New Patient Form

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{{field.Name.replace('dd/mm/yyyy','') + (field.GetFieldSetting('Required') ? '': '')}} {{field.Name.toLowerCase().includes('date') ? '(MM/DD/YYYY)' :''}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}} Please enter a {{field.Name.replace('dd/mm/yyyy','')}}.

{{field.Name + (field.GetFieldSetting('Required') ? '': '')}} (MM/DD/YYYY) {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}} Please enter a {{field.Name}}.

{{field.Name + (field.GetFieldSetting('Required') ? '': '')}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
{{field.Name}} Please enter a {{field.Name}}. (success)

{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.Name}}.

{{field.Name}} (MM/DD/YYYY){{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a valid {{field.Name}} (MM/DD/YYYY). (success)

{{field.Name}} (MM/DD/YYYY){{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a valid {{field.Name}} (MM/DD/YYYY). (success)

{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a valid {{field.Name}}. (success)

{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.Name}}. (success)
{{field.SubField1}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.SubField1}}. (success)

{{field.SubField2}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.SubField2}}. (success)
{{field.SubField3}} (MM/DD/YYYY){{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a valid {{field.SubField3}} (MM/DD/YYYY). (success)
{{field.SubField4}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
{{Gender}}
Please enter a {{field.SubField4}}.

Male

Female

Other

Them/They

Zee/Zer
(success)
{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.Name}}. (success)

{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.Name}}. (success)

{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.Name}}. (success)

{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.Name}}. (success)

{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.Name}}. (success)

{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.Name}}. (success)

{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.Name}}. (success)
{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
{{State}}
Please enter a {{field.Name}}.
- Alabama (AL)
- Alaska (AK)
- Arizona (AZ)
- Arkansas (AR)
- California (CA)
- Colorado (CO)
- Connecticut (CT)
- Delaware (DE)
- Florida (FL)
- Georgia (GA)
- Hawaii (HI)
- Idaho (ID)
- Illinois (IL)
- Indiana (IN)
- Iowa (IA)
- Kansas (KS)
- Kentucky (KY)
- Louisiana (LA)
- Maine (ME)
- Maryland (MD)
- Massachusetts (MA)
- Michigan (MI)
- Minnesota (MN)
- Mississippi (MS)
- Missouri (MO)
- Montana (MT)
- Nebraska (NE)
- Nevada (NV)
- New Hampshire (NH)
- New Jersey (NJ)
- New Mexico (NM)
- New York (NY)
- North Carolina (NC)
- North Dakota (ND)
- Ohio (OH)
- Oklahoma (OK)
- Oregon (OR)
- Pennsylvania (PA)
- Rhode Island (RI)
- South Carolina (SC)
- South Dakota (SD)
- Tennessee (TN)
- Texas (TX)
- Utah (UT)
- Vermont (VT)
- Virginia (VA)
- Washington (WA)
- West Virginia (WV)
- Wisconsin (WI)
- Wyoming (WY)
(success)
{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
{{OptOutSMS}}
Please enter a {{field.Name}}.
- Yes "I do" consent to text communication
- I "do not" consent to text communication
(success)
{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.Name}}. (success)

* {{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}

{{field.fieldType}}

{{field.fieldType}}

{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}

{{field.fieldExplainer}}
{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}} Select an Individual
- {{indi.FieldTxtValue}}
- Other
{{field.OtherType}}
{{field.fieldExplainer}}
{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}} Select an Individual
- {{indi.FieldTxtValue}}
- Other
{{field.OtherType}}
{{field.fieldExplainer}}
{{field.Name}}
{{field.fieldType}} *
{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
{{Gender}}
Please enter a {{field.Name}}.
- Male
- Female
- Other
- Them/They
- Zee/Zer
(success)
{{field.Name}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
{{MartialStatus}}
Please enter a {{field.Name}}.
- Single
- Married
- Child
- Widowed
- Divorced
(success)
{{field.Other}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}

Yes

No
{{field.Name}}
Select an Individual

{{indi.FieldTxtValue}}

Other

{{field.fieldType}}
{{field.fieldType}}
{{field.Name}}

{{indi.FieldTxtValue}}

{{field.fieldType}}
{{field.fieldType}}
{{field.Other}}

Yes

No

DK
{{field.Name}}
Select an Individual

{{indi.FieldTxtValue}}

Other

{{field.fieldType}}
{{field.fieldType}}
{{field.Name}}

{{indi.FieldTxtValue}}

{{field.fieldType}}
{{field.fieldType}}
{{field.Other}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}

