{"id":2044,"date":"2024-06-26T23:36:09","date_gmt":"2024-06-26T23:36:09","guid":{"rendered":"https:\/\/prodentalut.com\/?page_id=2044"},"modified":"2026-03-27T07:26:42","modified_gmt":"2026-03-27T13:26:42","slug":"npform","status":"publish","type":"page","link":"https:\/\/prodentalut.com\/es\/npform\/","title":{"rendered":"Formulario de Nuevo Paciente"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2044\" class=\"elementor elementor-2044\" data-elementor-post-type=\"page\">\n\t\t\t\t<div data-dce-background-overlay-color=\"#2C5D83\" data-dce-background-image-url=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/08\/Untitled-design-2024-08-15T140525.866.jpg\" class=\"elementor-element elementor-element-8d7ab20 e-con-full e-flex elementor-invisible e-con e-parent\" data-id=\"8d7ab20\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;default&quot;,&quot;animation_delay&quot;:100}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-448e619 elementor-invisible elementor-widget elementor-widget-text-editor\" data-id=\"448e619\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:50}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tDIGITAL FORM\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e4a0dc5 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"e4a0dc5\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Save Time By Completing The New Patient Form Online<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c39c70c elementor-invisible elementor-widget elementor-widget-text-editor\" data-id=\"c39c70c\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tIf you are a new patient, please fill out form below. Our office will have all the information when you come to your assigned clinic.\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-88ad559 e-flex e-con-boxed elementor-invisible e-con e-parent\" data-id=\"88ad559\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;default&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div data-dce-title-color=\"#013A65\" class=\"elementor-element elementor-element-7fdbb80 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"7fdbb80\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:100}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Welcome to Professional Dental<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-36f1a14 elementor-widget elementor-widget-heading\" data-id=\"36f1a14\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">New Patient Form<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-0c9e150 e-con-full e-flex elementor-invisible e-con e-parent\" data-id=\"0c9e150\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;default&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-6a9da7d e-con-full e-flex e-con e-child\" data-id=\"6a9da7d\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div data-dce-inline-align=\"{&quot;fields&quot;:[{&quot;custom_id&quot;:&quot;responpayment&quot;,&quot;field_id&quot;:&quot;1ec35a4&quot;}]}\" data-dce-field-description=\"{&quot;fields&quot;:[{&quot;custom_id&quot;:&quot;pdoffice&quot;,&quot;position&quot;:&quot;elementor-field&quot;,&quot;description&quot;:&quot;You can change it later&quot;,&quot;description_text&quot;:&quot;You can change it later&quot;},{&quot;custom_id&quot;:&quot;medicalundertreatexplain&quot;,&quot;position&quot;:&quot;elementor-field&quot;,&quot;description&quot;:&quot;The more details, the better&quot;,&quot;description_text&quot;:&quot;The more details, the better&quot;},{&quot;custom_id&quot;:&quot;medicalhospitalizedexplain&quot;,&quot;position&quot;:&quot;elementor-field&quot;,&quot;description&quot;:&quot;The more details, the better&quot;,&quot;description_text&quot;:&quot;The more details, the better&quot;},{&quot;custom_id&quot;:&quot;field_078ca55&quot;,&quot;position&quot;:&quot;elementor-field&quot;,&quot;description&quot;:&quot;The more details, the better&quot;,&quot;description_text&quot;:&quot;The more details, the better&quot;},{&quot;custom_id&quot;:&quot;medicalbisphosphaonateshowlong&quot;,&quot;position&quot;:&quot;elementor-field&quot;,&quot;description&quot;:&quot;The more details, the better&quot;,&quot;description_text&quot;:&quot;The more details, the better&quot;},{&quot;custom_id&quot;:&quot;medicalttobaccohowlong&quot;,&quot;position&quot;:&quot;elementor-field&quot;,&quot;description&quot;:&quot;The more details, the better&quot;,&quot;description_text&quot;:&quot;The more details, the better&quot;}]}\" class=\"elementor-element elementor-element-8cd5c9e elementor-button-align-end elementor-invisible elementor-widget elementor-widget-form\" data-id=\"8cd5c9e\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;NEXT&quot;,&quot;step_previous_label&quot;:&quot;PREVIOUS&quot;,&quot;field_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:10,&quot;sizes&quot;:[]},&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150,&quot;button_width&quot;:&quot;100&quot;,&quot;dce_confirm_dialog_enabled&quot;:&quot;no&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;,&quot;label_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"dce-conditions-js-error-notice elementor-message elementor-message-danger\" style=\"display: none;\">A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.<\/div>\t\t\t<script>\n\t\t\tsetTimeout(function() {\n\t\t\t\tlet el = document.querySelector(\".dce-conditions-js-error-notice\");\n\t\t\t\tif (el)\n\t\t\t\t\tel.style.display = \"block\";\n\t\t\t}, 6000);\n\t\t\t<\/script>\t\t<form class=\"elementor-form\" method=\"post\" name=\"NP Form\" aria-label=\"NP Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"2044\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"8cd5c9e\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div data-autocomplete-fields=\"[{&quot;id&quot;:&quot;personalpatientmailinadd&quot;,&quot;country&quot;:[&quot;US&quot;]},{&quot;id&quot;:&quot;responmail&quot;,&quot;country&quot;:[&quot;US&quot;]},{&quot;id&quot;:&quot;insuranceaddress&quot;,&quot;country&quot;:[&quot;US&quot;]}]\" data-field-conditions=\"[{&quot;id&quot;:&quot;fullnamefamilyfriend&quot;,&quot;condition&quot;:&quot;(personalhowhear == \\&quot;Family \\\/ 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&#039;No&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;responcity&quot;,&quot;condition&quot;:&quot;(guarantoroftheaccount == &#039;No&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;responzip&quot;,&quot;condition&quot;:&quot;(guarantoroftheaccount == &#039;No&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;responphone&quot;,&quot;condition&quot;:&quot;(guarantoroftheaccount == &#039;No&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;respworkphone&quot;,&quot;condition&quot;:&quot;(guarantoroftheaccount  == &#039;No&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;respcellphone&quot;,&quot;condition&quot;:&quot;(guarantoroftheaccount == &#039;No&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;responbirth&quot;,&quot;condition&quot;:&quot;(guarantoroftheaccount == &#039;No&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;responemployer&quot;,&quot;condition&quot;:&quot;(guarantoroftheaccount == &#039;No&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;responss&quot;,&quot;condition&quot;:&quot;(guarantoroftheaccount == &#039;No&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;field_0069474&quot;,&quot;condition&quot;:&quot;(doyouhaveinsurance == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;insurancegroup&quot;,&quot;condition&quot;:&quot;(doyouhaveinsurance == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;insuranceid&quot;,&quot;condition&quot;:&quot;(doyouhaveinsurance == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;insurancephone&quot;,&quot;condition&quot;:&quot;(doyouhaveinsurance == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;insuranceaddress&quot;,&quot;condition&quot;:&quot;(doyouhaveinsurance == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;insurancepolicyholder&quot;,&quot;condition&quot;:&quot;(doyouhaveinsurance == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;insurancedobpolicyholder&quot;,&quot;condition&quot;:&quot;(doyouhaveinsurance == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;insurancessn&quot;,&quot;condition&quot;:&quot;(doyouhaveinsurance == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;insuranceemployer&quot;,&quot;condition&quot;:&quot;(doyouhaveinsurance == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;insuranceworkphone&quot;,&quot;condition&quot;:&quot;(doyouhaveinsurance == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;insurancerelationshiptopatient&quot;,&quot;condition&quot;:&quot;(doyouhaveinsurance == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;medicalundertreatexplain&quot;,&quot;condition&quot;:&quot;(medicaltreatment == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;medicalhospitalizedexplain&quot;,&quot;condition&quot;:&quot;(medicalhospitalized == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;field_078ca55&quot;,&quot;condition&quot;:&quot;(medicaltakingmedications == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;medicalbisphosphaonateshowlong&quot;,&quot;condition&quot;:&quot;(medicalbisphosphaonates == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;medicalttobaccohowlong&quot;,&quot;condition&quot;:&quot;(medicalttobacco == &#039;Yes&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false}]\" 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class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_6ec801b elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-madeappt elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-madeappt\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDid You Make An Appointment?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[madeappt]\" id=\"form-field-madeappt\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-fullname elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-fullname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[fullname]\" id=\"form-field-fullname\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"First Name...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-lastname elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-lastname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[lastname]\" id=\"form-field-lastname\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Last Name...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-prefercalled elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-prefercalled\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPreferred Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[prefercalled]\" id=\"form-field-prefercalled\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Preferred Name...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-birthdate elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-birthdate\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBirthdate\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[birthdate]\" id=\"form-field-birthdate\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Birthdate...\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\" min=\"1910-07-01\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalpatientssnumber elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientssnumber\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSSN\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalpatientssnumber]\" id=\"form-field-personalpatientssnumber\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Social Security Number...