\n\n  <p>\n    Sincerely,<br>\n    Brenda<br>\n    New Patient Coordinator\n  <\/p>\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_c32192d elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Medical Questionnaire\" data-previousButton=\"\" data-nextButton=\"Medications &amp; Contacts\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_7658096 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7658096\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat is the main reason for your visit?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"New symptoms\" id=\"form-field-field_7658096-0\" name=\"form_fields[field_7658096][]\"> <label for=\"form-field-field_7658096-0\">New symptoms<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Follow-up visit\" id=\"form-field-field_7658096-1\" name=\"form_fields[field_7658096][]\"> <label for=\"form-field-field_7658096-1\">Follow-up visit<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Annual physical\" id=\"form-field-field_7658096-2\" name=\"form_fields[field_7658096][]\"> <label for=\"form-field-field_7658096-2\">Annual physical<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Medication refill\" id=\"form-field-field_7658096-3\" name=\"form_fields[field_7658096][]\"> <label for=\"form-field-field_7658096-3\">Medication refill<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Referral\/second opinion\" id=\"form-field-field_7658096-4\" name=\"form_fields[field_7658096][]\"> <label for=\"form-field-field_7658096-4\">Referral\/second opinion<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart-related concerns\" id=\"form-field-field_7658096-5\" name=\"form_fields[field_7658096][]\"> <label for=\"form-field-field_7658096-5\">Heart-related concerns<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Diabetes follow-up\" id=\"form-field-field_7658096-6\" name=\"form_fields[field_7658096][]\"> <label for=\"form-field-field_7658096-6\">Diabetes follow-up<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Blood pressure follow-up\" id=\"form-field-field_7658096-7\" name=\"form_fields[field_7658096][]\"> <label for=\"form-field-field_7658096-7\"> Blood pressure follow-up<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-field_7658096-8\" name=\"form_fields[field_7658096][]\"> <label for=\"form-field-field_7658096-8\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_d23cde8 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d23cde8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre you currently having any of these symptoms?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Chest pain\" id=\"form-field-field_d23cde8-0\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-0\">Chest pain<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Shortness of breath\" id=\"form-field-field_d23cde8-1\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-1\">Shortness of breath<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Palpitations\/skipped beats\" id=\"form-field-field_d23cde8-2\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-2\">Palpitations\/skipped beats<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Dizziness\/fainting\" id=\"form-field-field_d23cde8-3\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-3\">Dizziness\/fainting<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Swelling of legs\" id=\"form-field-field_d23cde8-4\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-4\">Swelling of legs<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Fatigue\/weakness\" id=\"form-field-field_d23cde8-5\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-5\">Fatigue\/weakness<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Headache\" id=\"form-field-field_d23cde8-6\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-6\">Headache<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cough\" id=\"form-field-field_d23cde8-7\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-7\">Cough<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Abdominal pain\" id=\"form-field-field_d23cde8-8\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-8\">Abdominal pain<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Numbness\/tingling\" id=\"form-field-field_d23cde8-9\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-9\">Numbness\/tingling<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Leg pain when walking\" id=\"form-field-field_d23cde8-10\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-10\">Leg pain when walking<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Weight gain\/loss\" id=\"form-field-field_d23cde8-11\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-11\">Weight gain\/loss<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" None\" id=\"form-field-field_d23cde8-12\" name=\"form_fields[field_d23cde8][]\"> <label for=\"form-field-field_d23cde8-12\"> None<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_ea32524 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ea32524\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow long have you had these symptoms?