Yes

No
{{field.Name}}
Select an Individual

{{indi.FieldTxtValue}}

Other

{{field.fieldType}}
{{field.fieldType}}
{{field.Name}}

{{indi.FieldTxtValue}}

{{field.fieldType}}
{{field.fieldType}}
{{field.Other}}

Yes

No
{{field.fieldType}}
Select an Individual

No Known Allergies

Acetaminophen

Acrylic

Anesthetics

Aspirin

Barbiturates

Codeine

Erythromycin

Fluoride

Ibuprofen

Iodine

Local anesthetic

Metals

Penicillin

Sedatives

Sulfa

Tetracycline

Latex

{{txtMulti}}

Other

{{field.OtherType}}
{{field.fieldType}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Select an Individual

No Known Allergies

Acetaminophen

Acrylic

Anesthetics

Aspirin

Barbiturates

Codeine

Erythromycin

Fluoride

Ibuprofen

Iodine

Local anesthetic

Metals

Penicillin

Sedatives

Sulfa

Tetracycline

Latex

{{txtMulti}}

Other

{{field.OtherType}}
{{field.Other}}

Yes

No
{{field.fieldType}}
Select an Individual

No Known Allergies

Acetaminophen

Acrylic

Anesthetics

Aspirin

Barbiturates

Codeine

Erythromycin

Fluoride

Ibuprofen

Iodine

Local anesthetic

Metals

Penicillin

Sedatives

Sulfa

Tetracycline

Latex

{{txtMulti}}

Other

{{field.OtherType}}
{{field.Other}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}

Yes

No
{{field.fieldType}}
Select an Individual

No Known Medical Conditions

Acid reflux (GERD)

ADD

ADHD

Alcoholism/Chemical dependency

Allergies

Anemia

Anxiety

Arthirits

Artifical Joints

Asthma

Autism

Autoimmune Disease

Back problems

Blood Disease/Disorder

Blood Transfusion

Bone Disease

Bulimia

Cancer/Chemotherapy

Cold/Sores

Convulsions/Seizures

COPD

Currently Pregnant

Cystic Fibrosis

Dementia

Depression

Diabetes

Dry Mouth

Epilepsy/Seizures/Convulsions

Excessive Bleeding

Fainting/Dizziness

Gallbladder Disease

Genetic Disorders

Glaucoma

Head Injuries

Hearing Impaired

Heart Attack

Heart Disease

Heart Murmur

Heart Surgery

Hepatitis B

Hepatitis C

High Blood Pressure

High Cholesterol

Hip or Joint Replacement

History of Alcohol Abuse

History of Drug Abuse

HIV

HPV

Immune Disorder

Insomnia

Jaundice

Kidney Dialysis

Kidney Disease

Latex Sensitivity

Low Blood Pressure

Migraines

Mitral Valve Prolapse

Multiple Sclerosis

Myasthenia Gravis

Neck and Back Problems

Osteoporosis

Pacemaker

Pre-Med Prior to Treatment

Psoriasis

Psychiatric Care

PTSD

Radiation Treatment

Respiratory Problems/Disorders

Rheumatric Fever

Sinus Problems

Sleep Apnea

Snoring

Stomach Ulcers

Stomach/GI Disorders

Stroke

Systemic lupus erythematosus

Thyroid Disease/Problems

TMJ/TMD

Tobacco, Vape, Dip usage(past or current usage)

Tuberculosis

Tumors or Growths

Vasculitis

Venereal Disease

Other

{{field.OtherType}}
{{field.fieldType}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Select an Individual

No Known Medical Conditions

Acid reflux (GERD)