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-pdoffice elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-pdoffice\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPreferred Office\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[pdoffice]\" id=\"form-field-pdoffice\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Bountiful\">Bountiful<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Centerville\">Centerville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Draper\">Draper<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eagle Mountain\">Eagle Mountain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Herriman\">Herriman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Layton\">Layton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Layton\">Layton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lehi\">Lehi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Logan\">Logan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Millcreek\">Millcreek<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Orem\">Orem<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Payson\">Payson<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pleasant Grove\">Pleasant Grove<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Riverton\">Riverton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Rose Park\">Rose Park<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saratoga Springs\">Saratoga Springs<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Springville\">Springville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Union Park\">Union Park<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Jordan\">West Jordan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Valley\">West Valley<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-personalpatientsex elementor-col-20 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientsex\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSex\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[personalpatientsex]\" id=\"form-field-personalpatientsex\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Male\">Male<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Female\">Female<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-personalpatientstatus elementor-col-20 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientstatus\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStatus\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[personalpatientstatus]\" id=\"form-field-personalpatientstatus\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Minor\">Minor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Single\">Single<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Married\">Married<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Divorced\">Divorced<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Widowed\">Widowed<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalpatientmailinadd elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientmailinadd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMailing Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalpatientmailinadd]\" id=\"form-field-personalpatientmailinadd\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Mailing Address...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-personalpatientstate elementor-col-20 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientstate\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tState\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[personalpatientstate]\" id=\"form-field-personalpatientstate\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alabama\">Alabama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alaska\">Alaska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arizona\">Arizona<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arkansas\">Arkansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"California\">California<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Colorado\">Colorado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Connecticut\">Connecticut<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Delaware\">Delaware<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Florida\">Florida<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Georgia\">Georgia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hawaii\">Hawaii<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Idaho\">Idaho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Illinois\">Illinois<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Indiana\">Indiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iowa\">Iowa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kansas\">Kansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kentucky\">Kentucky<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Louisiana\">Louisiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maine\">Maine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maryland\">Maryland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Massachusetts\">Massachusetts<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Michigan\">Michigan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Minnesota\">Minnesota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mississippi\">Mississippi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Missouri\">Missouri<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Montana\">Montana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nebraska\">Nebraska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nevada\">Nevada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Hampshire\">New Hampshire<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Jersey\">New Jersey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Mexico\">New Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New York\">New York<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Carolina\">North Carolina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Dakota\">North Dakota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ohio\">Ohio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oklahoma\">Oklahoma<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oregon\">Oregon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pennsylvania\">Pennsylvania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Rhode Island\">Rhode Island<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Carolina\">South Carolina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Dakota\">South Dakota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tennessee\">Tennessee<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Texas\">Texas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Utah\" selected=\"selected\">Utah<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vermont\">Vermont<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Virginia\">Virginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Washington\">Washington<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Virginia\">West Virginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Wisconsin\">Wisconsin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Wyoming\">Wyoming<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-personalpatientcity elementor-col-20 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientcity\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[personalpatientcity]\" id=\"form-field-personalpatientcity\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alpine\">Alpine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"American Fork\">American Fork<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Blanding\">Blanding<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bluffdale\">Bluffdale<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bountiful\">Bountiful<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Brigham City\">Brigham City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cedar City\">Cedar City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Centerville\">Centerville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clearfield\">Clearfield<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clinton\">Clinton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cottonwood Heights\">Cottonwood Heights<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Draper\">Draper<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eagle Mountain\">Eagle Mountain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ephraim\">Ephraim<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Farmington\">Farmington<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Grantsville\">Grantsville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Heber City\">Heber City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Herriman\">Herriman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Highland\">Highland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Holladay\">Holladay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hurricane\">Hurricane<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ivins\">Ivins<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kaysville\">Kaysville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Layton\">Layton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lehi\">Lehi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lindon\">Lindon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Logan\">Logan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Magna\">Magna<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mapleton\">Mapleton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Midvale\">Midvale<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Millcreek\">Millcreek<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Moab\">Moab<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Murray\">Murray<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nephi\">Nephi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Logan\">North Logan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Ogden\">North Ogden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ogden\">Ogden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Orem\">Orem<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Park City\">Park City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Payson\">Payson<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pleasant Grove\">Pleasant Grove<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Price\">Price<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Provo\">Provo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Richfield\">Richfield<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Riverton\">Riverton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Roosevelt\">Roosevelt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Roy\">Roy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Salt Lake City\">Salt Lake City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sandy\">Sandy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Santa Clara\">Santa Clara<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saratoga Springs\">Saratoga Springs<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Smithfield\">Smithfield<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Jordan\">South Jordan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Ogden\">South Ogden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spanish Fork\">Spanish Fork<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Springville\">Springville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"St. George\">St. George<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Taylorsville\">Taylorsville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tooele\">Tooele<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vernal\">Vernal<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-persozip elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-persozip\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tZip Code\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[persozip]\" id=\"form-field-persozip\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Zip Code...\" required=\"required\" min=\"\" max=\"99999\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalpatienthomephone elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatienthomephone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHome Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalpatienthomephone]\" id=\"form-field-personalpatienthomephone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Home Phone...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalpatientworkphone elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientworkphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWork Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalpatientworkphone]\" id=\"form-field-personalpatientworkphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Work Phone...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalpatientcellphone elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientcellphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCell Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalpatientcellphone]\" id=\"form-field-personalpatientcellphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Cell Phone...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-personalpatientemail elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientemail\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[personalpatientemail]\" id=\"form-field-personalpatientemail\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Email...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalpatientemployer elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientemployer\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmployer\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalpatientemployer]\" id=\"form-field-personalpatientemployer\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Employer...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalcontactemergency elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalcontactemergency\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmergency Contact\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalcontactemergency]\" id=\"form-field-personalcontactemergency\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Emergency Contact Name...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalemergencyphone elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalemergencyphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmergency Phone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalemergencyphone]\" id=\"form-field-personalemergencyphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Emergency Phone Number...