{"id":338,"date":"2023-01-17T19:09:07","date_gmt":"2023-01-17T19:09:07","guid":{"rendered":"https:\/\/uabmedicine.org\/blogs\/greyform\/?page_id=338"},"modified":"2023-01-17T19:09:07","modified_gmt":"2023-01-17T19:09:07","slug":"step-clinic-referral-form","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/step-clinic-referral-form\/","title":{"rendered":"STEP Clinic 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_72' ><div id='gf_72' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_72' id='gform_72'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/338#gf_72' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_72' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_72_20\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p class=\"lead\">The Staging Transition for Every Patient (STEP) program helps young adults with complex and chronic health conditions transfer from pediatric care at Children\u2019s of Alabama hospital to adult care at UAB Medicine. Many people with serious health conditions such as cerebral palsy, spina bifida, and neuromuscular disease are now living well into adulthood due to advances in treatment. The STEP program started in September 2020 to help with the transition to adult care, which can be difficult for both patients and their families due to medical and insurance changes. UAB Medicine\u2019s STEP Program is the first formal program of its kind in Alabama and the surrounding region.\n\nThe STEP program includes a primary care clinic for patients age 18 and older that provides medical care, referrals to adult specialists, and an individualized transition plan for each patient and family. The goal is to prevent interruptions in medical care and provide support services \u2013 such as physical therapy, social workers, counseling, and emergency planning \u2013 within a single primary care setting.<\/p><\/div><fieldset id=\"field_72_3\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Please select the option that best describes you.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_72_3'>\n\t\t\t<div class='gchoice gchoice_72_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='I am a patient&#039;s referring provider'  id='choice_72_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_72_3_0' id='label_72_3_0'>I am a patient's referring provider<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_72_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='I am a patient or parent\/guardian'  id='choice_72_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_72_3_1' id='label_72_3_1'>I am a patient or parent\/guardian<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_72_4\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Name of Provider<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 has_suffix gf_name_has_3 ginput_container_name' id='input_72_4'>\n                            \n                            <span id='input_72_4_3_container' class='name_first' >\n                                                    <input type='text' name='input_4.3' id='input_72_4_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_72_4_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_72_4_6_container' class='name_last' >\n                                                    <input type='text' name='input_4.6' id='input_72_4_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_72_4_6' >Last<\/label>\n                                                <\/span>\n                            <span id='input_72_4_8_container' class='name_suffix ' >\n                                                    <input type='text' name='input_4.8' id='input_72_4_8' value='' aria-label='Name suffix'   aria-required='false'     \/>\n                                                    <label for='input_72_4_8' >Credentials<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><div id=\"field_72_8\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_72_8' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_72_8' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_72_5\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Contact Person<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_72_5'>\n                            \n                            <span id='input_72_5_3_container' class='name_first' >\n                                                    <input type='text' name='input_5.3' id='input_72_5_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_72_5_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_72_5_6_container' class='name_last' >\n                                                    <input type='text' name='input_5.6' id='input_72_5_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_72_5_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_72_6\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_72_6' >Contact Number<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_6' id='input_72_6' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_72_9\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_72_9' >Fax Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_72_9' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_72_10\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_72_10' >Speciality<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_72_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_72_11\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_72_11' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_72_11_1_container' >\n                                        <input type='text' name='input_11.1' id='input_72_11_1' value=''    aria-required='false'    \/>\n                                        <label for='input_72_11_1' id='input_72_11_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_72_11_2_container' >\n                                        <input type='text' name='input_11.2' id='input_72_11_2' value=''     aria-required='false'   \/>\n                                        <label for='input_72_11_2' id='input_72_11_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_72_11_3_container' >\n                                    <input type='text' name='input_11.3' id='input_72_11_3' value=''    aria-required='false'    \/>\n                                    <label for='input_72_11_3' id='input_72_11_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_72_11_4_container' >\n                                        <select name='input_11.4' id='input_72_11_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_72_11_4' id='input_72_11_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_72_11_5_container' >\n                                    <input type='text' name='input_11.5' id='input_72_11_5' value=''    aria-required='false'    \/>\n                                    <label for='input_72_11_5' id='input_72_11_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_11.6' id='input_72_11_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_72_12\" class=\"gfield gfield--width-full 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_72_12'>\n                            \n                            <span id='input_72_12_3_container' class='name_first' >\n                                                    <input type='text' name='input_12.3' id='input_72_12_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_72_12_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_72_12_6_container' class='name_last' >\n                                                    <input type='text' name='input_12.6' id='input_72_12_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_72_12_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_72_13\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_72_13' >Patient Contact Number<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_13' id='input_72_13' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_72_14\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Patient 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_72_14' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_72_14_1_container' >\n                                        <input type='text' name='input_14.1' id='input_72_14_1' value=''    aria-required='true'    \/>\n                                        <label for='input_72_14_1' id='input_72_14_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_72_14_2_container' >\n                                        <input type='text' name='input_14.2' id='input_72_14_2' value=''     aria-required='false'   \/>\n                                        <label for='input_72_14_2' id='input_72_14_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_72_14_3_container' >\n                                    <input type='text' name='input_14.3' id='input_72_14_3' value=''    aria-required='true'    \/>\n                                    <label for='input_72_14_3' id='input_72_14_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_72_14_4_container' >\n                                        <select name='input_14.4' id='input_72_14_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_72_14_4' id='input_72_14_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_72_14_5_container' >\n                                    <input type='text' name='input_14.5' id='input_72_14_5' value=''    aria-required='true'    \/>\n                                    <label for='input_72_14_5' id='input_72_14_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_14.6' id='input_72_14_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_72_15\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_72_15' >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_15' id='input_72_15' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_72_15_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_72_15_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_72_15' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_72_16\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Reason for Referral<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_72_16'>\n\t\t\t<div class='gchoice gchoice_72_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Cerebral palsy'  id='choice_72_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_72_16_0' id='label_72_16_0'>Cerebral palsy<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_72_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Hydrocephalus'  id='choice_72_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_72_16_1' id='label_72_16_1'>Hydrocephalus<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_72_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Epilepsy'  id='choice_72_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_72_16_2' id='label_72_16_2'>Epilepsy<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_72_16_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Muscular dystrophy'  id='choice_72_16_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_72_16_3' id='label_72_16_3'>Muscular dystrophy<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_72_16_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Spina bifida'  id='choice_72_16_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_72_16_4' id='label_72_16_4'>Spina bifida<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_72_16_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Diabetes'  id='choice_72_16_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_72_16_5' id='label_72_16_5'>Diabetes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_72_16_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Kidney transplant'  id='choice_72_16_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_72_16_6' id='label_72_16_6'>Kidney transplant<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_72_16_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Genetic syndrome'  id='choice_72_16_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_72_16_7' id='label_72_16_7'>Genetic syndrome<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_72_16_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Autoimmune disease'  id='choice_72_16_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_72_16_8' id='label_72_16_8'>Autoimmune 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