ADD

ADHD

Alcoholism/Chemical dependency

Allergies

Anemia

Anxiety

Arthirits

Artifical Joints

Asthma

Autism

Autoimmune Disease

Back problems

Blood Disease/Disorder

Blood Transfusion

Bone Disease

Bulimia

Cancer/Chemotherapy

Cold/Sores

Convulsions/Seizures

COPD

Currently Pregnant

Cystic Fibrosis

Dementia

Depression

Diabetes

Dry Mouth

Epilepsy/Seizures/Convulsions

Excessive Bleeding

Fainting/Dizziness

Gallbladder Disease

Genetic Disorders

Glaucoma

Head Injuries

Hearing Impaired

Heart Attack

Heart Disease

Heart Murmur

Heart Surgery

Hepatitis B

Hepatitis C

High Blood Pressure

High Cholesterol

Hip or Joint Replacement

History of Alcohol Abuse

History of Drug Abuse

HIV

HPV

Immune Disorder

Insomnia

Jaundice

Kidney Dialysis

Kidney Disease

Latex Sensitivity

Low Blood Pressure

Migraines

Mitral Valve Prolapse

Multiple Sclerosis

Myasthenia Gravis

Neck and Back Problems

Osteoporosis

Pacemaker

Pre-Med Prior to Treatment

Psoriasis

Psychiatric Care

PTSD

Radiation Treatment

Respiratory Problems/Disorders

Rheumatric Fever

Sinus Problems

Sleep Apnea

Snoring

Stomach Ulcers

Stomach/GI Disorders

Stroke

Systemic lupus erythematosus

Thyroid Disease/Problems

TMJ/TMD

Tobacco, Vape, Dip usage(past or current usage)

Tuberculosis

Tumors or Growths

Vasculitis

Venereal Disease

Other

{{field.OtherType}}
{{field.Other}}

Yes

No
{{field.fieldType}}
Select an Individual

No Known Medical Conditions

Acid reflux (GERD)

ADD

ADHD

Alcoholism/Chemical dependency

Allergies

Anemia

Anxiety

Arthirits

Artifical Joints

Asthma

Autism

Autoimmune Disease

Back problems

Blood Disease/Disorder

Blood Transfusion

Bone Disease

Bulimia

Cancer/Chemotherapy

Cold/Sores

Convulsions/Seizures

COPD

Currently Pregnant

Cystic Fibrosis

Dementia

Depression

Diabetes

Dry Mouth

Epilepsy/Seizures/Convulsions

Excessive Bleeding

Fainting/Dizziness

Gallbladder Disease

Genetic Disorders

Glaucoma

Head Injuries

Hearing Impaired

Heart Attack

Heart Disease

Heart Murmur

Heart Surgery

Hepatitis B

Hepatitis C

High Blood Pressure

High Cholesterol

Hip or Joint Replacement

History of Alcohol Abuse

History of Drug Abuse

HIV

HPV

Immune Disorder

Insomnia

Jaundice

Kidney Dialysis

Kidney Disease

Latex Sensitivity

Low Blood Pressure

Migraines

Mitral Valve Prolapse

Multiple Sclerosis

Myasthenia Gravis

Neck and Back Problems

Osteoporosis

Pacemaker

Pre-Med Prior to Treatment

Psoriasis

Psychiatric Care

PTSD

Radiation Treatment

Respiratory Problems/Disorders

Rheumatric Fever

Sinus Problems

Sleep Apnea

Snoring

Stomach Ulcers

Stomach/GI Disorders

Stroke

Systemic lupus erythematosus

Thyroid Disease/Problems

TMJ/TMD

Tobacco, Vape, Dip usage(past or current usage)

Tuberculosis

Tumors or Growths

Vasculitis

Venereal Disease

Other

{{field.OtherType}}
{{field.Other}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}

Yes

No
{{field.fieldType}}
Select an Individual

No Known Medications

Acid Reflux

ADHD

Mixed amphetamine salts (Adderall)

Dexmethylphenidate (Focalin) Methylphenidate (Ritalin)

Lisdexamfetamine (Vyvanse) Guanfacine (Intuniv)

Clonidine (Kapvay) Atomexetine (Strattera)

Allergy

Claritin

Flonase

Singular

Bentolin

Zyrtech

Asthma

Albuterol Fluticasone

(Flovent) Montelukast (Singulair)

Antibiotics

Amoxicillin

Clindamycin

Coxycycline

Doxycycline

Tetracycline

Zithromax

Antidepressant

Adderall

Ambien (Zolpidem)

Celexa (Citalproam)

Cymbalta (Duloxentine)

Effexor (Venlafaxine)

Lexapro (Escitalopram)

Neurontin (Gabapentin)

Oleptro (Trazodone)

Prozac (Fluoxetine)

Xanax (Alprazolam)

Wellbutrin (Buproprion)

Zolof (Sertraline)

Arthritis

Ibuprofen (Advil, Motrin)

Naproxen (Aleve)

Celecoxib (Celebrex)

Diclofenac (Voltaren)

Methotrexate

Hydroxychloroquine (Plaquenil)

Sulfasalazine (Azulfidine)

Leflunomide (Arava)

Adalimumab (Humira)

Etanercept (Enbrel)

Infliximab (Remicade)

Certolizumab pegol (Cimzia)

Golimumab (Simponi)

