{"id":320,"date":"2023-01-17T18:53:36","date_gmt":"2023-01-17T18:53:36","guid":{"rendered":"https:\/\/uabmedicine.org\/blogs\/greyform\/?page_id=320"},"modified":"2023-01-17T18:53:36","modified_gmt":"2023-01-17T18:53:36","slug":"endoscopy-referral-form","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/endoscopy-referral-form\/","title":{"rendered":"Endoscopy Referral Form"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_67' style='display:none'><div id='gf_67' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_67' id='gform_67'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/320#gf_67' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_67' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_67_1\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Referring Physician<\/h3><\/div><fieldset id=\"field_67_2\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Non-UAB Referring Physician Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_67_2'>\n                            \n                            <span id='input_67_2_3_container' class='name_first' >\n                                                    <input type='text' name='input_2.3' id='input_67_2_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_67_2_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_67_2_6_container' class='name_last' >\n                                                    <input type='text' name='input_2.6' id='input_67_2_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_67_2_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_67_4\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_67_4'>\n                            \n                            <span id='input_67_4_3_container' class='name_first' >\n                                                    <input type='text' name='input_4.3' id='input_67_4_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_67_4_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_67_4_6_container' class='name_last' >\n                                                    <input type='text' name='input_4.6' id='input_67_4_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_67_4_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_67_3\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_3' >Office #:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_67_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_67_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_5' >Fax #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_67_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_67_6\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_6' >Office Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_67_6' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_67_76\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Patient PCP Known?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_76'>\n\t\t\t<div class='gchoice gchoice_67_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_67_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_76_0' id='label_67_76_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_67_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_76_1' id='label_67_76_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_67_7\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >PCP Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_67_7'>\n                            \n                            <span id='input_67_7_3_container' class='name_first' >\n                                                    <input type='text' name='input_7.3' id='input_67_7_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_67_7_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_67_7_6_container' class='name_last' >\n                                                    <input type='text' name='input_7.6' id='input_67_7_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_67_7_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_67_8\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_67_8'>\n                            \n                            <span id='input_67_8_3_container' class='name_first' >\n                                                    <input type='text' name='input_8.3' id='input_67_8_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_67_8_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_67_8_6_container' class='name_last' >\n                                                    <input type='text' name='input_8.6' id='input_67_8_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_67_8_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_67_9\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_9' >Office #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_67_9' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_67_10\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_10' >Fax #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_67_10' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_67_11\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Patient Information<\/h3><\/div><fieldset id=\"field_67_12\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_67_12'>\n                            \n                            <span id='input_67_12_3_container' class='name_first' >\n                                                    <input type='text' name='input_12.3' id='input_67_12_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_67_12_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_67_12_6_container' class='name_last' >\n                                                    <input type='text' name='input_12.6' id='input_67_12_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_67_12_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_67_13\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_13' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_13' id='input_67_13' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_67_13_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_67_13_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_67_13' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_67_14\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_14' >Social Security Number<\/label><div class='ginput_container ginput_container_number'><input name='input_14' id='input_67_14' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_description_67_14\" \/><\/div><div class='gfield_description' id='gfield_description_67_14'>SSN needed to create a UAB medical record. All information is transmitted securely. If patient is unwilling to  provide their social, you may enter 9's. <\/div><\/div><fieldset id=\"field_67_19\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_67_19' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_67_19_1_container' >\n                                        <input type='text' name='input_19.1' id='input_67_19_1' value=''    aria-required='true'    \/>\n                                        <label for='input_67_19_1' id='input_67_19_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_67_19_2_container' >\n                                        <input type='text' name='input_19.2' id='input_67_19_2' value=''     aria-required='false'   \/>\n                                        <label for='input_67_19_2' id='input_67_19_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_67_19_3_container' >\n                                    <input type='text' name='input_19.3' id='input_67_19_3' value=''    aria-required='true'    \/>\n                                    <label for='input_67_19_3' id='input_67_19_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_67_19_4_container' >\n                                        <select name='input_19.4' id='input_67_19_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_67_19_4' id='input_67_19_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_67_19_5_container' >\n                                    <input type='text' name='input_19.5' id='input_67_19_5' value=''    aria-required='true'    \/>\n                                    <label