{"id":330,"date":"2023-01-17T19:01:05","date_gmt":"2023-01-17T19:01:05","guid":{"rendered":"https:\/\/uabmedicine.org\/blogs\/greyform\/?page_id=330"},"modified":"2023-01-17T19:01:05","modified_gmt":"2023-01-17T19:01:05","slug":"omfs-referral-form-fmp","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/omfs-referral-form-fmp\/","title":{"rendered":"OMFS Referral Form &#8211; FMP"},"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_68' style='display:none'><div id='gf_68' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_68' id='gform_68'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/330#gf_68' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_68' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_68_38\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >OMS TKC \u2013 Fax 205.801.9045<\/br> OMS Hoover \u2013 Fax  205.278.5034<\/br>\nInverness - Fax 205.776.0313 (FAX)<\/div><div id=\"field_68_1\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Demographic Information<\/h3><\/div><div id=\"field_68_2\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_2' >Which Doctor Are You Referring Your Patient to?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_2' id='input_68_2' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='First Available' >First Available<\/option><option value='Dr. Anthony Morlandt-MD, DDS' >Dr. Anthony Morlandt-MD, DDS<\/option><option value='Dr. Yedeh Ying-MD, DMD' >Dr. Yedeh Ying-MD, DMD<\/option><option value='Dr. Patrick J. Louis- MD, DDS' >Dr. Patrick J. Louis- MD, DDS<\/option><option value='Dr. Somsak Sittitavornwong- DDS, DMD, MS' >Dr. Somsak Sittitavornwong- DDS, DMD, MS<\/option><option value='Dr. Michael T. Kase-DMD' >Dr. Michael T. Kase-DMD<\/option><option value='Dr. Brian Kinard- MD, DMD' >Dr. Brian Kinard- MD, DMD<\/option><option value='Dr. Kathlyn Powell-MD, DMD' >Dr. Kathlyn Powell-MD, DMD<\/option><option value='Mary Danner Harmon, PA' >Mary Danner Harmon, PA<\/option><option value='Dr. Jay Ponto, MD, DDS' >Dr. Jay Ponto, MD, DDS<\/option><\/select><\/div><\/div><div id=\"field_68_3\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Patient Information<\/h3><\/div><fieldset id=\"field_68_4\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >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_68_4'>\n                            \n                            <span id='input_68_4_3_container' class='name_first' >\n                                                    <input type='text' name='input_4.3' id='input_68_4_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_68_4_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_68_4_6_container' class='name_last' >\n                                                    <input type='text' name='input_4.6' id='input_68_4_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_68_4_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_68_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_5' >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_5' id='input_68_5' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_68_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_68_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_68_5' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_68_28\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_28' >Patient 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_28' id='input_68_28' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_68_34\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_34' >Alternate Phone #<\/label><div class='ginput_container ginput_container_phone'><input name='input_34' id='input_68_34' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_68_29\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Patient Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_68_29' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_68_29_1_container' >\n                                        <input type='text' name='input_29.1' id='input_68_29_1' value=''    aria-required='false'    \/>\n                                        <label for='input_68_29_1' id='input_68_29_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_68_29_2_container' >\n                                        <input type='text' name='input_29.2' id='input_68_29_2' value=''     aria-required='false'   \/>\n                                        <label for='input_68_29_2' id='input_68_29_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_68_29_3_container' >\n                                    <input type='text' name='input_29.3' id='input_68_29_3' value=''    aria-required='false'    \/>\n                                    <label for='input_68_29_3' id='input_68_29_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_68_29_4_container' >\n                                        <select name='input_29.4' id='input_68_29_4'     aria-required='false'    ><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_68_29_4' id='input_68_29_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_68_29_5_container' >\n                                    <input type='text' name='input_29.5' id='input_68_29_5' value=''    aria-required='false'    \/>\n                                    <label for='input_68_29_5' id='input_68_29_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_29.6' id='input_68_29_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_68_30\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_30' >Patient Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_30' id='input_68_30' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_68_32\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Emergency Contact<\/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_68_32'>\n                            \n                            <span id='input_68_32_3_container' class='name_first' >\n                                                    <input type='text' name='input_32.3' id='input_68_32_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_68_32_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_68_32_6_container' class='name_last' >\n                                                    <input type='text' name='input_32.6' id='input_68_32_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_68_32_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_68_33\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_33' >Emergency Contact Phone #<\/label><div class='ginput_container ginput_container_phone'><input name='input_33' id='input_68_33' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_68_6\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Referred by Doctor<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_68_6'>\n                            \n                            <span id='input_68_6_3_container' class='name_first' >\n                                                    <input type='text' name='input_6.3' id='input_68_6_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_68_6_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_68_6_6_container' class='name_last' >\n                                                    <input type='text' name='input_6.6' id='input_68_6_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_68_6_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_68_35\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Referring Physician Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_68_35' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_68_35_1_container' >\n                                        <input type='text' name='input_35.1' id='input_68_35_1' value=''    aria-required='false'    \/>\n                                        <label for='input_68_35_1' id='input_68_35_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_68_35_2_container' >\n                                        <input type='text' name='input_35.2' id='input_68_35_2' value=''     aria-required='false'   \/>\n                                        <label for='input_68_35_2' id='input_68_35_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_68_35_3_container' >\n                                    <input type='text' name='input_35.3' id='input_68_35_3' value=''    aria-required='false'    \/>\n                                    <label for='input_68_35_3' id='input_68_35_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_68_35_4_container' >\n                                        <select name='input_35.4' id='input_68_35_4'     aria-required='false'    ><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_68_35_4' id='input_68_35_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_68_35_5_container' >\n                                    <input type='text' name='input_35.5' id='input_68_35_5' value=''    aria-required='false'    \/>\n                                    <label for='input_68_35_5' id='input_68_35_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_35.6' id='input_68_35_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_68_36\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_36' >Referring Physician 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_36' id='input_68_36' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_68_37\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_37' >Referring Physician Fax #<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_68_37' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_68_7\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_7' >Requested Surgery \/Consult<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_7' id='input_68_7' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_9\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Reason for Referral<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_68_9'><div class='gchoice gchoice_68_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Extractions'  id='choice_68_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_9_1' id='label_68_9_1'>Extractions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Wisdom teeth'  id='choice_68_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_9_2' id='label_68_9_2'>Wisdom teeth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Dental Implants'  id='choice_68_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_9_3' id='label_68_9_3'>Dental Implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Pathology'  id='choice_68_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_9_4' id='label_68_9_4'>Pathology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Orthognathic consult'  id='choice_68_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_9_5' id='label_68_9_5'>Orthognathic consult<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Other Consultation'  id='choice_68_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_9_6' id='label_68_9_6'>Other Consultation<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_24\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Insurance Information<\/h3><\/div><div id=\"field_68_25\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_25' >Insurance Provider<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_68_25' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_68_26\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_26' >Group Number<\/label><div class='ginput_container ginput_container_number'><input name='input_26' id='input_68_26' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_68_27\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_27' >Policy\/Contract Number<\/label><div class='ginput_container ginput_container_number'><input name='input_27' id='input_68_27' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_68_10\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Extraction Information<\/h3><\/div><div id=\"field_68_23\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><img alt=\"omfs tooth extraction diagram\" src=https:\/\/uabmedicine-develop.go-vip.net\/uabmedicine\/wp-content\/uploads\/sites\/3\/2023\/04\/tooth-diagram.jpg><\/div><fieldset id=\"field_68_11\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Upper Permanent<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_68_11'><div class='gchoice gchoice_68_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='1'  id='choice_68_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_1' id='label_68_11_1'>1<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='2'  id='choice_68_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_2' id='label_68_11_2'>2<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='3'  id='choice_68_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_3' id='label_68_11_3'>3<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.4' type='checkbox'  value='4'  id='choice_68_11_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_4' id='label_68_11_4'>4<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.5' type='checkbox'  value='5'  id='choice_68_11_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_5' id='label_68_11_5'>5<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.6' type='checkbox'  value='6'  id='choice_68_11_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_6' id='label_68_11_6'>6<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.7' type='checkbox'  value='7'  id='choice_68_11_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_7' id='label_68_11_7'>7<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.8' type='checkbox'  value='8'  id='choice_68_11_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_8' id='label_68_11_8'>8<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.9' type='checkbox'  value='9'  id='choice_68_11_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_9' id='label_68_11_9'>9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.11' type='checkbox'  value='10'  id='choice_68_11_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_11' id='label_68_11_11'>10<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.12' type='checkbox'  value='11'  id='choice_68_11_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_12' id='label_68_11_12'>11<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.13' type='checkbox'  