{"id":1541,"date":"2024-07-05T18:10:02","date_gmt":"2024-07-05T18:10:02","guid":{"rendered":"https:\/\/dev2.therevity.com\/orthotime\/?page_id=1541"},"modified":"2024-07-05T18:11:39","modified_gmt":"2024-07-05T18:11:39","slug":"child-health-history","status":"publish","type":"page","link":"https:\/\/dev2.therevity.com\/orthotime\/child-health-history\/","title":{"rendered":"Child Health History"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1541\" class=\"elementor elementor-1541\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-33fe0fc e-flex e-con-boxed e-con e-parent\" data-id=\"33fe0fc\" 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<div class=\"elementor-element elementor-element-4ad4504 e-con-full e-flex e-con e-child\" data-id=\"4ad4504\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-c9c82a4 elementor-widget elementor-widget-theme-site-logo elementor-widget-image\" data-id=\"c9c82a4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"theme-site-logo.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/dev2.therevity.com\/orthotime\">\n\t\t\t<img decoding=\"async\" width=\"380\" height=\"98\" src=\"https:\/\/dev2.therevity.com\/orthotime\/wp-content\/uploads\/2024\/06\/Asset-1.png\" class=\"attachment-full size-full wp-image-42\" alt=\"\" srcset=\"https:\/\/dev2.therevity.com\/orthotime\/wp-content\/uploads\/2024\/06\/Asset-1.png 380w, https:\/\/dev2.therevity.com\/orthotime\/wp-content\/uploads\/2024\/06\/Asset-1-300x77.png 300w\" sizes=\"(max-width: 380px) 100vw, 380px\" \/>\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-31c2879 elementor-widget elementor-widget-text-editor\" data-id=\"31c2879\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>1248 East 90 North, Suite 201, American Fork, UT 84003<br \/>801.763.7977 www.itsorthotime.com<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-98f7442 eael-gravity-form-button-custom elementor-widget elementor-widget-eael-gravity-form\" data-id=\"98f7442\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"eael-gravity-form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t            <div class=\"eael-contact-form eael-gravity-form placeholder-hide eael-custom-radio-checkbox eael-contact-form-align-default\">\n                  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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Orthodontic Health History<\/h2>\n                            <p class='gform_description'>Jeremy R. Watson DDS, MS   1248 East 90 North, Suite 201, American Fork, UT 84003<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/orthotime\/wp-json\/wp\/v2\/pages\/1541#gf_4' data-formid='4' novalidate>\n        <div id='gf_progressbar_wrapper_4' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>2<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_4_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_above description_above validation_above'><div id=\"field_4_1\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_1'>Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_1' id='input_4_1' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_1_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_1_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_1' class='gform_hidden' value='https:\/\/dev2.therevity.com\/orthotime\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_4_3\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient\u2019s Name:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_3'>\n                            \n                            <span id='input_4_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_4_3_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_3_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_5\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name they would like to be called:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_5'>\n                            \n                            <span id='input_4_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_4_5_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_5_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_4_7\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_7'>Birth Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_4_7' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_7_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_7_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_7' class='gform_hidden' value='https:\/\/dev2.therevity.com\/orthotime\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_8\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_8'>Age:<\/label><div class='ginput_container ginput_container_number'><input name='input_8' id='input_4_8' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_4_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gf_list_inline field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Sex:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_10'><div class='gchoice gchoice_4_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Male'  id='choice_4_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_10_1' id='label_4_10_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Female'  id='choice_4_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_10_2' id='label_4_10_2' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_11\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient\u2019s Address:<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_11' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_11_1_container' >\n                                        <input type='text' name='input_11.1' id='input_4_11_1' value=''   placeholder='Address' aria-required='false'    \/>\n                                        <label for='input_4_11_1' id='input_4_11_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_11_3_container' >\n                                    <input type='text' name='input_11.3' id='input_4_11_3' value=''   placeholder='City' aria-required='false'    \/>\n                                    <label for='input_4_11_3' id='input_4_11_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_11_4_container' >\n                                        <input type='text' name='input_11.4' id='input_4_11_4' value=''     placeholder='State' aria-required='false'    \/>\n                                        <label for='input_4_11_4' id='input_4_11_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_11_5_container' >\n                                    <input type='text' name='input_11.5' id='input_4_11_5' value=''   placeholder='Zip' aria-required='false'    \/>\n                                    <label for='input_4_11_5' id='input_4_11_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_11.6' id='input_4_11_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_4_81\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >School:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_81'>\n                            \n                            <span id='input_4_81_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_81.3' id='input_4_81_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_81_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_82\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Grade:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_82'>\n                            \n                            <span id='input_4_82_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_82.3' id='input_4_82_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_82_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_4_84\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_84'>Hobbies\/sports:<\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_4_84' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_85\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mother\u2019s Name::<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_85'>\n                            \n                            <span id='input_4_85_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_85.3' id='input_4_85_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_85_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_86\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Father\u2019s Name:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_86'>\n                            \n                            <span id='input_4_86_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_86.3' id='input_4_86_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_86_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_4_13\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_13'>Mother\u2019s cell #:<\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_4_13' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_14\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_14'>Father\u2019s cell #:<\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_4_14' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_87\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_87'>Alt#:<\/label><div class='ginput_container ginput_container_phone'><input name='input_87' id='input_4_87' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_88\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_88'>Father\u2019s E-Mail Address:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_88' id='input_4_88' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_89\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_89'>Mother\u2019s E-Mail Address:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_89' id='input_4_89' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_4_90\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Siblings:<\/legend><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_90_cell1 gform-grid-col' ><input aria-invalid='false'   aria-label='Siblings:, Row 1' data-aria-label-template='Siblings:, Row {0}' type='text' name='input_90[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_16\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Emergency contact name and number:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_16'>\n                            \n                            <span id='input_4_16_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.3' id='input_4_16_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_16_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_92\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Parental Marital status:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_92'>\n                            \n                            <span id='input_4_92_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_92.3' id='input_4_92_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_92_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_93\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Who has legal custody of patient?<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_93'>\n                            \n                            <span id='input_4_93_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_93.3' id='input_4_93_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_93_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_26\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Dentist:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_26'>\n                            \n                            <span id='input_4_26_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_26.3' id='input_4_26_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_26_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_4_27\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_27'>Phone:<\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_4_27' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_28\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_28'>Date of last exam:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_28' id='input_4_28' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_28_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_28_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_28' class='gform_hidden' value='https:\/\/dev2.therevity.com\/orthotime\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_4_94\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Whom may we thank for referring you to us?<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_94'>\n                            \n                            <span id='input_4_94_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_94.3' id='input_4_94_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_94_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_95\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is the reason for today\u2019s visit?<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_95'>\n                            \n                            <span id='input_4_95_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_95.3' id='input_4_95_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_95_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_4_29\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">INSURANCE INFORMATION<\/h3><\/div><fieldset id=\"field_4_30\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Person financially responsible for this account:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_30'>\n                            \n                            <span id='input_4_30_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_30.3' id='input_4_30_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_30_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Insurance coverage for Orthodontic treatment?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_33'>\n\t\t\t<div class='gchoice gchoice_4_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Y'  id='choice_4_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_33_0' id='label_4_33_0' class='gform-field-label gform-field-label--type-inline'>Y<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='N'  id='choice_4_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_33_1' id='label_4_33_1' class='gform-field-label gform-field-label--type-inline'>N<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_34\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Insurance Company:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_34'>\n                            \n                            <span id='input_4_34_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.3' id='input_4_34_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_34_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_35\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address:<\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_4_35' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_35_1_container' >\n                                        <input type='text' name='input_35.1' id='input_4_35_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_35_1' id='input_4_35_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_35.4' id='input_4_35_4' value=''\/><input type='hidden' class='gform_hidden' name='input_35.6' id='input_4_35_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_4_36\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Primary Policy Holder Name:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_36'>\n                            \n                            <span id='input_4_36_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_36.3' id='input_4_36_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_36_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_4_37\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_37'>Birth Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_37' id='input_4_37' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_37_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_37_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_37' class='gform_hidden' value='https:\/\/dev2.therevity.com\/orthotime\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_38\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_38'>Ins. company phone #:<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_4_38' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_39\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_39'>ID#<\/label><div class='ginput_container ginput_container_number'><input name='input_39' id='input_4_39' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_4_40\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_40'>Group #<\/label><div class='ginput_container ginput_container_number'><input name='input_40' id='input_4_40' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_4_41\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Secondary Insurance Company:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_41'>\n                            \n                            <span id='input_4_41_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.3' id='input_4_41_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_41_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_42\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address:<\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_4_42' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_42_1_container' >\n                                        <input type='text' name='input_42.1' id='input_4_42_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_42_1' id='input_4_42_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_42.4' id='input_4_42_4' value=''\/><input