{"id":1196,"date":"2022-12-16T16:16:48","date_gmt":"2022-12-16T16:16:48","guid":{"rendered":"https:\/\/backbayoralsurgery.com\/?page_id=1196"},"modified":"2023-01-09T08:30:33","modified_gmt":"2023-01-09T13:30:33","slug":"patient-intake-form","status":"publish","type":"page","link":"https:\/\/backbayoralsurgery.com\/patient-intake-form\/","title":{"rendered":"Patient intake form"},"content":{"rendered":"<section id=\"bt_bb_section6646890e7b1ac\" class=\"bt_bb_section bt_bb_layout_boxed_1200 bt_bb_vertical_align_top bt_bb_top_spacing_medium bt_bb_bottom_spacing_normal\"  data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_medium&quot;,&quot;xl&quot;:&quot;medium&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_normal&quot;,&quot;xl&quot;:&quot;normal&quot;}}\"><div class=\"bt_bb_port\"><div class=\"bt_bb_cell\"><div class=\"bt_bb_cell_inner\"><div class=\"bt_bb_row_wrapper\"><div  class=\"bt_bb_row\"  data-bt-override-class=\"{}\"><div  class=\"bt_bb_column col-xl-2 col-xs-12 col-sm-12 col-md-12 col-lg-2 bt_bb_align_left bt_bb_vertical_align_top bt_bb_animation_fade_in animate bt_bb_padding_normal bt_bb_animation_fade_in animate\"  data-width=\"2\" data-bt-override-class=\"{}\"><div class=\"bt_bb_column_content\"><div class=\"bt_bb_separator bt_bb_border_style_none bt_bb_bottom_spacing_normal\" data-bt-override-class=\"null\"><\/div><div class=\"bt_bb_column_highlight\"><\/div><\/div><\/div><div  class=\"bt_bb_column col-xl-8 col-xs-12 col-sm-12 col-md-12 col-lg-8 bt_bb_align_left bt_bb_vertical_align_middle bt_bb_animation_fade_in animate bt_bb_padding_normal bt_bb_animation_fade_in animate\"  data-width=\"8\" data-bt-override-class=\"{}\"><div class=\"bt_bb_column_content\"><header class=\"bt_bb_headline bt_bb_color_scheme_3 bt_bb_dash_none bt_bb_size_large bt_bb_align_inherit bt_bb_dash_type_none\" style=\"; --primary-color:#8491a0; --secondary-color:#191919;\" data-bt-override-class=\"{&quot;bt_bb_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_size_large&quot;,&quot;xl&quot;:&quot;large&quot;},&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_inherit&quot;,&quot;xl&quot;:&quot;inherit&quot;}}\"><h2 class=\"bt_bb_headline_tag\"><span class=\"bt_bb_headline_content\"><span>Patient intake form<\/span><\/span><\/h2><\/header><div class=\"bt_bb_separator bt_bb_border_style_none bt_bb_bottom_spacing_normal\" data-bt-override-class=\"null\"><\/div><div class=\"bt_bb_contact_form_7\"><div class=\"wpcf7 no-js\" id=\"wpcf7-f1195-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/1196#wpcf7-f1195-o1\" method=\"post\" class=\"wpcf7-form init cf7mls-no-moving-animation\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"1195\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.7.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1195-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:1195,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;group-care-physician&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;care-physician&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-taking-medication&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;taking-medication&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-other-reaction&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;other-reaction&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-other-condition-explain&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;other-disease&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-smoke&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;smoke&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-recreational-drugs&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;recreational-drugs&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-woman&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;gender&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Female&quot;}]},{&quot;then_field&quot;:&quot;group-dental-insurance&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-insurance&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<\/div>\n<div class=\"fieldset-cf7mls-wrapper\" data-transition-effects><fieldset class=\"fieldset-cf7mls cf7mls_current_fs\"><h3><strong>Part 1\/4: Patient information<\/strong>\n<\/h3>\n<div class=\"bt_bb_cf7_form\">\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First name*\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"m-i\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"M.I.\" value=\"\" type=\"text\" name=\"m-i\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last name*\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"birth-date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Birth Date\" value=\"\" type=\"text\" name=\"birth-date\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" max=\"120\" aria-invalid=\"false\" placeholder=\"Age\" value=\"\" type=\"number\" name=\"age\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"gender\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"gender\"><option value=\"\">Gender<\/option><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"height\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Height\" value=\"\" type=\"text\" name=\"height\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"weight\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Weight\" value=\"\" type=\"text\" name=\"weight\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"soc-sec-num\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Social Security Number*\" value=\"\" type=\"text\" name=\"soc-sec-num\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p><br \/>\n&nbsp;\n\t<\/p>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"street-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Street Address\" value=\"\" type=\"text\" name=\"street-address\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"city\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"State\" value=\"\" type=\"text\" name=\"state\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"zip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Zip\" value=\"\" type=\"text\" name=\"zip\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p><br \/>\n&nbsp;\n\t<\/p>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cellphone-number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Cellphone number*\" value=\"\" type=\"tel\" name=\"cellphone-number\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"work-phone-number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Work phone number\" value=\"\" type=\"tel\" name=\"work-phone-number\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"home-phone-number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Home