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-personalhowhear elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalhowhear\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow Did You Hear About Us?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Instagram \" id=\"form-field-personalhowhear-0\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-0\">Instagram <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Facebook\" id=\"form-field-personalhowhear-1\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-1\">Facebook<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Google\" id=\"form-field-personalhowhear-2\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-2\">Google<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Website\" id=\"form-field-personalhowhear-3\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-3\">Website<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Insurance\" id=\"form-field-personalhowhear-4\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-4\">Insurance<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Family \/ Friend\" id=\"form-field-personalhowhear-5\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-5\">Family \/ Friend<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Other\" id=\"form-field-personalhowhear-6\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-6\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-fullnamefamilyfriend elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-fullnamefamilyfriend\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFull Name of Family \/ Friend\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[fullnamefamilyfriend]\" id=\"form-field-fullnamefamilyfriend\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Full Name of Family \/ Friend\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-otherreferral elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-otherreferral\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOther Referral\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[otherreferral]\" id=\"form-field-otherreferral\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Other Referral\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-responsibletitle elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-guarantoroftheaccount elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-guarantoroftheaccount\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre You The Guarantor Of The Account?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[guarantoroftheaccount]\" id=\"form-field-guarantoroftheaccount\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-responname elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName Of The Guarantor Of The Account\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[responname]\" id=\"form-field-responname\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Name of Guarantor...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-responrelation elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responrelation\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelationship To Patient\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[responrelation]\" id=\"form-field-responrelation\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Relationship to patient...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-responmail elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responmail\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMailing Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[responmail]\" id=\"form-field-responmail\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Mailing Addres...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-responstate elementor-col-20 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responstate\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tState\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[responstate]\" id=\"form-field-responstate\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alabama\">Alabama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alaska\">Alaska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arizona\">Arizona<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arkansas\">Arkansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"California\">California<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Colorado\">Colorado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Connecticut\">Connecticut<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Delaware\">Delaware<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Florida\">Florida<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Georgia\">Georgia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hawaii\">Hawaii<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Idaho\">Idaho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Illinois\">Illinois<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Indiana\">Indiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iowa\">Iowa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kansas\">Kansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kentucky\">Kentucky<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Louisiana\">Louisiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maine\">Maine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maryland\">Maryland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Massachusetts\">Massachusetts<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Michigan\">Michigan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Minnesota\">Minnesota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mississippi\">Mississippi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Missouri\">Missouri<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Montana\">Montana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nebraska\">Nebraska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nevada\">Nevada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Hampshire\">New Hampshire<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Jersey\">New Jersey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Mexico\">New Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New York\">New York<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Carolina\">North Carolina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Dakota\">North Dakota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ohio\">Ohio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oklahoma\">Oklahoma<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oregon\">Oregon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pennsylvania\">Pennsylvania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Rhode Island\">Rhode Island<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Carolina\">South Carolina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Dakota\">South Dakota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tennessee\">Tennessee<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Texas\">Texas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Utah\" selected=\"selected\">Utah<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vermont\">Vermont<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Virginia\">Virginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Washington\">Washington<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Virginia\">West Virginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Wisconsin\">Wisconsin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Wyoming\">Wyoming<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-responcity elementor-col-20 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responcity\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[responcity]\" id=\"form-field-responcity\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alpine\">Alpine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"American Fork\">American Fork<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Blanding\">Blanding<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bluffdale\">Bluffdale<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bountiful\">Bountiful<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Brigham City\">Brigham City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cedar City\">Cedar City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Centerville\">Centerville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clearfield\">Clearfield<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clinton\">Clinton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cottonwood Heights\">Cottonwood Heights<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Draper\">Draper<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eagle Mountain\">Eagle Mountain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ephraim\">Ephraim<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Farmington\">Farmington<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Grantsville\">Grantsville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Heber City\">Heber City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Herriman\">Herriman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Highland\">Highland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Holladay\">Holladay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hurricane\">Hurricane<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ivins\">Ivins<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kaysville\">Kaysville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Layton\">Layton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lehi\">Lehi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lindon\">Lindon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Logan\">Logan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Magna\">Magna<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mapleton\">Mapleton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Midvale\">Midvale<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Millcreek\">Millcreek<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Moab\">Moab<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Murray\">Murray<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nephi\">Nephi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Logan\">North Logan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Ogden\">North Ogden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ogden\">Ogden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Orem\">Orem<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Park City\">Park City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Payson\">Payson<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pleasant Grove\">Pleasant Grove<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Price\">Price<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Provo\">Provo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Richfield\">Richfield<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Riverton\">Riverton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Roosevelt\">Roosevelt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Roy\">Roy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Salt Lake City\">Salt Lake City<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sandy\">Sandy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Santa Clara\">Santa Clara<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saratoga Springs\">Saratoga Springs<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Smithfield\">Smithfield<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Jordan\">South Jordan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Ogden\">South Ogden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spanish Fork\">Spanish Fork<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Springville\">Springville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"St. George\">St. George<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Taylorsville\">Taylorsville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tooele\">Tooele<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vernal\">Vernal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-responzip elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responzip\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tZip Code\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[responzip]\" id=\"form-field-responzip\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Zip Code...\" required=\"required\" min=\"\" max=\"99999\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-responphone elementor-col-33 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHome Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[responphone]\" id=\"form-field-responphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Home Phone...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-respworkphone elementor-col-33 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-respworkphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWork Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[respworkphone]\" id=\"form-field-respworkphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Work Phone...