type='hidden' class='gform_hidden' name='input_42.6' id='input_4_42_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_4_43\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Primary Policy Holder Name:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_43'>\n                            \n                            <span id='input_4_43_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_43.3' id='input_4_43_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_43_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_4_44\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_44'>Birth Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_44' id='input_4_44' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_44_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_44_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_44' class='gform_hidden' value='https:\/\/dev2.therevity.com\/orthotime\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_45\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_45'>Ins. company phone #:<\/label><div class='ginput_container ginput_container_phone'><input name='input_45' id='input_4_45' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_46\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_46'>ID#<\/label><div class='ginput_container ginput_container_number'><input name='input_46' id='input_4_46' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_4_47\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_47'>Group #<\/label><div class='ginput_container ginput_container_number'><input name='input_47' id='input_4_47' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_4_48\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PATIENT PROFILE<\/h3><\/div><div id=\"field_4_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_49'>Is the patient concerned with the appearance of their smile?<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_4_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_50'>Why do you think orthodontic treatment is needed?<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_4_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_51'>Has there been any prior orthodontic treatment or appliances?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_4_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_52'>Is there any information that would help us better treat the patient?<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_4_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_4_53' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Continue next page'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_2' class='gform_page' data-js='page-field-id-53' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_2' class='gform_fields top_label form_sublabel_above description_above validation_above'><div id=\"field_4_54\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">HEALTH HISTORY<\/h3><\/div><fieldset id=\"field_4_55\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Has your child ever had a health problem?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_55'><div class='gchoice gchoice_4_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='YES'  id='choice_4_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_55_1' id='label_4_55_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='NO'  id='choice_4_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_55_2' id='label_4_55_2' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_56'>Please explain:<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_4_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Has your child ever been hospitalized?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_57'><div class='gchoice gchoice_4_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='YES'  id='choice_4_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_57_1' id='label_4_57_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='NO'  id='choice_4_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_57_2' id='label_4_57_2' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_59\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Please give reason and dates:<\/legend><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_59_cell1 gform-grid-col' ><input aria-invalid='false'   aria-label='Please give reason and dates:, Row 1' data-aria-label-template='Please give reason and dates:, Row {0}' type='text' name='input_59[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Is your child allergic to anything?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_60'><div class='gchoice gchoice_4_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='YES'  id='choice_4_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_60_1' id='label_4_60_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='NO'  id='choice_4_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_60_2' id='label_4_60_2' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_97\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Please give medication and reason.<\/legend><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_97_cell1 gform-grid-col' ><input aria-invalid='false'   aria-label='Please give medication and reason., Row 1' data-aria-label-template='Please give medication and reason., Row {0}' type='text' name='input_97[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_96\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Has your child started her menstrual cycle? (If applicable)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_96'><div class='gchoice gchoice_4_96_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.1' type='checkbox'  value='YES'  id='choice_4_96_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_96_1' id='label_4_96_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_96_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.2' type='checkbox'  value='NO'  id='choice_4_96_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_96_2' id='label_4_96_2' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_64\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please mark if you have or have had, any of the following medical problems:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_64'><div class='gchoice gchoice_4_64_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.1' type='checkbox'  value='Heart defect'  id='choice_4_64_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_1' id='label_4_64_1' class='gform-field-label gform-field-label--type-inline'>Heart defect<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.2' type='checkbox'  value='Liver disease'  id='choice_4_64_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_2' id='label_4_64_2' class='gform-field-label gform-field-label--type-inline'>Liver disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.3' type='checkbox'  value='Kidney disease'  id='choice_4_64_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_3' id='label_4_64_3' class='gform-field-label gform-field-label--type-inline'>Kidney disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.4' type='checkbox'  value='Bleeding\/transfusion'  id='choice_4_64_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_4' id='label_4_64_4' class='gform-field-label gform-field-label--type-inline'>Bleeding\/transfusion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.5' type='checkbox'  value='Asthma'  id='choice_4_64_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_5' id='label_4_64_5' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.6' type='checkbox'  value='Anemia'  id='choice_4_64_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_6' id='label_4_64_6' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.7' type='checkbox'  value='Autism'  id='choice_4_64_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_7' id='label_4_64_7' class='gform-field-label gform-field-label--type-inline'>Autism<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.8' type='checkbox'  value='ADHD\/ADD'  id='choice_4_64_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_8' id='label_4_64_8' class='gform-field-label gform-field-label--type-inline'>ADHD\/ADD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.9' type='checkbox'  value='Seizures'  id='choice_4_64_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_9' id='label_4_64_9' class='gform-field-label gform-field-label--type-inline'>Seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.11' type='checkbox'  value='Diabetes'  id='choice_4_64_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_11' id='label_4_64_11' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.12' type='checkbox'  