phone number\" value=\"\" type=\"tel\" name=\"home-phone-number\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email Address*\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p><br \/>\n&nbsp;\n\t<\/p>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"occupation\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"School name or occupation\" value=\"\" type=\"text\" name=\"occupation\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"occupation-term\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"occupation-term\"><option value=\"Full time\">Full time<\/option><option value=\"Part time\">Part time<\/option><option value=\"Retired\">Retired<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"marrital-status\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"marrital-status\"><option value=\"\">Marrital status<\/option><option value=\"Married\">Married<\/option><option value=\"Divorced\">Divorced<\/option><option value=\"Separated\">Separated<\/option><option value=\"Widowed\">Widowed<\/option><option value=\"Single\">Single<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p><br \/>\n&nbsp;<br \/>\n<strong>In case of emergency<\/strong>\n\t<\/p>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Contact name*\" value=\"\" type=\"text\" name=\"emergency-contact-name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Contact phone number*\" value=\"\" type=\"tel\" name=\"emergency-contact-phone\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-street-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Street address\" value=\"\" type=\"text\" name=\"emergency-contact-street-address\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"emergency-contact-city\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"State\" value=\"\" type=\"text\" name=\"emergency-contact-state\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-zip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Zip\" value=\"\" type=\"text\" name=\"emergency-contact-zip\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<p><div class=\"cf7mls-btns\"><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-1\">Next<img src=\"https:\/\/backbayoralsurgery.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"\" data-lazy-src=\"https:\/\/backbayoralsurgery.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<h3><strong>Part 2\/4: Insurance information<\/strong>\n<\/h3>\n<div class=\"bt_bb_cf7_form\">\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p>Do you have dental insurance?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-insurance\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-insurance\" value=\"Yes\" checked=\"checked\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-insurance\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"group-dental-insurance\" data-orig_data_id=\"group-dental-insurance\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ins-sub-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Insurance subscriber&#039;s name*\" value=\"\" type=\"text\" name=\"ins-sub-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ins-sub-birth-date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of birth*\" value=\"\" type=\"text\" name=\"ins-sub-birth-date\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ins-sub-soc-sec-num\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Subscriber&#039;s Social Security Number*\" value=\"\" type=\"text\" name=\"ins-sub-soc-sec-num\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"relation-insured\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Relationship to insured*\" value=\"\" type=\"text\" name=\"relation-insured\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<p><br \/>\n&nbsp;\n\t\t<\/p>\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ins-sub-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Subscriber&#039;s Address\" value=\"\" type=\"text\" name=\"ins-sub-address\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ins-sub-city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"ins-sub-city\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ins-sub-state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"State\" value=\"\" type=\"text\" name=\"ins-sub-state\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ins-sub-zip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Zip\" value=\"\" type=\"text\" name=\"ins-sub-zip\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ins-sub-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Phone Number\" value=\"\" type=\"tel\" name=\"ins-sub-phone\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<p><br \/>\n&nbsp;\n\t\t<\/p>\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ins-sub-employer\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Employer\" value=\"\" type=\"text\" name=\"ins-sub-employer\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ins-sub-occupation\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Occupation\" value=\"\" type=\"text\" name=\"ins-sub-occupation\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"employer-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Address\" value=\"\" type=\"text\" name=\"employer-address\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"employer-city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"employer-city\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"employer-state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"State\" value=\"\" type=\"text\" name=\"employer-state\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-4\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"employer-zip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Zip\" value=\"\" type=\"text\" name=\"employer-zip\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<p><br \/>\n&nbsp;\n\t\t<\/p>\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dental-insurance-plan\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Dental Insurance Plan*\" value=\"\" type=\"text\" name=\"dental-insurance-plan\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dental-insurance-id\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Subscriber&#039;s Dental insurance ID*\" value=\"\" type=\"text\" name=\"dental-insurance-id\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"medical-insurance\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Medical Insurance*\" value=\"\" type=\"text\" name=\"medical-insurance\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"medical-insurance-id\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Subscriber&#039;s