value='12'  id='choice_68_11_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_13' id='label_68_11_13'>12<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.14' type='checkbox'  value='13'  id='choice_68_11_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_14' id='label_68_11_14'>13<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.15' type='checkbox'  value='14'  id='choice_68_11_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_15' id='label_68_11_15'>14<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.16' type='checkbox'  value='15'  id='choice_68_11_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_16' id='label_68_11_16'>15<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_11_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.17' type='checkbox'  value='16'  id='choice_68_11_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_11_17' id='label_68_11_17'>16<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_12\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Lower Permanent<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_68_12'><div class='gchoice gchoice_68_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='32'  id='choice_68_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_1' id='label_68_12_1'>32<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='31'  id='choice_68_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_2' id='label_68_12_2'>31<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='30'  id='choice_68_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_3' id='label_68_12_3'>30<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='29'  id='choice_68_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_4' id='label_68_12_4'>29<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='28'  id='choice_68_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_5' id='label_68_12_5'>28<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.6' type='checkbox'  value='27'  id='choice_68_12_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_6' id='label_68_12_6'>27<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.7' type='checkbox'  value='26'  id='choice_68_12_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_7' id='label_68_12_7'>26<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.8' type='checkbox'  value='25'  id='choice_68_12_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_8' id='label_68_12_8'>25<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.9' type='checkbox'  value='24'  id='choice_68_12_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_9' id='label_68_12_9'>24<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.11' type='checkbox'  value='23'  id='choice_68_12_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_11' id='label_68_12_11'>23<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.12' type='checkbox'  value='22'  id='choice_68_12_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_12' id='label_68_12_12'>22<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.13' type='checkbox'  value='21'  id='choice_68_12_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_13' id='label_68_12_13'>21<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.14' type='checkbox'  value='20'  id='choice_68_12_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_14' id='label_68_12_14'>20<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.15' type='checkbox'  value='19'  id='choice_68_12_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_15' id='label_68_12_15'>19<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.16' type='checkbox'  value='18'  id='choice_68_12_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_16' id='label_68_12_16'>18<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_12_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.17' type='checkbox'  value='17'  id='choice_68_12_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_12_17' id='label_68_12_17'>17<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_13\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Upper Deciduous<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_68_13'><div class='gchoice gchoice_68_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='A'  id='choice_68_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_13_1' id='label_68_13_1'>A<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='B'  id='choice_68_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_13_2' id='label_68_13_2'>B<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='C'  id='choice_68_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_13_3' id='label_68_13_3'>C<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='D'  id='choice_68_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_13_4' id='label_68_13_4'>D<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='E'  id='choice_68_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_13_5' id='label_68_13_5'>E<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='F'  id='choice_68_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_13_6' id='label_68_13_6'>F<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='G'  id='choice_68_13_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_13_7' id='label_68_13_7'>G<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_13_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.8' type='checkbox'  value='H'  id='choice_68_13_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_13_8' id='label_68_13_8'>H<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_13_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.9' type='checkbox'  value='I'  id='choice_68_13_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_13_9' id='label_68_13_9'>I<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_13_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.11' type='checkbox'  value='J'  id='choice_68_13_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_13_11' id='label_68_13_11'>J<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_14\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Lower Deciduous<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_68_14'><div class='gchoice gchoice_68_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='T'  id='choice_68_14_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_14_1' id='label_68_14_1'>T<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='S'  id='choice_68_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_14_2' id='label_68_14_2'>S<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='R'  id='choice_68_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_14_3' id='label_68_14_3'>R<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='Q'  id='choice_68_14_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_14_4' id='label_68_14_4'>Q<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_14_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.5' type='checkbox'  value='P'  