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Days\" id=\"form-field-field_ea32524-0\" name=\"form_fields[field_ea32524][]\"> <label for=\"form-field-field_ea32524-0\">Days<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Weeks\" id=\"form-field-field_ea32524-1\" name=\"form_fields[field_ea32524][]\"> <label for=\"form-field-field_ea32524-1\">Weeks<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Months\" id=\"form-field-field_ea32524-2\" name=\"form_fields[field_ea32524][]\"> <label for=\"form-field-field_ea32524-2\">Months<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Years\" id=\"form-field-field_ea32524-3\" name=\"form_fields[field_ea32524][]\"> <label for=\"form-field-field_ea32524-3\">Years<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_fc29dc3 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fc29dc3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you been hospitalized or seen in an Emergency Room recently?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_fc29dc3-0\" name=\"form_fields[field_fc29dc3]\"> <label for=\"form-field-field_fc29dc3-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_fc29dc3-1\" name=\"form_fields[field_fc29dc3]\"> <label for=\"form-field-field_fc29dc3-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d6ed124 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d6ed124\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u201cIf yes, what was the reason?\u201d\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d6ed124]\" id=\"form-field-field_d6ed124\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_5846c0b elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5846c0b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDescribe your main concern\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_5846c0b]\" id=\"form-field-field_5846c0b\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_ad4ed56 elementor-col-100\">\n\t\t\t\t\t<h3>Past Medical History<\/h3>\n<p>\n  Please check any medical conditions you have had in the past:\n<\/p>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_ca89c12 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ca89c12\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHeart & Circulation\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" High blood pressure\" id=\"form-field-field_ca89c12-0\" name=\"form_fields[field_ca89c12][]\"> <label for=\"form-field-field_ca89c12-0\"> High blood pressure<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"High cholesterol\" id=\"form-field-field_ca89c12-1\" name=\"form_fields[field_ca89c12][]\"> <label for=\"form-field-field_ca89c12-1\">High cholesterol<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Coronary artery disease\" id=\"form-field-field_ca89c12-2\" name=\"form_fields[field_ca89c12][]\"> <label for=\"form-field-field_ca89c12-2\">Coronary artery disease<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart attack\" id=\"form-field-field_ca89c12-3\" name=\"form_fields[field_ca89c12][]\"> <label for=\"form-field-field_ca89c12-3\">Heart attack<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart failure\" id=\"form-field-field_ca89c12-4\" name=\"form_fields[field_ca89c12][]\"> <label for=\"form-field-field_ca89c12-4\">Heart failure<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Atrial fibrillation\/arrhythmia\" id=\"form-field-field_ca89c12-5\" name=\"form_fields[field_ca89c12][]\"> <label for=\"form-field-field_ca89c12-5\">Atrial fibrillation\/arrhythmia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pacemaker\/defibrillator\" id=\"form-field-field_ca89c12-6\" name=\"form_fields[field_ca89c12][]\"> <label for=\"form-field-field_ca89c12-6\">Pacemaker\/defibrillator<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Stroke\/TIA\" id=\"form-field-field_ca89c12-7\" name=\"form_fields[field_ca89c12][]\"> <label for=\"form-field-field_ca89c12-7\">Stroke\/TIA<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Poor circulation\/PAD\" id=\"form-field-field_ca89c12-8\" name=\"form_fields[field_ca89c12][]\"> <label for=\"form-field-field_ca89c12-8\">Poor circulation\/PAD<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Blood clots\/DVT\" id=\"form-field-field_ca89c12-9\" name=\"form_fields[field_ca89c12][]\"> <label for=\"form-field-field_ca89c12-9\">Blood clots\/DVT<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_aaedf61 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_aaedf61\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDiabetes & Metabolic\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Diabetes\" id=\"form-field-field_aaedf61-0\" name=\"form_fields[field_aaedf61][]\"> <label for=\"form-field-field_aaedf61-0\">Diabetes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Thyroid disease\" id=\"form-field-field_aaedf61-1\" name=\"form_fields[field_aaedf61][]\"> <label for=\"form-field-field_aaedf61-1\">Thyroid disease<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Obesity\" id=\"form-field-field_aaedf61-2\" name=\"form_fields[field_aaedf61][]\"> <label for=\"form-field-field_aaedf61-2\"> Obesity<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_4ec424e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4ec424e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLung Conditions\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Asthma\" id=\"form-field-field_4ec424e-0\" name=\"form_fields[field_4ec424e][]\"> <label