for='input_67_19_5' id='input_67_19_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_19.6' id='input_67_19_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_67_15\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_15' >Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_67_15' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_67_16\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_16' >Alternate Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_67_16' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_67_17\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_17' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_17' id='input_67_17' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_67_18\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Insurance Information<\/h3><\/div><div id=\"field_67_23\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_23' >Primary Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_67_23' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_67_24\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_67_24' >Policy #<\/label><div class='ginput_container ginput_container_number'><input name='input_24' id='input_67_24' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_67_72\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_72' >Policy#<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_67_72' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_67_21\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_67_21' >Group #<\/label><div class='ginput_container ginput_container_number'><input name='input_21' id='input_67_21' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_67_73\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_73' >Group#<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_67_73' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_67_22\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_22' >Secondary Name<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_67_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_67_25\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_67_25' >Policy #<\/label><div class='ginput_container ginput_container_number'><input name='input_25' id='input_67_25' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_67_74\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_74' >Policy#<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_67_74' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_67_26\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_67_26' >Group #<\/label><div class='ginput_container ginput_container_number'><input name='input_26' id='input_67_26' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_67_75\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_75' >Group#<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_67_75' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_67_27\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Request Procedure<\/h3><\/div><div id=\"field_67_28\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_28' >Diagnosis\/Indication for Procedure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_67_28' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_67_69\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Please check requested procedure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_67_69'><div class='gchoice gchoice_67_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Endoscopic Ultrasound'  id='choice_67_69_1'   aria-describedby=\"gfield_description_67_69\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_1' id='label_67_69_1'>Endoscopic Ultrasound<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.2' type='checkbox'  value='Rectal Endoscopic Ultrasound'  id='choice_67_69_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_2' id='label_67_69_2'>Rectal Endoscopic Ultrasound<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.3' type='checkbox'  value='Endoscopic Ultrasound with Pseudocyst Drainage'  id='choice_67_69_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_3' id='label_67_69_3'>Endoscopic Ultrasound with Pseudocyst Drainage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.4' type='checkbox'  value='Endoscopic Ultrasound \/ Fine Needle Aspiration'  id='choice_67_69_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_4' id='label_67_69_4'>Endoscopic Ultrasound \/ Fine Needle Aspiration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.5' type='checkbox'  value='Endoscopic Ultrasound \/ Pelvic Abscess Drain'  id='choice_67_69_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_5' id='label_67_69_5'>Endoscopic Ultrasound \/ Pelvic Abscess Drain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.6' type='checkbox'  value='EGD'  id='choice_67_69_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_6' id='label_67_69_6'>EGD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.7' type='checkbox'  value='EGD with EMR'  id='choice_67_69_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_7' id='label_67_69_7'>EGD with EMR<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.8' type='checkbox'  value='EGD with ESD'  id='choice_67_69_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_8' id='label_67_69_8'>EGD with ESD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.9' type='checkbox'  value='Colonoscopy'  id='choice_67_69_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_9' id='label_67_69_9'>Colonoscopy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.11' type='checkbox'  value='Colonoscopy with EMR'  id='choice_67_69_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_11' id='label_67_69_11'>Colonoscopy with EMR<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.12' type='checkbox'  value='Colonoscopy with ESD'  id='choice_67_69_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_12' id='label_67_69_12'>Colonoscopy with ESD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.13' type='checkbox'  value='Flex Sigmoidoscopy'  id='choice_67_69_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_13' id='label_67_69_13'>Flex Sigmoidoscopy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.14' type='checkbox'  value='Flex Sigmoidoscopy with RFA'  id='choice_67_69_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_14' id='label_67_69_14'>Flex Sigmoidoscopy with RFA<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.15' type='checkbox'  value='ERCP'  id='choice_67_69_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_15' id='label_67_69_15'>ERCP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.16' type='checkbox'  value='ERCP with Laser Lithotripsy'  id='choice_67_69_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_16' id='label_67_69_16'>ERCP with Laser Lithotripsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.17' type='checkbox'  value='EGD with RFA'  id='choice_67_69_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_17' id='label_67_69_17'>EGD with RFA<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.18' type='checkbox'  value='EGD with PEG'  id='choice_67_69_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_18' id='label_67_69_18'>EGD with PEG<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.19' type='checkbox'  value='EGD with PEG\/J'  id='choice_67_69_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_19' id='label_67_69_19'>EGD with PEG\/J<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.21' type='checkbox'  value='ERCP\/Spyglass'  id='choice_67_69_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_21' id='label_67_69_21'>ERCP\/Spyglass<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.22' type='checkbox'  value='Endoscopic Ultrasound\/Celiac Block'  id='choice_67_69_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_22' id='label_67_69_22'>Endoscopic Ultrasound\/Celiac Block<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.23' type='checkbox'  value='Upper Luminal Stenting'  id='choice_67_69_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_23' id='label_67_69_23'>Upper Luminal Stenting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.24' type='checkbox'  value='Lower Luminal Stenting'  id='choice_67_69_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_24' id='label_67_69_24'>Lower Luminal Stenting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.25' type='checkbox'  value='Antegrade Double Balloon Enteroscopy'  id='choice_67_69_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_25' id='label_67_69_25'>Antegrade Double Balloon Enteroscopy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.26' type='checkbox'  value='Retrograde Double Balloon Enteroscopy'  id='choice_67_69_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_26' id='label_67_69_26'>Retrograde Double Balloon Enteroscopy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_69_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.27' type='checkbox'  value='Double Balloon Enteroscopy with Direct Percutaneous Jejunostomy Placement'  id='choice_67_69_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_69_27' id='label_67_69_27'>Double Balloon Enteroscopy with Direct Percutaneous Jejunostomy Placement<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_67_69'><i>NOTE: If the procedure requested is EUS, EUS\/FNA or EUS\/drainage, the actual images must be sent via PCS or on a CD to UAB GI Lab 619 19th Street South Birmingham, AL 35294.