Medical Insurance ID*\" value=\"\" type=\"text\" name=\"medical-insurance-id\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<p><br \/>\n&nbsp;\n\t\t<\/p>\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"referring-dentist\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Referring dentist\" value=\"\" type=\"text\" name=\"referring-dentist\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"referring-physician\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Referring physician\" value=\"\" type=\"text\" name=\"referring-physician\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"referring-orthodontist\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Referring orthodontist\" value=\"\" type=\"text\" name=\"referring-orthodontist\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"reason-for-visit\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Reason for visit*\" value=\"\" type=\"text\" name=\"reason-for-visit\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"family-friends-patient\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Family\/Friends who have been patient&#039;s here\" value=\"\" type=\"text\" name=\"family-friends-patient\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<p><div class=\"cf7mls-btns\"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-2\">Back<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-2\">Next<img src=\"https:\/\/backbayoralsurgery.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"\" data-lazy-src=\"https:\/\/backbayoralsurgery.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<h3><strong>Part 3\/4: Health history<\/strong>\n<\/h3>\n<p>To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have and medication that you may be taking could have an important interrelationship with the care that you will be receiving.\n<\/p>\n<p>Please answer the following questions:\n<\/p>\n<div class=\"bt_bb_cf7_form\">\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p>1. Are you in good health?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"good-health\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"good-health\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"good-health\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p>2. Have there been any changes in your general health in the past year?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"change-general-health\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"change-general-health\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"change-general-health\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p>3. Are you under the care of a physician?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"care-physician\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"care-physician\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"care-physician\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"group-care-physician\" data-orig_data_id=\"group-care-physician\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-3\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"care-physician-condition\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"For what condition?*\" value=\"\" type=\"text\" name=\"care-physician-condition\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-3\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"physician-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name of physician*\" value=\"\" type=\"text\" name=\"physician-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-3\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"physician-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone*\" value=\"\" type=\"tel\" name=\"physician-phone\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-3\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"physician-date-last-visit\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of last visit*\" value=\"\" type=\"text\" name=\"physician-date-last-visit\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p>4. Have you had any illnesses, operation or have been hospitalizes in the past 5 years?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"illnesses-operation-hospitalizes\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"illnesses-operation-hospitalizes\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"illnesses-operation-hospitalizes\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p>5. Are you taking any medication(s) including non-prescription, homeopathic, natural remedies or vitamins?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"taking-medication\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"taking-medication\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"taking-medication\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"group-taking-medication\" data-orig_data_id=\"group-taking-medication\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n\t\t<div class=\"bt_bb_cf7_row\">\n\t\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"list-medication\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Please list*\" name=\"list-medication\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<p><strong>Pharmacy<\/strong>\n\t<\/p>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Pharmacy name\" value=\"\" type=\"text\" name=\"pharmacy-name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-street-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Street Address\" value=\"\" type=\"text\" name=\"pharmacy-street-address\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-3\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"pharmacy-city\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-3\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"State\" value=\"\" type=\"text\" name=\"pharmacy-state\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-3\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-zip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Zip\" value=\"\" type=\"text\" name=\"pharmacy-zip\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-3\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Phone number\" value=\"\" type=\"tel\" name=\"pharmacy-phone\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>&nbsp;\n\t<\/p>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p>6. Do you or have you ever had any of the following diseases or problems?