value='Handicap\/disabilities'  id='choice_4_64_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_12' id='label_4_64_12' class='gform-field-label gform-field-label--type-inline'>Handicap\/disabilities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.13' type='checkbox'  value='Cerebral palsy'  id='choice_4_64_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_13' id='label_4_64_13' class='gform-field-label gform-field-label--type-inline'>Cerebral palsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.14' type='checkbox'  value='Cleft lip\/palate'  id='choice_4_64_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_14' id='label_4_64_14' class='gform-field-label gform-field-label--type-inline'>Cleft lip\/palate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.15' type='checkbox'  value='AIDS'  id='choice_4_64_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_15' id='label_4_64_15' class='gform-field-label gform-field-label--type-inline'>AIDS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.16' type='checkbox'  value='Depression'  id='choice_4_64_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_16' id='label_4_64_16' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.17' type='checkbox'  value='Birth defect'  id='choice_4_64_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_17' id='label_4_64_17' class='gform-field-label gform-field-label--type-inline'>Birth defect<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.18' type='checkbox'  value='Speech\/hearing'  id='choice_4_64_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_18' id='label_4_64_18' class='gform-field-label gform-field-label--type-inline'>Speech\/hearing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.19' type='checkbox'  value='Artificial bones\/joints\/valves'  id='choice_4_64_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_19' id='label_4_64_19' class='gform-field-label gform-field-label--type-inline'>Artificial bones\/joints\/valves<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_64_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.21' type='checkbox'  value='Cancer'  id='choice_4_64_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_64_21' id='label_4_64_21' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_65'>Other Problems (Please explain)<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_4_65' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_66\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">DENTAL HISTORY<\/h3><\/div><fieldset id=\"field_4_67\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please mark if you have or have had, any of the following:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_67'><div class='gchoice gchoice_4_67_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.1' type='checkbox'  value='Clenching'  id='choice_4_67_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_67_1' id='label_4_67_1' class='gform-field-label gform-field-label--type-inline'>Clenching<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_67_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.2' type='checkbox'  value='Grinding teeth'  id='choice_4_67_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_67_2' id='label_4_67_2' class='gform-field-label gform-field-label--type-inline'>Grinding teeth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_67_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.3' type='checkbox'  value='Lip sucking'  id='choice_4_67_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_67_3' id='label_4_67_3' class='gform-field-label gform-field-label--type-inline'>Lip sucking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_67_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.4' type='checkbox'  value='Biting'  id='choice_4_67_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_67_4' id='label_4_67_4' class='gform-field-label gform-field-label--type-inline'>Biting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_67_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.5' type='checkbox'  value='Mouth breathing'  id='choice_4_67_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_67_5' id='label_4_67_5' class='gform-field-label gform-field-label--type-inline'>Mouth breathing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_67_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.6' type='checkbox'  value='Nail biting'  id='choice_4_67_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_67_6' id='label_4_67_6' class='gform-field-label gform-field-label--type-inline'>Nail biting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_67_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.7' type='checkbox'  value='Tongue thrust'  id='choice_4_67_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_67_7' id='label_4_67_7' class='gform-field-label gform-field-label--type-inline'>Tongue thrust<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_67_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.8' type='checkbox'  value='Jaw pain'  id='choice_4_67_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_67_8' id='label_4_67_8' class='gform-field-label gform-field-label--type-inline'>Jaw pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_67_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.9' type='checkbox'  value='Pain with chewing'  id='choice_4_67_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_67_9' id='label_4_67_9' class='gform-field-label gform-field-label--type-inline'>Pain with chewing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_67_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.11' type='checkbox'  value='Pain with Yawning'  id='choice_4_67_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_67_11' id='label_4_67_11' class='gform-field-label gform-field-label--type-inline'>Pain with Yawning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_67_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.12' type='checkbox'  value='Jaw making noise'  id='choice_4_67_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_67_12' id='label_4_67_12' class='gform-field-label gform-field-label--type-inline'>Jaw making noise<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_68'>Have there been any accidents or trauma to the teeth or face?<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_4_68' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_69'>Are there any teeth missing?<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_4_69' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_70'>Have any teeth been removed?<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_4_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_71\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_71'>Are there any other dental conditions or problems that we should be aware of?<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_4_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_78\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_4_75\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >CONSENT OF DENTAL TREATMENT<\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_4_75' tabindex='0'>I request and authorize Dr. Watson to examine, clean and provide dental treatment on my child\u2019s teeth. I further request and authorize the taking of dental x-rays as may be considered necessary by Dr. Watson to diagnose and\/or treat my child\u2019s dental problem. I will allow photographs to be taken of my child or child\u2019s teeth for diagnostic purposes. I understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. <br \/>\n<br \/>\nSignature__________________________________________ Relationship to patient___________________ Date_____________ <br \/>\n<\/div><div class='ginput_container ginput_container_consent'><input name='input_75.1' id='input_4_75_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_4_75\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_75_1' >I agree to the privacy policy.<\/label><input type='hidden' name='input_75.2' value='I agree to the privacy policy.' class='gform_hidden' \/><input type='hidden' name='input_75.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_4_80\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Jeremy R. Watson DDS, MS   1248 East 90 North, Suite 201, American Fork, UT 84003<\/h3><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_4' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_4' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_4' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_4' id='gform_theme_4' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_4' 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