Prednisone

Dexamethasone

Methylprednisolone

Acetaminophen (Tylenol)

Tramadol (Ultram)

Blood Pressure

Avapro (Irbesartan)

Coreg (Carvedilol)

Coumadin (Warfarin)

Crestor (Rosuvastatin)

Klor-Con (Potassium Chloride)

Lasic (Furosemide)

Lipitor (Atorvastatin Calcium)

Lopressor (Metoprolol)

Losartan (Cozaar)

Metformin (Gluophage)

Microzide (Hydrochlorothiazide)

Plavix (Clopidogrel)

Pravachol (Pravastatin)

Prinivil (Lisinopril)

Tenormin (Atenolol)

Toprol XL (Metoprolol)

Tricor (Fenofibrate)

Zestoretic (Lisinopril)

Zocor (Simvastatin)

Cholesterol

Avapro (Irbesartan)

Coreg (Carvedilol)

Coumadin (Warfarin)

Crestor (Rosuvastatin)

Klor-Con (Potassium Chloride)

Lasic (Furosemide)

Lipitor (Atorvastatin Calcium)

Lopressor (Metoprolol)

Losartan (Cozaar)

Metformin (Gluophage)

Microzide (Hydrochlorothiazide)

Plavix (Clopidogrel)

Pravachol (Pravastatin)

Prinivil (Lisinopril)

Tenormin (Atenolol)

Toprol XL (Metoprolol)

Tricor (Fenofibrate)

Zestoretic (Lisinopril)

Zocor (Simvastatin)

Diabetes

Avapro (Irbesartan)

Coreg (Carvedilol)

Coumadin (Warfarin)

Crestor (Rosuvastatin)

Dapagliflozin

Exenatide

Glipizide

Klor-Con (Potassium Chloride)

Lasic (Furosemide)

Lipitor (Atorvastatin Calcium)

Lopressor (Metoprolol)

Losartan (Cozaar)

Metformin (Gluophage)

Microzide (Hydrochlorothiazide)

Pioglitazone

Plavix (Clopidogrel)

Pravachol (Pravastatin)

Prinivil (Lisinopril)

Sitaglitptin

Tenormin (Atenolol)

Toprol XL (Metoprolol)

Tricor (Fenofibrate)

Zestoretic (Lisinopril)

Zocor (Simvastatin)

Osteoporosis

Pain Medication

Aspirin

Codeine

Ibprofen

Tramadol

Thyroid

Other

{{field.OtherType}}
{{field.fieldType}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Select an Individual

No Known Medications

Acid Reflux

ADHD

Mixed amphetamine salts (Adderall)

Dexmethylphenidate (Focalin) Methylphenidate (Ritalin)

Lisdexamfetamine (Vyvanse) Guanfacine (Intuniv)

Clonidine (Kapvay) Atomexetine (Strattera)

Allergy

Claritin

Flonase

Singular

Bentolin

Zyrtech

Asthma

Albuterol Fluticasone

(Flovent) Montelukast (Singulair)

Antibiotics

Amoxicillin

Clindamycin

Coxycycline

Doxycycline

Tetracycline

Zithromax

Antidepressant

Adderall

Ambien (Zolpidem)

Celexa (Citalproam)

Cymbalta (Duloxentine)

Effexor (Venlafaxine)

Lexapro (Escitalopram)

Neurontin (Gabapentin)

Oleptro (Trazodone)

Prozac (Fluoxetine)

Xanax (Alprazolam)

Wellbutrin (Buproprion)

Zolof (Sertraline)

Arthritis

Ibuprofen (Advil, Motrin)

Naproxen (Aleve)

Celecoxib (Celebrex)

Diclofenac (Voltaren)

Methotrexate

Hydroxychloroquine (Plaquenil)

Sulfasalazine (Azulfidine)

Leflunomide (Arava)

Adalimumab (Humira)

Etanercept (Enbrel)

Infliximab (Remicade)

Certolizumab pegol (Cimzia)

Golimumab (Simponi)

Prednisone

Dexamethasone

Methylprednisolone

Acetaminophen (Tylenol)

Tramadol (Ultram)

Blood Pressure

Avapro (Irbesartan)

Coreg (Carvedilol)

Coumadin (Warfarin)

Crestor (Rosuvastatin)

Klor-Con (Potassium Chloride)

Lasic (Furosemide)

Lipitor (Atorvastatin Calcium)

Lopressor (Metoprolol)

Losartan (Cozaar)

Metformin (Gluophage)

Microzide (Hydrochlorothiazide)