<\/i><\/div><\/fieldset><div id=\"field_67_30\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_30' >Notes regarding requested procedure<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_67_30' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_67_31\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_31' >Allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_67_31' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_67_71\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Prior Endoscopies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_71'>\n\t\t\t<div class='gchoice gchoice_67_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_67_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_71_0' id='label_67_71_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_67_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_71_1' id='label_67_71_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_67_34\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_34' >Prior Endoscopies type and date performed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_34' id='input_67_34' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_67_34_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_67_34_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_67_34' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_67_35\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >History of gastric bypass, Billroth or Roux-en-Y<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_35'>\n\t\t\t<div class='gchoice gchoice_67_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_67_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_35_0' id='label_67_35_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_67_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_35_1' id='label_67_35_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_67_36\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_36' >If Yes, which procedure<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_67_36' type='text' value='' class='medium'  aria-describedby=\"gfield_description_67_36\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_67_36'><i>Note: Patients with altered anatomy, if ERCP being ordered, would require Double Balloon Enteroscopy\/ERCP<\/i><\/div><\/div><fieldset id=\"field_67_37\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Diabetes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_37'>\n\t\t\t<div class='gchoice gchoice_67_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes'  id='choice_67_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_37_0' id='label_67_37_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_67_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_37_1' id='label_67_37_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_67_38\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_38' >If Yes, what type and medications?<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_67_38' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_67_39\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Asthma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_39'>\n\t\t\t<div class='gchoice gchoice_67_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Yes'  id='choice_67_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_39_0' id='label_67_39_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_67_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_39_1' id='label_67_39_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_67_40\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Emphysema<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_40'>\n\t\t\t<div class='gchoice gchoice_67_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_67_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_40_0' id='label_67_40_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_67_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_40_1' id='label_67_40_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_67_41\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >COPD<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_41'>\n\t\t\t<div class='gchoice gchoice_67_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Yes'  id='choice_67_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_41_0' id='label_67_41_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='No'  id='choice_67_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_41_1' id='label_67_41_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_67_42\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Home Oxygen<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_42'>\n\t\t\t<div class='gchoice gchoice_67_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_67_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_42_0' id='label_67_42_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_67_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_42_1' id='label_67_42_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_67_43\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Obstructive Sleep Apnea<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_43'>\n\t\t\t<div class='gchoice gchoice_67_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_67_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_43_0' id='label_67_43_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_67_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_43_1' id='label_67_43_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_67_44\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >CPAP machine<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_44'>\n\t\t\t<div class='gchoice gchoice_67_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_67_44_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_67_44\"   \/>\n\t\t\t\t\t<label for='choice_67_44_0' id='label_67_44_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_67_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_44_1' id='label_67_44_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_67_44'><i>Note: If yes then CPAP must be brought to hospital with the patient. <\/i><\/div><\/fieldset><fieldset id=\"field_67_45\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Does patient see a Cardiologist?