id='choice_68_14_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_14_5' id='label_68_14_5'>P<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_14_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.6' type='checkbox'  value='O'  id='choice_68_14_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_14_6' id='label_68_14_6'>O<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_14_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.7' type='checkbox'  value='N'  id='choice_68_14_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_14_7' id='label_68_14_7'>N<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_14_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.8' type='checkbox'  value='M'  id='choice_68_14_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_14_8' id='label_68_14_8'>M<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_14_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.9' type='checkbox'  value='L'  id='choice_68_14_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_14_9' id='label_68_14_9'>L<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_14_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.11' type='checkbox'  value='K'  id='choice_68_14_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_14_11' id='label_68_14_11'>K<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_15\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Radiographs or Clinical Photos<\/h3><\/div><fieldset id=\"field_68_16\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Radiographs \/ Clinical Photos<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_68_16'><div class='gchoice gchoice_68_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Being Mailed'  id='choice_68_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_16_1' id='label_68_16_1'>Being Mailed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Given to Patient'  id='choice_68_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_16_2' id='label_68_16_2'>Given to Patient<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Please Take'  id='choice_68_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_16_3' id='label_68_16_3'>Please Take<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Being Emailed'  id='choice_68_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_16_4' id='label_68_16_4'>Being Emailed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_68_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Attached with This Referral'  id='choice_68_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_68_16_5' id='label_68_16_5'>Attached with This Referral<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_20\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_20' >File<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_20' id='input_68_20' type='file' class='medium' aria-describedby=\"gfield_upload_rules_68_20\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_68_20'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_68_20'><\/div><\/div><\/div><div id=\"field_68_17\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_17' >Type<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_68_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_68_18\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_18' >Date of x-ray<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_18' id='input_68_18' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_68_18_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_68_18_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_68_18' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_68_19\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_68_19' >Location<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_68_19' class='medium gfield_select'     aria-invalid=\"false\" ><option value='The Kirklin Clinic of UAB Hospital' >The Kirklin Clinic of UAB Hospital<\/option><option value='UAB Medicine Hoover' >UAB Medicine Hoover<\/option><option value='Oral Surgery Clinic at UAB Medicine Inverness' >Oral Surgery Clinic at UAB Medicine Inverness<\/option><\/select><\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_68' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_68\"]){return false;}  if( !jQuery(\"#gform_68\")[0].checkValidity || jQuery(\"#gform_68\")[0].checkValidity()){window[\"gf_submitting_68\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_68\"]){return false;} if( !jQuery(\"#gform_68\")[0].checkValidity || jQuery(\"#gform_68\")[0].checkValidity()){window[\"gf_submitting_68\"]=true;}  jQuery(\"#gform_68\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=68&amp;title=&amp;description=&amp;tabindex=0' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_68' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='68' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_68' value='WyJbXSIsImQ4OGVkZmY0NjE4YzNjYTY4YTYyNWRhMjJjNDUzY2JkIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_68' id='gform_target_page_number_68' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_68' id='gform_source_page_number_68' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_68' id='gform_ajax_frame_68' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 68, 'https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery('#gform_ajax_frame_68').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_68');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_68').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_68').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_68').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_68').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_68').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_68').val();gformInitSpinner( 68, 'https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery(document).trigger('gform_page_loaded', [68, current_page]);window['gf_submitting_68'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_68').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_68').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [68]);window['gf_submitting_68'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_68').text());}, 50);}else{jQuery('#gform_68').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [68, current_page]);} );} );\n<\/script>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":5,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"\/web\/sites\/blogs\/greyform\/wp-content\/plugins\/uab-blank-page-templates\/templates\/uabmed-blank-template.php","meta":{"footnotes":""},"class_list":["post-330","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/330","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/users\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/comments?post=330"}],"version-history":[{"count":1,"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/330\/revisions"}],"predecessor-version":[{"id":331,"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/330\/revisions\/331"}],"wp:attachment":[{"href":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/media?parent=330"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}