Plavix (Clopidogrel)

Pravachol (Pravastatin)

Prinivil (Lisinopril)

Tenormin (Atenolol)

Toprol XL (Metoprolol)

Tricor (Fenofibrate)

Zestoretic (Lisinopril)

Zocor (Simvastatin)

Cholesterol

Avapro (Irbesartan)

Coreg (Carvedilol)

Coumadin (Warfarin)

Crestor (Rosuvastatin)

Klor-Con (Potassium Chloride)

Lasic (Furosemide)

Lipitor (Atorvastatin Calcium)

Lopressor (Metoprolol)

Losartan (Cozaar)

Metformin (Gluophage)

Microzide (Hydrochlorothiazide)

Plavix (Clopidogrel)

Pravachol (Pravastatin)

Prinivil (Lisinopril)

Tenormin (Atenolol)

Toprol XL (Metoprolol)

Tricor (Fenofibrate)

Zestoretic (Lisinopril)

Zocor (Simvastatin)

Diabetes

Avapro (Irbesartan)

Coreg (Carvedilol)

Coumadin (Warfarin)

Crestor (Rosuvastatin)

Dapagliflozin

Exenatide

Glipizide

Klor-Con (Potassium Chloride)

Lasic (Furosemide)

Lipitor (Atorvastatin Calcium)

Lopressor (Metoprolol)

Losartan (Cozaar)

Metformin (Gluophage)

Microzide (Hydrochlorothiazide)

Pioglitazone

Plavix (Clopidogrel)

Pravachol (Pravastatin)

Prinivil (Lisinopril)

Sitaglitptin

Tenormin (Atenolol)

Toprol XL (Metoprolol)

Tricor (Fenofibrate)

Zestoretic (Lisinopril)

Zocor (Simvastatin)

Osteoporosis

Pain Medication

Aspirin

Codeine

Ibprofen

Tramadol

Thyroid

Other

{{field.OtherType}}
{{field.Other}}

Yes

No
{{field.fieldType}}
Select an Individual

No Known Medications

Acid Reflux

ADHD

Mixed amphetamine salts (Adderall)

Dexmethylphenidate (Focalin) Methylphenidate (Ritalin)

Lisdexamfetamine (Vyvanse) Guanfacine (Intuniv)

Clonidine (Kapvay) Atomexetine (Strattera)

Allergy

Claritin

Flonase

Singular

Bentolin

Zyrtech

Asthma

Albuterol Fluticasone

(Flovent) Montelukast (Singulair)

Antibiotics

Amoxicillin

Clindamycin

Coxycycline

Doxycycline

Tetracycline

Zithromax

Antidepressant

Adderall

Ambien (Zolpidem)

Celexa (Citalproam)

Cymbalta (Duloxentine)

Effexor (Venlafaxine)

Lexapro (Escitalopram)

Neurontin (Gabapentin)

Oleptro (Trazodone)

Prozac (Fluoxetine)

Xanax (Alprazolam)

Wellbutrin (Buproprion)

Zolof (Sertraline)

Arthritis

Ibuprofen (Advil, Motrin)

Naproxen (Aleve)

Celecoxib (Celebrex)

Diclofenac (Voltaren)

Methotrexate

Hydroxychloroquine (Plaquenil)

Sulfasalazine (Azulfidine)

Leflunomide (Arava)

Adalimumab (Humira)

Etanercept (Enbrel)

Infliximab (Remicade)

Certolizumab pegol (Cimzia)

Golimumab (Simponi)

Prednisone

Dexamethasone

Methylprednisolone

Acetaminophen (Tylenol)

Tramadol (Ultram)

Blood Pressure

Avapro (Irbesartan)

Coreg (Carvedilol)

Coumadin (Warfarin)

Crestor (Rosuvastatin)

Klor-Con (Potassium Chloride)

Lasic (Furosemide)

Lipitor (Atorvastatin Calcium)

Lopressor (Metoprolol)

Losartan (Cozaar)

Metformin (Gluophage)

Microzide (Hydrochlorothiazide)

Plavix (Clopidogrel)

Pravachol (Pravastatin)

Prinivil (Lisinopril)

Tenormin (Atenolol)

Toprol XL (Metoprolol)

Tricor (Fenofibrate)

Zestoretic (Lisinopril)

Zocor (Simvastatin)

Cholesterol

Avapro (Irbesartan)

Coreg (Carvedilol)

Coumadin (Warfarin)

Crestor (Rosuvastatin)