for=\"form-field-field_4ec424e-0\">Asthma<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"COPD\/emphysema\" id=\"form-field-field_4ec424e-1\" name=\"form_fields[field_4ec424e][]\"> <label for=\"form-field-field_4ec424e-1\">COPD\/emphysema<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Sleep apnea\" id=\"form-field-field_4ec424e-2\" name=\"form_fields[field_4ec424e][]\"> <label for=\"form-field-field_4ec424e-2\">Sleep apnea<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_f2eb4aa elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f2eb4aa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tKidney \/ Liver\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Kidney disease\" id=\"form-field-field_f2eb4aa-0\" name=\"form_fields[field_f2eb4aa][]\"> <label for=\"form-field-field_f2eb4aa-0\">Kidney disease<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Liver disease\" id=\"form-field-field_f2eb4aa-1\" name=\"form_fields[field_f2eb4aa][]\"> <label for=\"form-field-field_f2eb4aa-1\">Liver disease<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_b8cd37c elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b8cd37c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOther Conditions\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cancer\" id=\"form-field-field_b8cd37c-0\" name=\"form_fields[field_b8cd37c][]\"> <label for=\"form-field-field_b8cd37c-0\">Cancer<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Lupus\/autoimmune disease\" id=\"form-field-field_b8cd37c-1\" name=\"form_fields[field_b8cd37c][]\"> <label for=\"form-field-field_b8cd37c-1\">Lupus\/autoimmune disease<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Arthritis\" id=\"form-field-field_b8cd37c-2\" name=\"form_fields[field_b8cd37c][]\"> <label for=\"form-field-field_b8cd37c-2\">Arthritis<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Neuropathy\" id=\"form-field-field_b8cd37c-3\" name=\"form_fields[field_b8cd37c][]\"> <label for=\"form-field-field_b8cd37c-3\"> Neuropathy<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Depression\/anxiety\" id=\"form-field-field_b8cd37c-4\" name=\"form_fields[field_b8cd37c][]\"> <label for=\"form-field-field_b8cd37c-4\">Depression\/anxiety<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Dementia\/memory problems\" id=\"form-field-field_b8cd37c-5\" name=\"form_fields[field_b8cd37c][]\"> <label for=\"form-field-field_b8cd37c-5\">Dementia\/memory problems<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other:\" id=\"form-field-field_b8cd37c-6\" name=\"form_fields[field_b8cd37c][]\"> <label for=\"form-field-field_b8cd37c-6\">Other:<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"None of the above\" id=\"form-field-field_b8cd37c-7\" name=\"form_fields[field_b8cd37c][]\"> <label for=\"form-field-field_b8cd37c-7\">None of the above<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-repeater_start elementor-field-group elementor-column elementor-field-group-field_747cdd8 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_747cdd8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPREVIOUS SURGERIES OR HOSPITALIZATIONS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-repeater-start\">\n\t\t\t<textarea class=\"repeater-field-header-data hidden\"><div class=\"repeater-field-header\">\n\t\t\t\t<div class=\"repeater-field-header-title\"> <\/div>\n\t\t\t\t<div class=\"repeater-field-header-acctions\">\n\t\t\t\t\t<ul>\n\t\t\t\t\t\t<li><i class=\"repeater-icon icon-down-open repeater-field-header-acctions-toogle\" aria-hidden=\"true\"><\/i><\/li>\n\t\t\t\t\t\t<li><i class=\"repeater-icon icon-cancel-1 repeater-field-header-acctions-remove\" aria-hidden=\"true\"><\/i><\/li>\n\t\t\t\t\t<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div><\/textarea>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3131ac5 elementor-col-75\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3131ac5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSurgery \/ Procedure \/ Hospitalization\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3131ac5]\" id=\"form-field-field_3131ac5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_dccb3fc elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dccb3fc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tYear\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_dccb3fc]\" id=\"form-field-field_dccb3fc\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-repeater elementor-field-group elementor-column elementor-field-group-field_f4b4eda elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f4b4eda\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tExamples: heart stents, bypass surgery, pacemaker, joint replacement, spine surgery, cancer surgery.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-repeater-end\" data-initial_rows=\"1\" data-initial_rows_map=\"\" data-map_id=\"elementor-field-group-field_f4b4eda\" data-limit=\"5\">\n\t\t\t<div class=\"repeater-field-warp-item\">\n\t\t\t<\/div>\n\t\t\t<div class=\"repeater-field-footer\"><a href=\"#\" class=\"repeater-field-button-add\" style=\"padding:3px 24px 3px 24px; border-width:0px 0px 0px 0px; border-radius:5px 5px 5px 5px; color:#ffffff; background:#69727d; border-color:#69727d; border-style:solid; \">Add more...