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-respcellphone elementor-col-33 elementor-sm-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-respcellphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCell Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[respcellphone]\" id=\"form-field-respcellphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Cell Phone...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-responbirth elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responbirth\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBirthdate\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[responbirth]\" id=\"form-field-responbirth\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Birthdate\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-responemployer elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responemployer\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmployer\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[responemployer]\" id=\"form-field-responemployer\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Employer Name...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-responss elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responss\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSSN #\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[responss]\" id=\"form-field-responss\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Social Security Number...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-responpayment elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responpayment\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPreferred Method Of Payment\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cash\" id=\"form-field-responpayment-0\" name=\"form_fields[responpayment][]\"> <label for=\"form-field-responpayment-0\">Cash<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Personal Check\" id=\"form-field-responpayment-1\" name=\"form_fields[responpayment][]\"> <label for=\"form-field-responpayment-1\">Personal Check<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Credit Card\" id=\"form-field-responpayment-2\" name=\"form_fields[responpayment][]\"> <label for=\"form-field-responpayment-2\">Credit Card<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"CareCredit\" id=\"form-field-responpayment-3\" name=\"form_fields[responpayment][]\"> <label for=\"form-field-responpayment-3\">CareCredit<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Others\" id=\"form-field-responpayment-4\" name=\"form_fields[responpayment][]\"> <label for=\"form-field-responpayment-4\">Others<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-insuranceinfo elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-doyouhaveinsurance elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-doyouhaveinsurance\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have insurance?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[doyouhaveinsurance]\" id=\"form-field-doyouhaveinsurance\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0069474 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0069474\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0069474]\" id=\"form-field-field_0069474\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Insurance Name...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insurancegroup elementor-col-25 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurancegroup\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGroup #\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insurancegroup]\" id=\"form-field-insurancegroup\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Group Number...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insuranceid elementor-col-25 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insuranceid\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tID #\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insuranceid]\" id=\"form-field-insuranceid\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"ID Number...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insurancephone elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurancephone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance Phone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insurancephone]\" id=\"form-field-insurancephone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Insurance Phone Number...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insuranceaddress elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insuranceaddress\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInsurance Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insuranceaddress]\" id=\"form-field-insuranceaddress\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Insurance Address...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insurancepolicyholder elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurancepolicyholder\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName Of Policy Holder\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insurancepolicyholder]\" id=\"form-field-insurancepolicyholder\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Name of Policy Holder...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-insurancedobpolicyholder elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurancedobpolicyholder\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDOB Of Policy Holder\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[insurancedobpolicyholder]\" id=\"form-field-insurancedobpolicyholder\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"DOB Policy Holder...\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insurancessn elementor-col-33 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurancessn\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSSN#\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insurancessn]\" id=\"form-field-insurancessn\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Social Security Number...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insuranceemployer elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insuranceemployer\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmployer\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insuranceemployer]\" id=\"form-field-insuranceemployer\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Employer...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insuranceworkphone elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insuranceworkphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWork Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insuranceworkphone]\" id=\"form-field-insuranceworkphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Work Phone...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-insurancerelationshiptopatient elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurancerelationshiptopatient\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelationship To Patient\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[insurancerelationshiptopatient]\" id=\"form-field-insurancerelationshiptopatient\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"It&#039;s me\">It&#039;s me<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Parent\">Parent<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guardian \/ Tutor\">Guardian \/ Tutor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spouse \">Spouse <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Son \/ Daughter\">Son \/ Daughter<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-medicalhistory elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalphysician elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalphysician\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhysician Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalphysician]\" id=\"form-field-medicalphysician\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Physician \/ Doctor Name...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalofficephone elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalofficephone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOffice Phone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalofficephone]\" id=\"form-field-medicalofficephone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Office Phone\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-medicaldateoflastvisit elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicaldateoflastvisit\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate Of Last Visit\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[medicaldateoflastvisit]\" id=\"form-field-medicaldateoflastvisit\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field\" placeholder=\"Date of Last Visit...\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicaltreatment elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicaltreatment\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre You Under Medical Treatment Now?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicaltreatment]\" id=\"form-field-medicaltreatment\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalundertreatexplain elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalundertreatexplain\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease Explain\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalundertreatexplain]\" id=\"form-field-medicalundertreatexplain\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Please Explain...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicalhospitalized elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalhospitalized\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave You Been Hospitalized Within The Last 5 Years?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicalhospitalized]\" id=\"form-field-medicalhospitalized\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalhospitalizedexplain elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalhospitalizedexplain\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease Explain\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalhospitalizedexplain]\" id=\"form-field-medicalhospitalizedexplain\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Please Explain...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicaltakingmedications elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicaltakingmedications\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre You Taking Medications, Including Blood Thinners?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicaltakingmedications]\" id=\"form-field-medicaltakingmedications\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_078ca55 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_078ca55\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease Explain\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_078ca55]\" id=\"form-field-field_078ca55\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Please Explain...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicalbisphosphaonates elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalbisphosphaonates\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEver Taken Bisphosphaonates?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicalbisphosphaonates]\" id=\"form-field-medicalbisphosphaonates\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalbisphosphaonateshowlong elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalbisphosphaonateshowlong\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow Long?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalbisphosphaonateshowlong]\" id=\"form-field-medicalbisphosphaonateshowlong\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"For How Long...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicaltakenphenfen elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicaltakenphenfen\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave You Ever Taken Phen Fen?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicaltakenphenfen]\" id=\"form-field-medicaltakenphenfen\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicalcontrolledsusbstances elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalcontrolledsusbstances\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tUse Controlled Susbstances?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicalcontrolledsusbstances]\" id=\"form-field-medicalcontrolledsusbstances\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicalttobacco elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalttobacco\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Use Tobacco?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicalttobacco]\" id=\"form-field-medicalttobacco\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalttobaccohowlong elementor-col-50 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalttobaccohowlong\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow Used & How Long?