Klor-Con (Potassium Chloride)

Lasic (Furosemide)

Lipitor (Atorvastatin Calcium)

Lopressor (Metoprolol)

Losartan (Cozaar)

Metformin (Gluophage)

Microzide (Hydrochlorothiazide)

Plavix (Clopidogrel)

Pravachol (Pravastatin)

Prinivil (Lisinopril)

Tenormin (Atenolol)

Toprol XL (Metoprolol)

Tricor (Fenofibrate)

Zestoretic (Lisinopril)

Zocor (Simvastatin)

Diabetes

Avapro (Irbesartan)

Coreg (Carvedilol)

Coumadin (Warfarin)

Crestor (Rosuvastatin)

Dapagliflozin

Exenatide

Glipizide

Klor-Con (Potassium Chloride)

Lasic (Furosemide)

Lipitor (Atorvastatin Calcium)

Lopressor (Metoprolol)

Losartan (Cozaar)

Metformin (Gluophage)

Microzide (Hydrochlorothiazide)

Pioglitazone

Plavix (Clopidogrel)

Pravachol (Pravastatin)

Prinivil (Lisinopril)

Sitaglitptin

Tenormin (Atenolol)

Toprol XL (Metoprolol)

Tricor (Fenofibrate)

Zestoretic (Lisinopril)

Zocor (Simvastatin)

Osteoporosis

Pain Medication

Aspirin

Codeine

Ibprofen

Tramadol

Thyroid

{{indi.FieldTxtValue}}

Other

{{field.OtherType}}
{{field.fieldType}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}} Select an Individual
- {{indi.FieldTxtValue}}
{{field.OtherType}}
{{field.fieldExplainer}}
{{field.Name}}

Yes

No
{{field.SubField1}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.SubField1}}. (success)
{{field.SubField2}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.SubField2}}. (success)
{{field.SubField3}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
{{State}}
Please enter a {{field.SubField3}}.

Alabama (AL)

Alaska (AK)

Arizona (AZ)

Arkansas (AR)

California (CA)

Colorado (CO)

Connecticut (CT)

Delaware (DE)

Florida (FL)

Georgia (GA)

Hawaii (HI)

Idaho (ID)

Illinois (IL)

Indiana (IN)

Iowa (IA)

Kansas (KS)

Kentucky (KY)

Louisiana (LA)

Maine (ME)

Maryland (MD)

Massachusetts (MA)

Michigan (MI)

Minnesota (MN)

Mississippi (MS)

Missouri (MO)

Montana (MT)

Nebraska (NE)

Nevada (NV)

New Hampshire (NH)

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New York (NY)

North Carolina (NC)

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Ohio (OH)

Oklahoma (OK)

Oregon (OR)

Pennsylvania (PA)

Rhode Island (RI)

South Carolina (SC)

South Dakota (SD)

Tennessee (TN)

Texas (TX)

Utah (UT)

Vermont (VT)

Virginia (VA)

Washington (WA)

West Virginia (WV)

Wisconsin (WI)

Wyoming (WY)

(success)
{{field.SubField4}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.SubField4}}. (success)
{{field.Name}}

Yes

No

{{field.SubField1}}

Yes

No

{{field.SubField2}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.SubField2}}. (success)

{{field.SubField3}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.SubField3}}. (success)

{{field.SubField4}} (MM/DD/YYYY){{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a valid {{field.SubField4}} (MM/DD/YYYY). (success)

{{field.SubField5}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.SubField5}}. (success)

{{field.SubField6}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.SubField6}}. (success)

{{field.extra}}

{{field.SubField7}}
Please enter a {{field.SubField7}}. (success)

{{field.SubField8}}
Please enter a {{field.SubField8}}. (success)

{{field.Name}}

Yes

No

{{field.SubField1}}

Yes

No

{{field.SubField2}} {{(field.Settings[0].Options[1].Name=='Required Subscriber Name' && field.Settings[0].Options[1].Value == true ? '*' : '')}}
Please enter a {{field.SubField2}}. (success)

{{field.SubField3}} {{(field.Settings[0].Options[2].Name=='Required Subscriber SSN' && field.Settings[0].Options[2].Value == true ? '*' : '')}}
Please enter a {{field.SubField3}}. (success)

{{field.SubField4}} (MM/DD/YYYY){{(field.Settings[0].Options[3].Name=='Required Subscriber Date of Birth' && field.Settings[0].Options[3].Value == true ? '*' : '')}}
Please enter a valid {{field.SubField4}} (MM/DD/YYYY). (success)