\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p>a. Heart trouble, heart attack, angina, high blood pressure, stroke, arteriosclerosis or any other heart condition<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"heart-condition\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"heart-condition\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"heart-condition\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_element\">\n\t\t<p>b. Rheumatic heart disease<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"rheumatic-heart\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"rheumatic-heart\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"rheumatic-heart\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>c. Damaged heart valves, artificial valves or heart murmur<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"damaged-heart\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"damaged-heart\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"damaged-heart\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>d. Chest pain upon exertion<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"chest-pain\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"chest-pain\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"chest-pain\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>e. Shortness of breath after mild exercise<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"shortness-of-breath\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"shortness-of-breath\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"shortness-of-breath\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>f. Do your ankles swell<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ankles-swell\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"ankles-swell\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"ankles-swell\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>g. Allergies or hay fever<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-hay-fever\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"allergies-hay-fever\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"allergies-hay-fever\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>h. Sinus trouble<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sinus-trouble\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"sinus-trouble\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"sinus-trouble\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>i. Asthma<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"asthma\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"asthma\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"asthma\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>j. Fainting spells or seizures<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fainting-seizures\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"fainting-seizures\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"fainting-seizures\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>k. Diabetes<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"diabetes\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"diabetes\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"diabetes\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>l. Hepatitis, jaundice or liver disease<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hepatitis-jaundice-liver\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"hepatitis-jaundice-liver\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"hepatitis-jaundice-liver\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>m. Frequent or recurring mouth sours<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mouth-sours\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mouth-sours\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mouth-sours\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>n. Thyroid problems<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"thyroid-problems\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"thyroid-problems\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"thyroid-problems\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>o. Respiratory problems, emphysema, bronchitis, etc.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"respiratory-problems\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"respiratory-problems\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"respiratory-problems\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>p. Arthritis or painful, swollen joints including jaw joint (TMJ)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"arthritis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"arthritis\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"arthritis\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>q. Stomach ulcer or hyperacidity<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"stomach-ulcer\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"stomach-ulcer\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"stomach-ulcer\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>r. Kidney trouble<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kidney-trouble\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"kidney-trouble\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"kidney-trouble\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>s. Tuberculosis<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tuberculosis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"tuberculosis\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"tuberculosis\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>t. Persistent swollen neck glands<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"swollen-neck-glands\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"swollen-neck-glands\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"swollen-neck-glands\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>u. Epilepsy or neurological disorder<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"epilepsy\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"epilepsy\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"epilepsy\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>v. Any disease, drug or transplant operation that has depressed your immune system<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"immune-system\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"immune-system\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"immune-system\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>w. Have you ever had treatment for a tumor or