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalttobaccohowlong]\" id=\"form-field-medicalttobaccohowlong\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"How Used &amp; How Long?\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-allergictoanyofthefollowing elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-allergictoanyofthefollowing\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre You Allergic Or Have You Had Any Reactions To The Following?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Local Anesthetics\" id=\"form-field-allergictoanyofthefollowing-0\" name=\"form_fields[allergictoanyofthefollowing][]\"> <label for=\"form-field-allergictoanyofthefollowing-0\">Local Anesthetics<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Penicilin \/ Antibiotics\" id=\"form-field-allergictoanyofthefollowing-1\" name=\"form_fields[allergictoanyofthefollowing][]\"> <label for=\"form-field-allergictoanyofthefollowing-1\">Penicilin \/ Antibiotics<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Latex Rubber\" id=\"form-field-allergictoanyofthefollowing-2\" name=\"form_fields[allergictoanyofthefollowing][]\"> <label for=\"form-field-allergictoanyofthefollowing-2\">Latex Rubber<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Any Metals\" id=\"form-field-allergictoanyofthefollowing-3\" name=\"form_fields[allergictoanyofthefollowing][]\"> <label for=\"form-field-allergictoanyofthefollowing-3\">Any Metals<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Codeine\" id=\"form-field-allergictoanyofthefollowing-4\" name=\"form_fields[allergictoanyofthefollowing][]\"> <label for=\"form-field-allergictoanyofthefollowing-4\">Codeine<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-allergictoanyofthefollowing-5\" name=\"form_fields[allergictoanyofthefollowing][]\"> <label for=\"form-field-allergictoanyofthefollowing-5\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-haveanyofthefollowing elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-haveanyofthefollowing\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Currently Have Or Have You Ever Had Any Of The Following?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"High Blood Pressure\" id=\"form-field-haveanyofthefollowing-0\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-0\">High Blood Pressure<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Diabetes \" id=\"form-field-haveanyofthefollowing-1\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-1\">Diabetes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart Murmur \" id=\"form-field-haveanyofthefollowing-2\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-2\">Heart Murmur <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Mitral Valve Prolapse\" id=\"form-field-haveanyofthefollowing-3\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-3\">Mitral Valve Prolapse<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Seizures \" id=\"form-field-haveanyofthefollowing-4\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-4\">Seizures <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Anemia \" id=\"form-field-haveanyofthefollowing-5\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-5\">Anemia <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Thyroid Problems \" id=\"form-field-haveanyofthefollowing-6\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-6\">Thyroid Problems <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Tuberculosis\" id=\"form-field-haveanyofthefollowing-7\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-7\">Tuberculosis<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Liver Disease \" id=\"form-field-haveanyofthefollowing-8\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-8\">Liver Disease <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cardiac Pacemaker \" id=\"form-field-haveanyofthefollowing-9\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-9\">Cardiac Pacemaker <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Rheumatic Fever \" id=\"form-field-haveanyofthefollowing-10\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-10\">Rheumatic Fever <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Kidney Disease\" id=\"form-field-haveanyofthefollowing-11\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-11\">Kidney Disease<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Emphysema \" id=\"form-field-haveanyofthefollowing-12\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-12\">Emphysema <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"STD \" id=\"form-field-haveanyofthefollowing-13\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-13\">STD <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Glaucoma \" id=\"form-field-haveanyofthefollowing-14\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-14\">Glaucoma <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Radiation Therapy\" id=\"form-field-haveanyofthefollowing-15\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-15\">Radiation Therapy<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Low Blood\" id=\"form-field-haveanyofthefollowing-16\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-16\">Low Blood<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pressure\" id=\"form-field-haveanyofthefollowing-17\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-17\">Pressure<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart Attack \" id=\"form-field-haveanyofthefollowing-18\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-18\">Heart Attack <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Swollen Ankles \" id=\"form-field-haveanyofthefollowing-19\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-19\">Swollen Ankles <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Epilepsy \/ Convulsions\" id=\"form-field-haveanyofthefollowing-20\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-20\">Epilepsy \/ Convulsions<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Asthma \" id=\"form-field-haveanyofthefollowing-21\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-21\">Asthma <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"AIDS\/HIV \" id=\"form-field-haveanyofthefollowing-22\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-22\">AIDS\/HIV <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Stroke\" id=\"form-field-haveanyofthefollowing-23\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-23\">Stroke<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Fainting\" id=\"form-field-haveanyofthefollowing-24\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-24\">Fainting<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart Disease\" id=\"form-field-haveanyofthefollowing-25\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-25\">Heart Disease<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Respiratory Problems \" id=\"form-field-haveanyofthefollowing-26\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-26\">Respiratory Problems <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Leukemia \" id=\"form-field-haveanyofthefollowing-27\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-27\">Leukemia <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cancer\" id=\"form-field-haveanyofthefollowing-28\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-28\">Cancer<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Joint Replacement\" id=\"form-field-haveanyofthefollowing-29\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-29\">Joint Replacement<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Stomach Problems \" id=\"form-field-haveanyofthefollowing-30\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-30\">Stomach Problems <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hay Fever\/ Allergies \" id=\"form-field-haveanyofthefollowing-31\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-31\">Hay Fever\/ Allergies <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hepatitis\/Jaundice\" id=\"form-field-haveanyofthefollowing-32\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-32\">Hepatitis\/Jaundice<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_efb8361 elementor-col-100\">\n\t\t\t\t\tSleeping And Breathing\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingwaktired elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingwaktired\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Usually Wake Feeling Tired?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingwaktired]\" id=\"form-field-sleepingwaktired\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingsnore elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingsnore\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Habitually Snore?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingsnore]\" id=\"form-field-sleepingsnore\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingwakingheadeaches elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingwakingheadeaches\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Headaches Frequently Wake You Up?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingwakingheadeaches]\" id=\"form-field-sleepingwakingheadeaches\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingdrownsiness elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingdrownsiness\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Experience Daytime Drowness?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingdrownsiness]\" id=\"form-field-sleepingdrownsiness\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingstopbreathing elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingstopbreathing\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHas Anyone Observed You Stop Breathing While Asleep?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingstopbreathing]\" id=\"form-field-sleepingstopbreathing\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingblocknasal elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingblocknasal\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Have Blocked Nasal Passages?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingblocknasal]\" id=\"form-field-sleepingblocknasal\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepinggrindteeth elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepinggrindteeth\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Grind Your Teeth Whiile Asleep?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepinggrindteeth]\" id=\"form-field-sleepinggrindteeth\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingwakechoking elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingwakechoking\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Ever Wake Up Choking or Gasping?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingwakechoking]\" id=\"form-field-sleepingwakechoking\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_94244ef elementor-col-100\">\n\t\t\t\t\tWomen Only\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-womenpregnant elementor-col-33 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-womenpregnant\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre You Pregnant Or Do You Think You Might Be Pregnant?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[womenpregnant]\" id=\"form-field-womenpregnant\" class=\"elementor-field-textual elementor-size-md\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-womennursing elementor-col-33 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-womennursing\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre You Nursing?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[womennursing]\" id=\"form-field-womennursing\" class=\"elementor-field-textual elementor-size-md\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-womencontraceptives elementor-col-33 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-womencontraceptives\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre You Taking Contraceptives?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[womencontraceptives]\" id=\"form-field-womencontraceptives\" class=\"elementor-field-textual elementor-size-md\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_0961b63 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-dentalpreviousdentist elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentalpreviousdentist\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPrevious Dentist\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[dentalpreviousdentist]\" id=\"form-field-dentalpreviousdentist\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Previous Dentist...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-dentalpreviousclinic elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentalpreviousclinic\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPrevious Clinic\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[dentalpreviousclinic]\" id=\"form-field-dentalpreviousclinic\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Previous Clinic Name...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-dentaltimesbrush elementor-col-25 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentaltimesbrush\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow Many Times A Day Do You Brush?