{{field.SubField5}} {{(field.Settings[0].Options[4].Name=='Required Name of Insurance Company' && field.Settings[0].Options[4].Value == true ? '*' : '')}}
Please enter a {{field.SubField5}}. (success)

{{field.SubField11}} {{(field.Settings[0].Options[5].Name=='Required Phone Number of Insurance Company' && field.Settings[0].Options[5].Value == true ? '*' : '')}}
Please enter a {{field.SubField11}}. (success)

{{field.SubField12}} {{(field.Settings[0].Options[6].Name=='Required Address of Insurance Company' && field.Settings[0].Options[6].Value == true ? '*' : '')}}
Please enter a {{field.SubField12}}. (success)

{{field.SubField6}} {{(field.Settings[0].Options[7].Name=='Required Subscriber ID' && field.Settings[0].Options[7].Value == true ? '*' : '')}}
Please enter a {{field.SubField6}}. (success)

{{field.extra}}

{{field.SubField7}}
Please enter a {{field.SubField7}}. (success)

{{field.SubField8}}
Please enter a {{field.SubField8}}. (success)

{{field.SubField9}}

Re-capture photo

{{field.SubField10}}

Re-capture photo

{{field.Name}}

Yes

No

{{field.SubField1}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.SubField1}}. (success)

{{field.SubField2}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field.SubField2}}. (success)

{{field.Name.replace('dd/mm/yyyy','') + (field.GetFieldSetting('Required') ? '': '')}} {{field.Name.toLowerCase().includes('date') ? '(MM/DD/YYYY)' :''}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}} Please enter a {{field.Name.replace('dd/mm/yyyy','')}}.

Patient Photo {{(field.Settings[0].Options[6].Name=='Required' && field.Settings[0].Options[6].Value == true ? '*' : '')}}

Take a selfie or upload a headshot of your self.

Re-capture photo
{{field.Other}}
- {{mp.DiseaseName}} {{(mp.Value == true ? '*' : '')}}
  
  Yes No
Add unlisted medical problems here (comma seprated)
{{field.Name}} {{(field.Settings[0].Options[5].Name=='Required' && field.Settings[0].Options[5].Value == true ? '*' : '')}}

{{field.Subtitle}}

Re-capture photo
{{field.Other}}

Yes

No
{{field.fieldType}}
Select an Individual

No Known Allergies

Acetaminophen

Acrylic

Anesthetics

Aspirin

Barbiturates

Codeine

Erythromycin

Fluoride

Ibuprofen

Iodine

Local anesthetic

Metals

Penicillin

Sedatives

Sulfa

Tetracycline

Latex

Other

{{field.OtherType}}
{{field.Other}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}

Yes

No
{{field.fieldType}}
Select an Individual

No Known Medical Conditions

Acid reflux (GERD)

ADD

ADHD

Alcoholism/Chemical dependency

Allergies

Anemia

Anxiety

Arthirits

Artifical Joints

Asthma

Autism

Autoimmune Disease

Back problems

Blood Disease/Disorder

Blood Transfusion

Bone Disease

Bulimia

Cancer/Chemotherapy

Cold/Sores

Convulsions/Seizures

COPD

Currently Pregnant

Cystic Fibrosis

Dementia

Depression

Diabetes

Dry Mouth

Epilepsy/Seizures/Convulsions

Excessive Bleeding

Fainting/Dizziness

Gallbladder Disease

Genetic Disorders

Glaucoma

Head Injuries

Hearing Impaired

Heart Attack

Heart Disease

Heart Murmur

Heart Surgery

Hepatitis B

Hepatitis C

High Blood Pressure

High Cholesterol

Hip or Joint Replacement

History of Alcohol Abuse

History of Drug Abuse

HIV

HPV

Immune Disorder

Insomnia

Jaundice

Kidney Dialysis

Kidney Disease

Latex Sensitivity

Low Blood Pressure

Migraines

Mitral Valve Prolapse

Multiple Sclerosis

Myasthenia Gravis

Neck and Back Problems

Osteoporosis

Pacemaker

Pre-Med Prior to Treatment

Psoriasis

Psychiatric Care

PTSD

Radiation Treatment

Respiratory Problems/Disorders

Rheumatric Fever

Sinus Problems

Sleep Apnea

Snoring

Stomach Ulcers

Stomach/GI Disorders

Stroke

Systemic lupus erythematosus

Thyroid Disease/Problems

TMJ/TMD

Tobacco, Vape, Dip usage(past or current usage)

Tuberculosis

Tumors or Growths

Vasculitis

Venereal Disease

{{indi.FieldTxtValue}}

Other

{{field.OtherType}}

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{{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}} Please enter a {{field[2]}}.