growth<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tumor\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"tumor\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"tumor\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>x. Cancer<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cancer\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"cancer\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"cancer\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>y. Have you ever had abnormal bleeding<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"abnormal-bleeding\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"abnormal-bleeding\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"abnormal-bleeding\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>z. Have you ever required a blood transfusion<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"blood-transfusion\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"blood-transfusion\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"blood-transfusion\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<p>&nbsp;\n<\/p>\n<div class=\"bt_bb_cf7_row\">\n\t<div class=\"bt_bb_cf7_element\">\n\t\t<p>7. Are you allergic to or have you had a reaction to:\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"bt_bb_cf7_row\">\n\t<div class=\"bt_bb_cf7_element\">\n\t\t<p>a. Local anesthetics<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"local-anesthetics\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"local-anesthetics\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"local-anesthetics\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>b. Penicillin or antibiotics<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"penicillin\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"penicillin\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"penicillin\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>c. Sulfa drugs<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sulfa-drugs\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"sulfa-drugs\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"sulfa-drugs\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>d. Aspirin<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"aspirin\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"aspirin\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"aspirin\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>e. Barbiturates or sleeping pills<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sleeping-pills\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"sleeping-pills\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"sleeping-pills\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>f. Codeine or other narcotics<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"codeine-narcotics\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"codeine-narcotics\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"codeine-narcotics\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>g. Iodine<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"iodine\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"iodine\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"iodine\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"bt_bb_cf7_element\">\n\t<p>h. Other<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-reaction\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"other-reaction\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"other-reaction\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"group-other-reaction\" data-orig_data_id=\"group-other-reaction\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"other-reaction-specify\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Please specify*\" value=\"\" type=\"text\" name=\"other-reaction-specify\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<p>&nbsp;\n<\/p>\n<div class=\"bt_bb_cf7_row\">\n\t<div class=\"bt_bb_cf7_element\">\n\t\t<p>8. Do you have any other condition or disease you think the doctor should know about?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-disease\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"other-disease\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"other-disease\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div data-id=\"group-other-condition-explain\" data-orig_data_id=\"group-other-condition-explain\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"other-condition-explain\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Please explain*\" name=\"other-condition-explain\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"bt_bb_cf7_row\">\n\t<div class=\"bt_bb_cf7_element\">\n\t\t<p>9. Do you smoke?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"smoke\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"smoke\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"smoke\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div data-id=\"group-smoke\" data-orig_data_id=\"group-smoke\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"how-much-smoke\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"How much?*\" value=\"\" type=\"text\" name=\"how-much-smoke\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"bt_bb_cf7_row\">\n\t<div class=\"bt_bb_cf7_element\">\n\t\t<p>10. Do you use recreational drugs?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"recreational-drugs\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"recreational-drugs\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"recreational-drugs\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div data-id=\"group-recreational-drugs\" data-orig_data_id=\"group-recreational-drugs\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"often-recreational-drugs\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"What and how often?*\" name=\"often-recreational-drugs\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"bt_bb_cf7_row\">\n\t<div class=\"bt_bb_cf7_element\">\n\t\t<p>11. Are you wearing contact lenses?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"contact-lenses\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"contact-lenses\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"contact-lenses\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"bt_bb_cf7_row\">\n\t<div class=\"bt_bb_cf7_element\">\n\t\t<p>12. Are you wearing removable dental appliances?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-appliances\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-appliances\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-appliances\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"bt_bb_cf7_row\">\n\t<div class=\"bt_bb_cf7_element\">\n\t\t<p>13. Do you wish to talk to the doctor privately about anything?