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[dentaltimesbrush]\" id=\"form-field-dentaltimesbrush\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">0<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">2<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">3<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">4<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5\">5<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6\">6<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-dentaltimesfloss elementor-col-25 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentaltimesfloss\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow Many Times A Week Do You Floss?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[dentaltimesfloss]\" id=\"form-field-dentaltimesfloss\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">0<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">2<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">3<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">4<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5\">5<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6\">6<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7\">7<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"More\">More<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-dentalratesmile elementor-col-25 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentalratesmile\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow Would You Rate Your Smile?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[dentalratesmile]\" id=\"form-field-dentalratesmile\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">0<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">2<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">3<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">4<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5\">5<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6\">6<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7\">7<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8\">8<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9\">9<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10\">10<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-dentalrequireantibiotic elementor-col-25 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentalrequireantibiotic\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRequire Antibiotic Pre-Medications?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[dentalrequireantibiotic]\" id=\"form-field-dentalrequireantibiotic\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-dentalanyfollowing elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentalanyfollowing\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo You Have Any Of The Following?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Red, Swollen, Bleeding Gums\" id=\"form-field-dentalanyfollowing-0\" name=\"form_fields[dentalanyfollowing][]\"> <label for=\"form-field-dentalanyfollowing-0\">Red, Swollen, Bleeding Gums<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pain in teeth\" id=\"form-field-dentalanyfollowing-1\" name=\"form_fields[dentalanyfollowing][]\"> <label for=\"form-field-dentalanyfollowing-1\">Pain in teeth<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Teeth Sensitive to hot, cold or sweets\" id=\"form-field-dentalanyfollowing-2\" name=\"form_fields[dentalanyfollowing][]\"> <label for=\"form-field-dentalanyfollowing-2\">Teeth Sensitive to hot, cold or sweets<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Broken or chipped teeth or fillings\" id=\"form-field-dentalanyfollowing-3\" name=\"form_fields[dentalanyfollowing][]\"> <label for=\"form-field-dentalanyfollowing-3\">Broken or chipped teeth or fillings<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Snoring\" id=\"form-field-dentalanyfollowing-4\" name=\"form_fields[dentalanyfollowing][]\"> <label for=\"form-field-dentalanyfollowing-4\">Snoring<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Anxiety\" id=\"form-field-dentalanyfollowing-5\" name=\"form_fields[dentalanyfollowing][]\"> <label for=\"form-field-dentalanyfollowing-5\">Anxiety<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_45edc5d elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_eb8116a elementor-col-100\">\n\t\t\t\t\tRead Professional Dental Forms That You Are Accepting By Signing:\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_32fba46 elementor-col-100\">\n\t\t\t\t\t<a href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2025\/01\/Consent-Form-1.pdf\" style=\"color:#5EB2F2\" target=\"_blank\">Click Here To Read Consent Form<\/a> <br>\n<a href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2025\/01\/Financial-Policy.pdf\" style=\"color:#5EB2F2\" target=\"_blank\">Click Here To Read Financial Policy<\/a> <br>\n<a href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2025\/01\/Notice-of-Privacy-Practice-@PD-English-2.pdf\" style=\"color:#5EB2F2\" target=\"_blank\">Click Here To Read Privacy Practices<\/a><br>\n<a href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2025\/03\/Notice-of-Non-covered.pdf\" style=\"color:#5EB2F2\" target=\"_blank\">Click Here To Read Notice of Non-covered Dental Products and Services<\/a><br>\n<a href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2026\/03\/Professional-Dental-Agreement-to-use-image-1.pdf\" style=\"color:#5EB2F2\" target=\"_blank\">Click Here To Read Social Media Consent Form<\/a>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_57789c8 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_57789c8]\" id=\"form-field-field_57789c8\" class=\"elementor-field elementor-size-md  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_57789c8\">I accept to share my information with Professional Dental & Orthodontics and I confirm I read the Forms and Terms & Conditions<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-consentaccept elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[consentaccept]\" id=\"form-field-consentaccept\" class=\"elementor-field elementor-size-md  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-consentaccept\">I understand and accept Professional Dental Consent Form, Financial Policy, Privacy Practices and Notice of Non Covered Dental Products and Services<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a0e077b elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a0e077b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFull Name (Your Name Is Valid As Your Signature)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a0e077b]\" id=\"form-field-field_a0e077b\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Full Name As Shown in ID...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-consentrelation elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-consentrelation\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelationship To Patient\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[consentrelation]\" id=\"form-field-consentrelation\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Relationship to patient...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-dce_form_signature elementor-field-group elementor-column elementor-field-group-signatureprivacy elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-signatureprivacy\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDigital Signature\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div style=\"width: 100%; display: block;\">\n\t\t\t<div class=\"dce-signature-wrapper\" style=\"width: var(--canvas-width); min-width: 200px;\">\n\t\t\t\t<div style=\"position: relative; display: inline-block; width: 100%;\">\n\t\t\t\t\t<button type=\"button\"\n\t\t\t\t\t\t\tclass=\"dce-signature-button-clear\"\n\t\t\t\t\t\t\tdata-action=\"clear\"\n\t\t\t\t\t\t\tstyle=\"position: absolute; top: 0; right: 0; z-index: 10;\">\n\t\t\t\t\t\t<svg class=\"e-font-icon-svg e-eicon-close\" viewBox=\"0 0 1000 1000\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M742 167L500 408 258 167C246 154 233 150 217 150 196 150 179 158 167 167 154 179 150 196 150 212 150 229 154 242 171 254L408 500 167 742C138 771 138 800 167 829 196 858 225 858 254 829L496 587 738 829C750 842 767 846 783 846 800 846 817 842 829 829 842 817 846 804 846 783 846 767 842 750 829 737L588 500 833 258C863 229 863 200 833 171 804 137 775 137 742 167Z\"><\/path><\/svg>\t\t\t\t\t<\/button>\n\t\t\t\t\t<input type=\"dce_form_signature\" name=\"form_fields[signatureprivacy]\" id=\"form-field-signatureprivacy\" class=\"elementor-field elementor-size-md \" required=\"required\" style=\"width: 0; height: 0; opacity: 0; position: absolute; pointer-events: none;\">\n\t\t\t\t\t<canvas class=\"dce-signature-canvas\" data-pen-color=\"#000000\" data-background-color=\"#ffffff\" data-jpeg=\"no\" data-aspect-ratio=\"2\" width=\"1\" height=\"1\" style=\"width: 100%; height: calc(100% \/ 2); border-style: solid; touch-action: none; user-select: none;\"><\/canvas>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-paper-plane\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M476 3.2L12.5 270.6c-18.1 10.4-15.8 35.6 2.2 43.2L121 358.4l287.3-253.2c5.5-4.9 13.3 2.6 8.6 8.3L176 407v80.5c0 23.6 28.5 32.9 42.5 15.8L282 426l124.6 52.2c14.2 6 30.4-2.9 33-18.2l72-432C515 7.8 493.3-6.8 476 3.2z\"><\/path><\/svg>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">SUBMIT<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t<style>.elementor-element.elementor-element-8cd5c9e .elementor-field-group { align-self: flex-start; }<\/style>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-078fce0 elementor-invisible elementor-widget elementor-widget-text-editor\" data-id=\"078fce0\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>By submitting this form, you agree to share your personal, medical, and insurance information with Professional Dental. If you have any questions, please call us at 801-785-8000.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-707a77f e-flex e-con-boxed e-con e-parent\" data-id=\"707a77f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0e792c7 elementor-widget elementor-widget-spacer\" data-id=\"0e792c7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div data-dce-background-overlay-color=\"#2C5D83\" class=\"elementor-element elementor-element-e45e368 e-con-full e-flex elementor-invisible e-con e-parent\" data-id=\"e45e368\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;default&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-7162255 e-flex e-con-boxed elementor-invisible e-con e-child\" data-id=\"7162255\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;default&quot;,&quot;animation_delay&quot;:100}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0788c12 elementor-widget elementor-widget-heading\" data-id=\"0788c12\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"elementor-heading-title elementor-size-default\">Prefer Paper? <\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4868867 elementor-widget elementor-widget-ucaddon_dual_color_heading\" data-id=\"4868867\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"ucaddon_dual_color_heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n<!-- start Dual Color Heading -->\n\n<div class=\"ue-dual-color-heading\">\n  <h3>\n    <span class=\"ue-title-one\">Download All The <\/span> <span class=\"ue-title-two\">Forms And Read Them Carefully<\/span>\n  <\/h3>\n<\/div>\n<!-- end Dual Color Heading -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bb75dfe elementor-widget elementor-widget-heading\" data-id=\"bb75dfe\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"elementor-heading-title elementor-size-default\">All patients must read carefully and accept our Terms and Conditions and sign our Consent Form, Financial Policy and Privacy Policy.<\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-b918233 e-con-full e-flex e-con e-child\" data-id=\"b918233\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6432ef4 elementor-widget elementor-widget-button\" data-id=\"6432ef4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2026\/01\/Printing-New-Patient-Form-PD-12-16-2025-1-1.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-cloud-download-alt\" viewBox=\"0 0 640 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M537.6 226.6c4.1-10.7 6.4-22.4 6.4-34.6 0-53-43-96-96-96-19.7 0-38.1 6-53.3 16.2C367 64.2 315.3 32 256 32c-88.4 0-160 71.6-160 160 0 2.7.1 5.4.2 8.1C40.2 219.8 0 273.2 0 336c0 79.5 64.5 144 144 144h368c70.7 0 128-57.3 128-128 0-61.9-44-113.6-102.4-125.4zm-132.9 88.7L299.3 420.7c-6.2 6.2-16.4 6.2-22.6 0L171.3 315.3c-10.1-10.1-2.9-27.3 11.3-27.3H248V176c0-8.8 7.2-16 16-16h48c8.8 0 16 7.2 16 16v112h65.4c14.2 0 21.4 17.2 11.3 27.3z\"><\/path><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">New Patient Form<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bfc50f8 elementor-widget elementor-widget-button\" data-id=\"bfc50f8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2025\/01\/Financial-Policy.pdf\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-cloud-download-alt\" viewBox=\"0 0 640 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M537.6 226.6c4.1-10.7 6.4-22.4 6.4-34.6 0-53-43-96-96-96-19.7 0-38.1 6-53.3 16.2C367 64.2 315.3 32 256 32c-88.4 0-160 71.6-160 160 0 2.7.1 5.4.2 8.1C40.2 219.8 0 273.2 0 336c0 79.5 64.5 144 144 144h368c70.7 0 128-57.3 128-128 0-61.9-44-113.6-102.4-125.4zm-132.9 88.7L299.3 420.7c-6.2 6.2-16.4 6.2-22.6 0L171.3 315.3c-10.1-10.1-2.9-27.3 11.3-27.3H248V176c0-8.8 7.2-16 16-16h48c8.8 0 16 7.2 16 16v112h65.4c14.2 0 21.4 17.2 11.3 27.3z\"><\/path><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Financial Policy<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6fd6e56 elementor-widget elementor-widget-text-editor\" data-id=\"6fd6e56\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Question? Call Us For More Information <a href=\"tel:8017858000\">(801) 785 &#8211; 8000<\/a>, We Are Here To Help.