<\/a><\/div>\n\t\t\t<input type=\"hidden\" name=\"form_fields[field_f4b4eda]\" id=\"form-field-field_f4b4eda\" class=\"elementor-field elementor-size-sm  elementor-field-repeater-data\">\n\t\t\t<textarea class=\"elementor-field-repeater-data-html hidden\"><\/textarea>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_6faeefa elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6faeefa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have any medication allergies?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No known allergies\" id=\"form-field-field_6faeefa-0\" name=\"form_fields[field_6faeefa][]\"> <label for=\"form-field-field_6faeefa-0\">No known allergies<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_6faeefa-1\" name=\"form_fields[field_6faeefa][]\"> <label for=\"form-field-field_6faeefa-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5e7c527 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5e7c527\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf yes, Please List  Allergies:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5e7c527]\" id=\"form-field-field_5e7c527\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_39eb5b9 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_39eb5b9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFamily History\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart disease\" id=\"form-field-field_39eb5b9-0\" name=\"form_fields[field_39eb5b9][]\"> <label for=\"form-field-field_39eb5b9-0\">Heart disease<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Stroke \" id=\"form-field-field_39eb5b9-1\" name=\"form_fields[field_39eb5b9][]\"> <label for=\"form-field-field_39eb5b9-1\">Stroke <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Diabetes\" id=\"form-field-field_39eb5b9-2\" name=\"form_fields[field_39eb5b9][]\"> <label for=\"form-field-field_39eb5b9-2\">Diabetes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart attack\" id=\"form-field-field_39eb5b9-3\" name=\"form_fields[field_39eb5b9][]\"> <label for=\"form-field-field_39eb5b9-3\">Heart attack<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"High blood pressure \" id=\"form-field-field_39eb5b9-4\" name=\"form_fields[field_39eb5b9][]\"> <label for=\"form-field-field_39eb5b9-4\">High blood pressure <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cancer\" id=\"form-field-field_39eb5b9-5\" name=\"form_fields[field_39eb5b9][]\"> <label for=\"form-field-field_39eb5b9-5\">Cancer<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"None known\" id=\"form-field-field_39eb5b9-6\" name=\"form_fields[field_39eb5b9][]\"> <label for=\"form-field-field_39eb5b9-6\">None known<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_27d5056 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_27d5056\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you smoke?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Never smoked\" id=\"form-field-field_27d5056-0\" name=\"form_fields[field_27d5056]\"> <label for=\"form-field-field_27d5056-0\">Never smoked<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Former smoker\" id=\"form-field-field_27d5056-1\" name=\"form_fields[field_27d5056]\"> <label for=\"form-field-field_27d5056-1\">Former smoker<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Current smoker\" id=\"form-field-field_27d5056-2\" name=\"form_fields[field_27d5056]\"> <label for=\"form-field-field_27d5056-2\">Current smoker<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_e357d5f elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e357d5f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAlcohol\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\" None\" id=\"form-field-field_e357d5f-0\" name=\"form_fields[field_e357d5f]\"> <label for=\"form-field-field_e357d5f-0\"> None<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Occasional\" id=\"form-field-field_e357d5f-1\" name=\"form_fields[field_e357d5f]\"> <label for=\"form-field-field_e357d5f-1\">Occasional<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Regular use\" id=\"form-field-field_e357d5f-2\" name=\"form_fields[field_e357d5f]\"> <label for=\"form-field-field_e357d5f-2\">Regular use<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_efe5fb0 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_efe5fb0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSenior Health (Optional):\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"History of falls\" id=\"form-field-field_efe5fb0-0\" name=\"form_fields[field_efe5fb0]\"> <label for=\"form-field-field_efe5fb0-0\">History of falls<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Uses walker\/cane\" id=\"form-field-field_efe5fb0-1\" name=\"form_fields[field_efe5fb0]\"> <label for=\"form-field-field_efe5fb0-1\">Uses walker\/cane<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Difficulty with memory\" id=\"form-field-field_efe5fb0-2\" name=\"form_fields[field_efe5fb0]\"> <label for=\"form-field-field_efe5fb0-2\">Difficulty with memory<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Needs help with daily activities\" id=\"form-field-field_efe5fb0-3\" name=\"form_fields[field_efe5fb0]\"> <label for=\"form-field-field_efe5fb0-3\">Needs help with daily activities<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_ad7bbb2 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Medications &amp; Contacts\" data-previousButton=\"\" data-nextButton=\"Authorization\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-repeater_start elementor-field-group elementor-column elementor-field-group-field_dddbedf elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dddbedf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCurrent Medications\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-repeater-start\">\n\t\t\t<textarea class=\"repeater-field-header-data hidden\"><div class=\"repeater-field-header\">\n\t\t\t\t<div class=\"repeater-field-header-title\"> <\/div>\n\t\t\t\t<div class=\"repeater-field-header-acctions\">\n\t\t\t\t\t<ul>\n\t\t\t\t\t\t<li><i class=\"repeater-icon icon-down-open repeater-field-header-acctions-toogle\" aria-hidden=\"true\"><\/i><\/li>\n\t\t\t\t\t\t<li><i class=\"repeater-icon icon-cancel-1 repeater-field-header-acctions-remove\" aria-hidden=\"true\"><\/i><\/li>\n\t\t\t\t\t<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div><\/textarea>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_421ae01 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_421ae01\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMedication Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_421ae01]\" id=\"form-field-field_421ae01\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8fd7f9f elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8fd7f9f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDose\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8fd7f9f]\" id=\"form-field-field_8fd7f9f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a6c57d5 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a6c57d5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow Often\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a6c57d5]\" id=\"form-field-field_a6c57d5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-repeater elementor-field-group elementor-column elementor-field-group-field_1fe60cd elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-repeater-end\" data-initial_rows=\"1\" data-initial_rows_map=\"\" data-map_id=\"elementor-field-group-field_1fe60cd\" data-limit=\"5\">\n\t\t\t<div class=\"repeater-field-warp-item\">\n\t\t\t<\/div>\n\t\t\t<div class=\"repeater-field-footer\"><a href=\"#\" class=\"repeater-field-button-add\" style=\"padding:3px 24px 3px 24px; border-width:0px 0px 0px 0px; border-radius:5px 5px 5px 5px; color:#FFFFFF; background:; border-color:#69727d; border-style:solid; \">+ Add Another Medication<\/a><\/div>\n\t\t\t<input type=\"hidden\" name=\"form_fields[field_1fe60cd]\" id=\"form-field-field_1fe60cd\" class=\"elementor-field elementor-size-sm  elementor-field-repeater-data\">\n\t\t\t<textarea class=\"elementor-field-repeater-data-html hidden\"><\/textarea>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-repeater_start elementor-field-group elementor-column elementor-field-group-field_b6e57bb elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b6e57bb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAdditional Medications\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-repeater-start\">\n\t\t\t<textarea class=\"repeater-field-header-data hidden\"><div class=\"repeater-field-header\">\n\t\t\t\t<div class=\"repeater-field-header-title\"> <\/div>\n\t\t\t\t<div class=\"repeater-field-header-acctions\">\n\t\t\t\t\t<ul>\n\t\t\t\t\t\t<li><i class=\"repeater-icon icon-down-open repeater-field-header-acctions-toogle\" aria-hidden=\"true\"><\/i><\/li>\n\t\t\t\t\t\t<li><i class=\"repeater-icon icon-cancel-1 repeater-field-header-acctions-remove\" aria-hidden=\"true\"><\/i><\/li>\n\t\t\t\t\t<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div><\/textarea>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f25769d elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f25769d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMedication Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f25769d]\" id=\"form-field-field_f25769d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_de64fac elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_de64fac\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDose\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_de64fac]\" id=\"form-field-field_de64fac\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2bc80e8 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2bc80e8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow Often\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2bc80e8]\" id=\"form-field-field_2bc80e8\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-repeater elementor-field-group elementor-column elementor-field-group-field_76a7b04 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-repeater-end\" data-initial_rows=\"1\" data-initial_rows_map=\"\" data-map_id=\"elementor-field-group-field_76a7b04\" data-limit=\"5\">\n\t\t\t<div class=\"repeater-field-warp-item\">\n\t\t\t<\/div>\n\t\t\t<div class=\"repeater-field-footer\"><a href=\"#\" class=\"repeater-field-button-add\" style=\"padding:3px 24px 3px 24px; border-width:0px 0px 0px 0px; border-radius:5px 5px 5px 5px; color:#FFFFFF; background:; border-color:#69727d; border-style:solid; \">+ Add Another Medication<\/a><\/div>\n\t\t\t<input type=\"hidden\" name=\"form_fields[field_76a7b04]\" id=\"form-field-field_76a7b04\" class=\"elementor-field