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"talk-to-the-doctor\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"talk-to-the-doctor\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"talk-to-the-doctor\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div data-id=\"group-woman\" data-orig_data_id=\"group-woman\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n\t<p><br \/>\n&nbsp;<br \/>\n<strong>If you are a woman<\/strong>\n\t<\/p>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p>14. Are you pregnant or trying to become pregnant?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pregnant\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"pregnant\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"pregnant\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p>15. Do you have problems associated with your menstrual period?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"problem-menstrual-period\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"problem-menstrual-period\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"problem-menstrual-period\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p>16. Are you nursing?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nursing\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"nursing\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"nursing\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p>17. Are you taking any form of oral contraceptive?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"oral-contraceptive\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"oral-contraceptive\" value=\"Yes\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"oral-contraceptive\" value=\"No\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<p><div class=\"cf7mls-btns\"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-3\">Back<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-3\">Next<img src=\"https:\/\/backbayoralsurgery.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"\" data-lazy-src=\"https:\/\/backbayoralsurgery.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<h3><strong>Part 4\/4: Policies and consent<\/strong>\n<\/h3>\n<p><strong>Cellphone use policy<\/strong><br \/>\nI provide consent to Back Bay Oral and Maxillofacial Surgery dental practice to use my cellphone number to contact me regarding treatment, insurance and my account with the method chosen below. I understand that I can withdraw my consent at any time.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cellphone-policy\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"cellphone-policy[]\" value=\"I consent\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">I consent<\/span><\/span><\/span><\/span>\n<\/p>\n<div class=\"bt_bb_cf7_form\">\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t<p>Choose the best way to contact you*\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"bt_bb_cf7_element bt_bb_column col-xl-6\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cellphone-policy-choice\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"cellphone-policy-choice\"><option value=\"Call\">Call<\/option><option value=\"Text\">Text<\/option><option value=\"Call and text\">Call and text<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<p>&nbsp;<br \/>\n<strong>Notice of privacy policy<\/strong><br \/>\nI acknowledge that I have received a copy of Back Bay Oral & Maxillofacial Surgery's Notice of Privacy Policy. I have been given the opportunity to ask any questions regarding this notice.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"privacy-policy\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"privacy-policy[]\" value=\"I confirm\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">I confirm<\/span><\/span><\/span><\/span>\n<\/p>\n<p>&nbsp;<br \/>\n<strong>Confirmation<\/strong><br \/>\nI certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any member of the staff responsible for any errors or omissions that I may have made in the completion of this form.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"certify\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"certify[]\" value=\"I certify\" tabindex=\"\" \/><span class=\"wpcf7-list-item-label\">I certify<\/span><\/span><\/span><\/span>\n<\/p>\n<div class=\"bt_bb_cf7_form\">\n\t<div class=\"bt_bb_cf7_row\">\n\t\t<div class=\"bt_bb_cf7_element\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"medical-history-update\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Medical history update, relevant information or any questions\" name=\"medical-history-update\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p><input class=\"wpcf7-form-control has-spinner wpcf7-submit\" type=\"submit\" value=\"Submit form\" \/>\n\t<\/p>\n<\/div>\n<p><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-4\">Back<\/button><button type=\"button\" style=\"display: none;\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-4\"><img src=\"https:\/\/backbayoralsurgery.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"\" data-lazy-src=\"https:\/\/backbayoralsurgery.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button>\n<\/p><\/fieldset><\/div><p style=\"display: none !important;\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"201\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div><\/div><div class=\"bt_bb_separator bt_bb_border_style_none bt_bb_bottom_spacing_normal\" data-bt-override-class=\"null\"><\/div><div  class=\"bt_bb_text\" ><p>We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager in advance depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and\/or medical insurance, we will be glad to fill out the proper forms, but please complete the identifying information on this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge.<\/p>\n<\/div><div class=\"bt_bb_separator bt_bb_border_style_none bt_bb_bottom_spacing_normal\" data-bt-override-class=\"null\"><\/div><div class=\"bt_bb_column_highlight\"><\/div><\/div><\/div><div  class=\"bt_bb_column col-xl-2 col-xs-12 col-sm-12 col-md-12 col-lg-2 bt_bb_align_left bt_bb_vertical_align_top bt_bb_padding_normal\"  data-width=\"2\" data-bt-override-class=\"{}\"><div class=\"bt_bb_column_content\"><div class=\"bt_bb_separator bt_bb_border_style_none bt_bb_bottom_spacing_normal\" data-bt-override-class=\"null\"><\/div><div class=\"bt_bb_column_highlight\"><\/div><\/div><\/div><\/div><\/div><\/div><!-- cell_inner --><\/div><!-- cell --><\/div><!-- port --><\/section>","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":1284,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v19.14 - 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