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-a92ecf2 e-flex e-con-boxed elementor-invisible e-con e-child\" data-id=\"a92ecf2\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;default&quot;,&quot;animation_delay&quot;:150}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div data-dce-background-image-url=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/08\/Untitled-design-2024-08-07T150116.247.jpg\" class=\"elementor-element elementor-element-9c904e7 elementor-widget elementor-widget-ucaddon_blox_play_button\" data-id=\"9c904e7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"ucaddon_blox_play_button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n<!-- start Video Play Button -->\n\t\t<link id='font-awesome-css' href='https:\/\/prodentalut.com\/wp-content\/plugins\/unlimited-elements-for-elementor-premium\/assets_libraries\/font-awesome6\/fontawesome-all.min.css' type='text\/css' rel='stylesheet' >\n\t\t<link id='font-awesome-4-shim-css' href='https:\/\/prodentalut.com\/wp-content\/plugins\/unlimited-elements-for-elementor-premium\/assets_libraries\/font-awesome6\/fontawesome-v4-shims.min.css' type='text\/css' rel='stylesheet' >\n\t\t<link id='lity-css' href='https:\/\/prodentalut.com\/wp-content\/plugins\/unlimited-elements-for-elementor-premium\/assets_libraries\/lity\/lity.min.css' type='text\/css' rel='stylesheet' >\n\n<style>\/* widget: Video Play Button *\/\n\n#uc_blox_play_button_elementor_9c904e7\n{\n width:100%;\n}\n.container_uc_blox_play_button_elementor_9c904e7{\n  display: flex;\n  justify-content: center;\n}\n\n#uc_blox_play_button_elementor_9c904e7 a\n{\n  display:inline-block;\n  transition:0.5s;\n  text-decoration:none;\n}\n.ue_play_button{text-align:center;}\n\n#uc_blox_play_button_elementor_9c904e7 a:hover\n{\n  transform:scale(1.1,1.1);\n}\n\n#uc_blox_play_button_elementor_9c904e7 a span.video-button\n{\n  display:inline-block;\n  align-items: center;\n  justify-content: center;\n  flex-direction: column; \n  display:flex;\n  position:relative;\n  transition:0.3s;\n  line-height:1em;\n}\n\n.ue-play-bg{\n  background-size:cover;\n  background-position:center;\n  background-repeat:none;\n  max-width:100%; \n}\n\n#uc_blox_play_button_elementor_9c904e7 a span.video-button svg\n{\n  height:1em;\n  width:1em;\n}\n\n#uc_blox_play_button_elementor_9c904e7 i\n{\n\n  vertical-align:middle;\n  transition:0.3s;\n}\n\n#uc_blox_play_button_elementor_9c904e7 a span:before\n{\n  content: '';\n    display: inline-block;\n    position: absolute;\n    top: -2px;\n    left: -2px;\n    bottom: -2px;\n    right: -2px;\n    border-radius: inherit;\n    border: 1px solid #F1F7FC;\n    -webkit-animation: btnIconRipple 2s cubic-bezier(0.23, 1, 0.32, 1) both infinite;\n    animation: btnIconRipple 2s cubic-bezier(0.23, 1, 0.32, 1) both infinite;\n    border-color: #F1F7FC;\n}\n\n@keyframes btnIconRipple {\n  0% {\n    border-width: 4px;\n            transform: scale(1);\n  }\n  80% {\n    border-width: 1px;\n            transform: scale(1.35);\n  }\n  100% {\n    opacity: 0;\n  }\n}\n\n\n.ue-play-bg\n{\n  display:flex;\n  align-items:center;\n  justify-content:center;\n}\n\n\n\n\n\n\n\n\n\n\n\t\t  .button_uc_blox_play_button_elementor_9c904e7{\n          animation: ue-video-popup-waggle 5s infinite;\n      }\n\n      @keyframes ue-video-popup-waggle {\n          0% {\n              transform: none;\n          }\n\n          10% {\n              transform: rotateZ(-20deg) scale(1.2);\n          }\n\n          13% {\n              transform: rotateZ(25deg) scale(1.2);\n          }\n\n          15% {\n              transform: rotateZ(-15deg) scale(1.2);\n          }\n\n          17% {\n              transform: rotateZ(15deg) scale(1.2);\n          }\n\n          20% {\n              transform: rotateZ(-12deg) scale(1.2);\n          }\n\n          22% {\n              transform: rotateZ(0) scale(1.2);\n          }\n\n          25%,\n          100% {\n              transform: rotateZ(0) scale(1);\n          }\n      }\n\t\n\t\t\n\t\n\t\n\t\n\t\n\t\n\n.lity-close{\n  display: flex;\n  align-items: center;\n  justify-content: center;\n  padding:0!important;\n  color:;\n  font-size: !important;\n  background-color:;\n      }\n.lity-close *{\n  transition: all 200ms;\n}\n.lity-close:hover{\n  background-color:;\n  color:;\n}\n@media (max-width: 767px) {\n .lity-close{\n    font-size: !important;\n  }\n}\n@media (max-width: 1024px) {\n .lity-close{\n    font-size: !important;\n  }\n}\n\n<\/style>\n\n  <div class=\"container_uc_blox_play_button_elementor_9c904e7\">\n     <div class=\"ue-play-bg\" id=\"ue-play-bg_uc_blox_play_button_elementor_9c904e7\" style=\"--imgurl: url(https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/08\/Untitled-design-2024-08-07T150116.247.jpg); background-image: linear-gradient(#0000000D, #0000000D), var(--imgurl);\">\n\t\n     <div id=\"uc_blox_play_button_elementor_9c904e7\" class=\"ue_play_button\" data-path=\"\/\/www.youtube.com\/watch?v=\">\n          <a href=\"\/\/www.youtube.com\/watch?v=RG9w71TJQ64&autoplay=0&mute=1\" class=\"button_uc_blox_play_button_elementor_9c904e7\" data-lity>\n         <span class=\"video-button\">\n          <i class='fas fa-play'><\/i>\n  <\/span>  \n<\/a>\n<\/div>\n<\/div><\/div>\n<!-- end Video Play Button -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-49c116d e-flex e-con-boxed elementor-invisible e-con e-parent\" data-id=\"49c116d\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;default&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-72b0238 e-con-full e-flex e-con e-child\" data-id=\"72b0238\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-35be9a1 elementor-invisible elementor-widget elementor-widget-text-editor\" data-id=\"35be9a1\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:100}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tWe Accept Most Dental Insurances\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-dce-title-color=\"#013A65\" class=\"elementor-element elementor-element-a5b5b5c elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"a5b5b5c\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Dental Insurances We Take\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a2815c8 elementor-grid-5 elementor-grid-mobile-2 elementor-grid-tablet-2 elementor-invisible elementor-widget elementor-widget-loop-grid\" data-id=\"a2815c8\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;template_id&quot;:1480,&quot;columns&quot;:5,&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:300,&quot;columns_mobile&quot;:2,&quot;row_gap_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:15,&quot;sizes&quot;:[]},&quot;_skin&quot;:&quot;post&quot;,&quot;columns_tablet&quot;:&quot;2&quot;,&quot;edit_handle_selector&quot;:&quot;[data-elementor-type=\\&quot;loop-item\\&quot;]&quot;,&quot;row_gap&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;row_gap_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"loop-grid.post\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-loop-container elementor-grid\" role=\"list\">\n\t\t<style id=\"loop-1480\">.elementor-1480 .elementor-element.elementor-element-99d8a0a{--display:flex;}.elementor-widget-image .widget-image-caption{color:var( --e-global-color-text );font-family:var( --e-global-typography-text-font-family ), Sans-serif;font-weight:var( --e-global-typography-text-font-weight );}.elementor-1480 .elementor-element.elementor-element-eacfdb2 img{width:60%;max-width:60%;transition-duration:0.4s;}.elementor-1480 .elementor-element.elementor-element-eacfdb2:hover img{filter:brightness( 100% ) contrast( 100% ) saturate( 100% ) blur( 0px ) hue-rotate( 0deg );}<\/style>\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1506 post-1506 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/13-300x133.png\" class=\"attachment-medium size-medium wp-image-1510\" alt=\"Unum logo representing Professional Dental&#039;s partnership with Unum for dental insurance in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/13-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/13.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Professional 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srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/15-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/15.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Professional Dental\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1507 post-1507 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" 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size-medium wp-image-1513\" alt=\"DMBA logo representing Professional Dental\u2019s trusted partnerships in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/11-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/11.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Professional Dental\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1479 post-1479 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/4-2-300x133.png\" class=\"attachment-medium size-medium wp-image-1470\" alt=\"MetLife logo representing Professional Dental&#039;s partnership with MetLife for reliable dental insurance services in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/4-2-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/4-2.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Professional Dental\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1478 post-1478 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div 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data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/2-4-300x133.png\" class=\"attachment-medium size-medium wp-image-1468\" alt=\"Cigna Dental logo, representing Professional Dental&#039;s partnership with Cigna for reliable dental insurance coverage in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/2-4-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/2-4.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Professional Dental\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1476 post-1476 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/10-300x133.png\" class=\"attachment-medium size-medium wp-image-1466\" alt=\"Aflac Dental logo, symbolizing Professional Dental&#039;s collaboration with Aflac for trusted dental insurance plans in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/10-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/10.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Professional Dental\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1475 post-1475 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/9-300x133.png\" class=\"attachment-medium size-medium wp-image-1465\" alt=\"Aetna Dental logo, representing Professional Dental\u2019s partnership with Aetna for reliable dental insurance coverage in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/9-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/9.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Professional Dental\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1474 post-1474 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/Untitled-design-2024-06-24T150736.993-300x133.png\" class=\"attachment-medium size-medium wp-image-1495\" alt=\"RELIANCE logo representing Professional Dental&#039;s collaboration with RELIANCE for dental insurance services in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/Untitled-design-2024-06-24T150736.993-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/Untitled-design-2024-06-24T150736.993.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Professional Dental\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1473 post-1473 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/7-300x133.png\" class=\"attachment-medium size-medium wp-image-1463\" alt=\"United Dental logo, showcasing Professional Dental\u2019s partnership for accessible and comprehensive dental insurance in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/7-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/7.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Professional Dental\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1472 post-1472 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/6-300x133.png\" class=\"attachment-medium size-medium wp-image-1462\" alt=\"Delta Dental logo, representing Professional Dental\u2019s partnership for high-quality dental care and insurance options in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/6-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/6.