elementor-size-sm  elementor-field-repeater-data\">\n\t\t\t<textarea class=\"elementor-field-repeater-data-html hidden\"><\/textarea>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b34f420 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b34f420\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPharmacy Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b34f420]\" id=\"form-field-field_b34f420\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_489fd2f elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_489fd2f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPharmacy Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_489fd2f]\" id=\"form-field-field_489fd2f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_20890fa elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_20890fa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPrimary Care Provider\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_20890fa]\" id=\"form-field-field_20890fa\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2435c19 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2435c19\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmergency Contact Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2435c19]\" id=\"form-field-field_2435c19\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b1d99c6 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b1d99c6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelationship\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b1d99c6]\" id=\"form-field-field_b1d99c6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_0d98925 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0d98925\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_0d98925]\" id=\"form-field-field_0d98925\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_39d740a elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Authorization &amp; Submit\" data-previousButton=\"\" data-nextButton=\"Review\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_0547887 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0547887\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAuthorization to Release Medical Records\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"I authorize the release of my medical records to Caceres Medical Group for medical evaluation and treatment.\" id=\"form-field-field_0547887-0\" name=\"form_fields[field_0547887]\"> <label for=\"form-field-field_0547887-0\">I authorize the release of my medical records to Caceres Medical Group for medical evaluation and treatment.<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8d27905 elementor-col-100\">\n\t\t\t\t\t<div>\n  <h3 style=\"font-family: 'Playfair Display', serif; font-size: 16px; font-weight: 500; color: #74252A;\">\n    FINANCIAL POLICY\n  <\/h3>\n\n  <ul style=\"font-family: 'Open Sans', sans-serif; font-size: 14px; line-height: 1.8; color: #000;\">\n    <li>We bill Medicare, PPO, and Managed Care plans.<\/li>\n    <li>Deductibles and co-payments are due at time of service.<\/li>\n    <li>For non-contracted plans, payment is due at visit and we will submit claims on your behalf.<\/li>\n    <li>Please bring physical insurance cards (no electronic-only cards).<\/li>\n    <li>Returned checks are subject to a processing fee.<\/li>\n    <li>Missed appointments without notice may be subject to a fee.<\/li>\n  <\/ul>\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_9b5ed60 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9b5ed60\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFinancial  Agreement\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"I agree to the financial policy.\" id=\"form-field-field_9b5ed60-0\" name=\"form_fields[field_9b5ed60]\"> <label for=\"form-field-field_9b5ed60-0\">I agree to the financial policy.<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_453ab17 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_453ab17\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_453ab17]\" id=\"form-field-field_453ab17\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_16709fd elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_16709fd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_16709fd]\" id=\"form-field-field_16709fd\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_4889aee elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4889aee\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_4889aee]\" id=\"form-field-field_4889aee\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_65f0f6a elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_65f0f6a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhysician\/Clinic\/Hospital Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_65f0f6a]\" id=\"form-field-field_65f0f6a\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_95da9ba elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_95da9ba\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\/Fax\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_95da9ba]\" id=\"form-field-field_95da9ba\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_7eb0432 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7eb0432\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRecords to send (check)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Office