{{field[2]}}
{{field[3]}} Please enter a {{field[2]}}. (success)

{{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field[2]}}.

{{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a valid {{field[2]}} (MM/DD/YYYY). (success)

{{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field[2]}}. (success)

{{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field[2]}}. (success)

{{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field[2]}}. (success)

{{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field[2]}}. (success)

{{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field[2]}}. (success)

{{field[2]}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field[2]}}. (success)

{{field[2]}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field[2]}}. (success)

{{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field[2]}}. (success)
{{field[2]}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
{{field[3]}}
Please enter a {{field[2]}}.
- Alabama (AL)
- Alaska (AK)
- Arizona (AZ)
- Arkansas (AR)
- California (CA)
- Colorado (CO)
- Connecticut (CT)
- Delaware (DE)
- Florida (FL)
- Georgia (GA)
- Hawaii (HI)
- Idaho (ID)
- Illinois (IL)
- Indiana (IN)
- Iowa (IA)
- Kansas (KS)
- Kentucky (KY)
- Louisiana (LA)
- Maine (ME)
- Maryland (MD)
- Massachusetts (MA)
- Michigan (MI)
- Minnesota (MN)
- Mississippi (MS)
- Missouri (MO)
- Montana (MT)
- Nebraska (NE)
- Nevada (NV)
- New Hampshire (NH)
- New Jersey (NJ)
- New Mexico (NM)
- New York (NY)
- North Carolina (NC)
- North Dakota (ND)
- Ohio (OH)
- Oklahoma (OK)
- Oregon (OR)
- Pennsylvania (PA)
- Rhode Island (RI)
- South Carolina (SC)
- South Dakota (SD)
- Tennessee (TN)
- Texas (TX)
- Utah (UT)
- Vermont (VT)
- Virginia (VA)
- Washington (WA)
- West Virginia (WV)
- Wisconsin (WI)
- Wyoming (WY)
(success)
{{field[2]}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
Please enter a {{field[2]}}. (success)

* {{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}

{{field[2]}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}

{{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
{{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}} Select an Individual
{{field[2]}} {{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}} Select an Individual
{{field[2]}}
* {{field[3]}}
{{field[2]}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
{{field[3]}}
Please enter a {{field[2]}}.
- Male
- Female
(success)
{{field[2]}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}}
{{field[3]}}
Please enter a {{field[2]}}.
- Single
- Married
- Child
- Widowed
- Divorced
(success)
{{field.Name.replace('dd/mm/yyyy','') + (field.GetFieldSetting('Required') ? '': '')}} {{field.Name.toLowerCase().includes('date') ? '(MM/DD/YYYY)' :''}}{{(field.Settings[0].Options[0].Name=='Required' && field.Settings[0].Options[0].Value == true ? '*' : '')}} Please enter a {{field.Name.replace('dd/mm/yyyy','')}}.

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Foxcreek Family Dental LLC to use this information to properly provide dental services to you.

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Medication Required

select a medication to continue.

Patient Photo {{(field.Settings[0].Options[6].Name=='Required' && field.Settings[0].Options[6].Value == true ? '*' : '')}}

Take a selfie or upload a headshot of your self.

Take a photo or view library

{{field.Name}} {{(field.Settings[0].Options[5].Name=='Required' && field.Settings[0].Options[5].Value == true ? '*' : '')}}

{{field.Subtitle}}

Take a photo or view library

Select a Language

Select a Language

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Medication Required

{{Gender}}

{{State}}

{{OptOutSMS}}

{{Gender}}

{{MartialStatus}}

{{State}}

{{field.SubField9}}

Click here to take a picture or browse

{{field.SubField10}}

Click here to take a picture or browse

Patient Photo {{(field.Settings[0].Options[6].Name=='Required' && field.Settings[0].Options[6].Value == true ? '*' : '')}}

Take a selfie or upload a headshot of your self.

Take a photo or view library

Add unlisted medical problems here (comma seprated)

{{field.Name}} {{(field.Settings[0].Options[5].Name=='Required' && field.Settings[0].Options[5].Value == true ? '*' : '')}}

{{field.Subtitle}}

Take a photo or view library

Select a Language

{{field[3]}}

{{field[3]}}

{{field[3]}}

Select a Language

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Select a Photo

Take a Photo