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_45'>\n\t\t\t<div class='gchoice gchoice_67_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Yes'  id='choice_67_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_45_0' id='label_67_45_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='No'  id='choice_67_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_45_1' id='label_67_45_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_67_46\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >If yes, Physician Name<\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_67_46'>\n                            \n                            <span id='input_67_46_3_container' class='name_first' >\n                                                    <input type='text' name='input_46.3' id='input_67_46_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_67_46_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_67_46_6_container' class='name_last' >\n                                                    <input type='text' name='input_46.6' id='input_67_46_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_67_46_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_67_47\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_47' >Office #<\/label><div class='ginput_container ginput_container_phone'><input name='input_47' id='input_67_47' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_67_48\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Hypertension<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_48'>\n\t\t\t<div class='gchoice gchoice_67_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Yes'  id='choice_67_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_48_0' id='label_67_48_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='No'  id='choice_67_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_48_1' id='label_67_48_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_67_49\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Echo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_49'>\n\t\t\t<div class='gchoice gchoice_67_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Yes'  id='choice_67_49_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_67_49\"   \/>\n\t\t\t\t\t<label for='choice_67_49_0' id='label_67_49_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='No'  id='choice_67_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_49_1' id='label_67_49_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_67_49'><i>Note: If yes, please send copy with records. <\/i><\/div><\/fieldset><fieldset id=\"field_67_50\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >CAD<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_50'>\n\t\t\t<div class='gchoice gchoice_67_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Yes'  id='choice_67_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_50_0' id='label_67_50_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='No'  id='choice_67_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_50_1' id='label_67_50_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_67_51\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >CABG<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_51'>\n\t\t\t<div class='gchoice gchoice_67_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Yes'  id='choice_67_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_51_0' id='label_67_51_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='No'  id='choice_67_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_51_1' id='label_67_51_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_67_54\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_54' >If Yes, date of procedure<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_54' id='input_67_54' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_67_54_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_67_54_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_67_54' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_67_52\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >CHF<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_52'>\n\t\t\t<div class='gchoice gchoice_67_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Yes'  id='choice_67_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_52_0' id='label_67_52_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='No'  id='choice_67_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_52_1' id='label_67_52_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_67_55\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >MI<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_55'>\n\t\t\t<div class='gchoice gchoice_67_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_67_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_55_0' id='label_67_55_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_67_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_55_1' id='label_67_55_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_67_56\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >LVAD<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_56'>\n\t\t\t<div class='gchoice gchoice_67_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Yes'  id='choice_67_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_56_0' id='label_67_56_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='No'  id='choice_67_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_56_1' id='label_67_56_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_67_57\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Cardiac Stents<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_57'>\n\t\t\t<div class='gchoice gchoice_67_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes'  id='choice_67_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_57_0' id='label_67_57_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_67_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_57_1' id='label_67_57_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_67_59\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_59' >If yes, Year(s)<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_67_59' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_67_60\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Pacemaker\/Defibrillator<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_60'>\n\t\t\t<div class='gchoice gchoice_67_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Yes'  id='choice_67_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_60_0' id='label_67_60_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='No'  id='choice_67_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_60_1' id='label_67_60_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_67_61\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_61' >If yes, Make\/Model<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_67_61' type='text' value='' class='medium'  aria-describedby=\"gfield_description_67_61\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_67_61'><i>Note: If yes, please include Pacemaker\/Defibrillator card with records or patient must bring card with them. <\/i><\/div><\/div><fieldset id=\"field_67_62\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Recent Hospitalizations<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_62'>\n\t\t\t<div class='gchoice gchoice_67_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Yes'  id='choice_67_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_62_0' id='label_67_62_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_67_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_62_1' id='label_67_62_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_67_63\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_63' >If yes, admitted for<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_67_63' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_67_70\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_70' >All current medication(s)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_70' id='input_67_70' class='textarea medium'  aria-describedby=\"gfield_description_67_70\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_67_70'>If not otherwise documented in patient records.<\/div><\/div><fieldset id=\"field_67_65\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Blood Thinners<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_65'>\n\t\t\t<div class='gchoice gchoice_67_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Yes'  id='choice_67_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_65_0' id='label_67_65_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='No'  id='choice_67_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_65_1' id='label_67_65_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_67_66\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_67_66' >If yes, list blood thinners: Coumadin, Plavix, Aspirin, Fish Oil, etc.<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_67_66' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_67_67\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><strong>PATIENT MUST HAVE CURRENT HISTORY & PHYSICAL OR THE LAST CLINIC VISIT NOTES.<\/br>\n<\/br>\nPlease fax or upload all records that correspond to the above marked 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