visit notes\" id=\"form-field-field_7eb0432-0\" name=\"form_fields[field_7eb0432][]\"> <label for=\"form-field-field_7eb0432-0\"> Office visit notes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\" Imaging reports\" id=\"form-field-field_7eb0432-1\" name=\"form_fields[field_7eb0432][]\"> <label for=\"form-field-field_7eb0432-1\"> Imaging reports<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Lab results \" id=\"form-field-field_7eb0432-2\" name=\"form_fields[field_7eb0432][]\"> <label for=\"form-field-field_7eb0432-2\">Lab results <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hospital discharge summary\" id=\"form-field-field_7eb0432-3\" name=\"form_fields[field_7eb0432][]\"> <label for=\"form-field-field_7eb0432-3\">Hospital discharge summary<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-signature elementor-field-group elementor-column elementor-field-group-field_72c50c4 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_72c50c4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient Signature\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class='width-100'><div class='elementor-signature-container' style='width: 400px' ><div class='elementor_signature_clear'><img src='https:\/\/artistryminds.org\/fahad\/wp-content\/plugins\/signature-field-for-elementor-forms\/lib\/images\/remove-icon.png' alt='' \/><\/div><div class='elementor-signature-field'  data-id=\"field_72c50c4\" data-background=\"#ffffff\" data-color=\"#000000\" data-width=\"400\" data-height=\"200\" data-name=\"0\" style='width:400px; height: 200px; background: #ffffff'><\/div><\/div>  <input type=\"hidden\" type=\"hidden\" name=\"form_fields[field_72c50c4]\" id=\"form-field-field_72c50c4\" class=\"elementor-field elementor-size-sm  elementor-upload-field-signature elementor-upload-field-signature-field_72c50c4\"><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_28d5ea7 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_28d5ea7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_28d5ea7]\" id=\"form-field-field_28d5ea7\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_8743c67 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8743c67\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHIPAA Agreement\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"I acknowledge that I have been offered a copy of the Notice of Privacy Practices (HIPA\u0410).\" id=\"form-field-field_8743c67-0\" name=\"form_fields[field_8743c67]\"> <label for=\"form-field-field_8743c67-0\">I acknowledge that I have been offered a copy of the Notice of Privacy Practices (HIPA\u0410).<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-signature elementor-field-group elementor-column elementor-field-group-field_41af3ed elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_41af3ed\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient\/Representative Signature\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class='width-100'><div class='elementor-signature-container' style='width: 400px' ><div class='elementor_signature_clear'><img src='https:\/\/artistryminds.org\/fahad\/wp-content\/plugins\/signature-field-for-elementor-forms\/lib\/images\/remove-icon.png' alt='' \/><\/div><div class='elementor-signature-field'  data-id=\"field_41af3ed\" data-background=\"#ffffff\" data-color=\"#000000\" data-width=\"400\" data-height=\"200\" data-name=\"0\" style='width:400px; height: 200px; background: #ffffff'><\/div><\/div>  <input type=\"hidden\" type=\"hidden\" name=\"form_fields[field_41af3ed]\" id=\"form-field-field_41af3ed\" class=\"elementor-field elementor-size-sm  elementor-upload-field-signature elementor-upload-field-signature-field_41af3ed\"><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_331254e elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_331254e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_331254e]\" id=\"form-field-field_331254e\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Submit Form<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>New Patient Packet Welcome to Caceres Medical Group Comprehensive Healthcare with Compassion and Excellence<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"","ast-site-content-layout":"full-width-container","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center 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center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-439","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/artistryminds.org\/fahad\/es\/wp-json\/wp\/v2\/pages\/439","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/artistryminds.org\/fahad\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/artistryminds.org\/fahad\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/artistryminds.org\/fahad\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/artistryminds.org\/fahad\/es\/wp-json\/wp\/v2\/comments?post=439"}],"version-history":[{"count":37,"href":"https:\/\/artistryminds.org\/fahad\/es\/wp-json\/wp\/v2\/pages\/439\/revisions"}],"predecessor-version":[{"id":846,"href":"https:\/\/artistryminds.org\/fahad\/es\/wp-json\/wp\/v2\/pages\/439\/revisions\/846"}],"wp:attachment":[{"href":"https:\/\/artistryminds.org\/fahad\/es\/wp-json\/wp\/v2\/media?parent=439"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}