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Professional Dental\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1471 post-1471 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/5-1-300x133.png\" class=\"attachment-medium size-medium wp-image-1461\" alt=\"Guardian logo, representing Professional Dental\u2019s reliable dental insurance options for patients in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/5-1-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/5-1.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Professional Dental\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1460 post-1460 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/1-4-300x133.png\" class=\"attachment-medium size-medium wp-image-1467\" alt=\"Humana Dental logo, representing Professional Dental&#039;s partnership with Humana for dependable dental insurance coverage in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/1-4-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/1-4.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Professional Dental\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-d100d16 e-con-full e-flex e-con e-child\" data-id=\"d100d16\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div data-dce-title-color=\"#013A65\" class=\"elementor-element elementor-element-203088b elementor-widget__width-auto elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"203088b\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:100}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Not in the list? Chances are we accept it<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f3ff020 elementor-invisible elementor-widget elementor-widget-button\" data-id=\"f3ff020\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"#\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-long-arrow-alt-right\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M313.941 216H12c-6.627 0-12 5.373-12 12v56c0 6.627 5.373 12 12 12h301.941v46.059c0 21.382 25.851 32.09 40.971 16.971l86.059-86.059c9.373-9.373 9.373-24.569 0-33.941l-86.059-86.059c-15.119-15.119-40.971-4.411-40.971 16.971V216z\"><\/path><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Contact Us For More Information (801) 785 \u2013 8000<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-4c4a7f6 e-flex e-con-boxed e-con e-parent\" data-id=\"4c4a7f6\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div data-dce-background-image-url=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/Untitled-design-2024-06-19T221800.787-1024x427.jpg\" class=\"elementor-element elementor-element-d22b857 e-con-full e-flex elementor-invisible e-con e-child\" data-id=\"d22b857\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;default&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4c2a69a elementor-invisible elementor-widget elementor-widget-text-editor\" data-id=\"4c2a69a\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:100}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tNEWSLETTER\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f12254d elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"f12254d\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">Follow Our Newsletter To Stay Tuned\n<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-84a6cd9 elementor-button-align-stretch elementor-invisible elementor-widget elementor-widget-form\" data-id=\"84a6cd9\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;button_width&quot;:&quot;40&quot;,&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width_mobile&quot;:&quot;100&quot;,&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:250,&quot;step_type&quot;:&quot;progress_bar&quot;,&quot;dce_confirm_dialog_enabled&quot;:&quot;no&quot;,&quot;label_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;field_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\" aria-label=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"2044\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"84a6cd9\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"New Patient Form - Professional Dental\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"2044\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_5d9c7dc elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-email elementor-col-60 elementor-sm-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFull Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Full Name\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_e45e8a5 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8f15e7b elementor-col-60 elementor-sm-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8f15e7b\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPhone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8f15e7b]\" id=\"form-field-field_8f15e7b\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Phone Number\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_33be23f elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_e2175fc elementor-col-60 elementor-sm-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e2175fc\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEmail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_e2175fc]\" id=\"form-field-field_e2175fc\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Email\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_4ea4c12 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_71fb5be elementor-col-60 elementor-sm-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_71fb5be\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tLocation\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_71fb5be]\" id=\"form-field-field_71fb5be\" class=\"elementor-field-textual elementor-size-lg\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Nearest Location*\">Nearest Location*<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Centerville\">Centerville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Draper\">Draper<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eagle Mountain\">Eagle Mountain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Herriman\">Herriman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Layton\">Layton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lehi\">Lehi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Logan\">Logan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Orem\">Orem<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Payson\">Payson<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pleasant Grove\">Pleasant Grove<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Riverton\">Riverton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saratoga Springs\">Saratoga Springs<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Springville\">Springville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Jordan\">West Jordan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Valley\">West Valley<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-40 e-form__buttons elementor-sm-100\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-lg\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Subscribe<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-423b4a4 e-con-full e-flex elementor-invisible e-con e-child\" data-id=\"423b4a4\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;default&quot;,&quot;animation_delay&quot;:250}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-59afa91 elementor-widget elementor-widget-text-editor\" data-id=\"59afa91\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tOr follow us on social media\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-54ff9c9 elementor-widget elementor-widget-ucaddon_social_icons_glare_effect\" data-id=\"54ff9c9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"ucaddon_social_icons_glare_effect.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n<!-- start Social Icons Glare Effect -->\n\n<style>\/* widget: Social Icons Glare Effect *\/\n\n#uc_social_icons_glare_effect_elementor_54ff9c9 *{\n\n\tbox-sizing: border-box;\n}\n\n#uc_social_icons_glare_effect_elementor_54ff9c9{\n\tposition:relative;\n\twidth:100%;\n}\n\n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button {\n    box-shadow: 0 0 30px 0 rgba(0, 0, 0, 0.05);\n    display: inline-block;\n    opacity: 1;\n    overflow: hidden;\n    position: relative;\n    text-align: center;\n    transition: all 0.35s cubic-bezier(0.31, -0.105, 0.43, 1.59) 0s;\n    \n}\n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button::before {\n    content: \"\";\n    height: 100%;\n    left: 0%;\n    position: absolute;\n    top: 100%;\n    transition: all 0.35s;\n    width: 100%;\n}\n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button i {\n    transform: scale(0.8);\n    transition: all 0.35s cubic-bezier(0.31, -0.105, 0.43, 1.59) 0s;\n    vertical-align: middle;\n}\n\n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button:focus::before, \n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button:hover::before {\n    left: 0%;\n    top: 0%;\n}\n\n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button i {\n\tcolor:#000000;\n}\n\n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button:hover i {\n\tcolor:#ffffff;\n}\n\n<\/style>\n\n<div class=\"uc_stylish_social_buttons\" id=\"uc_social_icons_glare_effect_elementor_54ff9c9\"> \n    <!--uc_container_holder--> \n    <div class=\"uc_social-buttons\">\n    \t<a href=\"https:\/\/www.facebook.com\/ProfessionalDentalandOrtho\" class=\"uc_social-button\" target=\"_blank\" rel=\"noopener\"><i class=\"fab fa-facebook\"><\/i><\/a>\n<a href=\"https:\/\/twitter.com\/prodentalutok\" class=\"uc_social-button\" target=\"_blank\" rel=\"noopener\"><i class=\"fab fa-twitter\"><\/i><\/a>\n<a href=\"https:\/\/www.instagram.com\/professionaldentalut\/\" class=\"uc_social-button\" target=\"_blank\" rel=\"noopener\"><i class=\"fab fa-instagram\"><\/i><\/a>\n<a href=\"https:\/\/www.tiktok.com\/@professionaldentalut\" class=\"uc_social-button\" target=\"_blank\" rel=\"noopener\"><i class=\"fab fa-tiktok\"><\/i><\/a>\n<a href=\"https:\/\/www.linkedin.com\/company\/prodentalut\/\" class=\"uc_social-button\" target=\"_blank\" rel=\"noopener\"><i class=\"fab fa-linkedin-in\"><\/i><\/a>\n\n    <\/div>\n<\/div>\n<!-- end Social Icons Glare Effect -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div data-dce-background-overlay-color=\"#FD9191\" data-dce-background-image-url=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/Untitled-design-2024-06-19T221800.787-1024x427.jpg\" class=\"elementor-element elementor-element-cf02c78 e-con-full e-flex elementor-invisible e-con e-child\" data-id=\"cf02c78\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;default&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-3e203d4 e-con-full e-flex e-con e-child\" data-id=\"3e203d4\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a1194ea elementor-invisible elementor-widget elementor-widget-image\" data-id=\"a1194ea\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"512\" height=\"512\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/medical-kit.png\" class=\"attachment-large size-large wp-image-740\" alt=\"- Professional Dental\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/medical-kit.png 512w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/medical-kit-300x300.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/medical-kit-150x150.png 150w\" sizes=\"(max-width: 512px) 100vw, 512px\" title=\"- Professional Dental\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-0e93252 e-con-full e-flex e-con e-child\" data-id=\"0e93252\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-aaab9c0 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"aaab9c0\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Emergency phone line:<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-8bb6665 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"8bb6665\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"elementor-heading-title elementor-size-default\"><a href=\"tel:8017858000\">(801) 785 - 8000<\/a><\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>DIGITAL FORM Save Time By Completing The New Patient Form Online If you are a new patient, please fill out form below. Our office will have all the information when you come to your assigned clinic. Welcome to Professional Dental New Patient Form By submitting this form, you agree to share your personal, medical, and [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-2044","page","type-page","status-publish","hentry"],"office":null,"reviews":null,"user-image":null,"_links":{"self":[{"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/pages\/2044","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/comments?post=2044"}],"version-history":[{"count":46,"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/pages\/2044\/revisions"}],"predecessor-version":[{"id":70888,"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/pages\/2044\/revisions\/70888"}],"wp:attachment":[{"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/media?parent=2044"}],"curies":[{"name":"gracias","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}