{"id":717,"date":"2025-03-15T17:12:55","date_gmt":"2025-03-15T17:12:55","guid":{"rendered":"https:\/\/deerfieldpt.com\/?page_id=717"},"modified":"2025-05-15T15:48:37","modified_gmt":"2025-05-15T15:48:37","slug":"intake-form","status":"publish","type":"page","link":"https:\/\/deerfieldpt.com\/?page_id=717","title":{"rendered":"Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"717\" class=\"elementor elementor-717\">\n\t\t\t\t<div class=\"elementor-element elementor-element-43ba06e e-flex e-con-boxed e-con e-parent\" data-id=\"43ba06e\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-e9fc001 e-con-full e-flex e-con e-child\" data-id=\"e9fc001\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-b798c63 e-con-full e-flex e-con e-child\" data-id=\"b798c63\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a55a258 elementor-widget elementor-widget-wpforms\" data-id=\"a55a258\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<style id=\"wpforms-css-vars-elementor-widget-a55a258\">\n\t\t\t\t.elementor-widget-wpforms.elementor-element-a55a258 {\n\t\t\t\t--wpforms-field-text-color: #B72704;\n--wpforms-label-color: #B72704;\n--wpforms-label-sublabel-color: #B72704;\n--wpforms-field-size-input-height: 31px;\n--wpforms-field-size-input-spacing: 10px;\n--wpforms-field-size-font-size: 14px;\n--wpforms-field-size-line-height: 17px;\n--wpforms-field-size-padding-h: 9px;\n--wpforms-field-size-checkbox-size: 14px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 0.75;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-696\"><form id=\"wpforms-form-696\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"696\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F717\" data-token=\"1476ee767206e31069e50621703ab393\" data-token-time=\"1790149093\"><div class=\"wpforms-head-container\"><div class=\"wpforms-title\">Patient Info and Medical History Form<\/div><\/div><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-696-field_5-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Patient&#039;s Legal name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-696-field_5\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][5][first]\" aria-errormessage=\"wpforms-696-field_5-error\" required><label for=\"wpforms-696-field_5\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-696-field_5-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][5][last]\" aria-errormessage=\"wpforms-696-field_5-last-error\" required><label for=\"wpforms-696-field_5-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-696-field_24-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">Gender <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-696-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-696-field_24_1\" name=\"wpforms[fields][24]\" value=\"Male\" aria-errormessage=\"wpforms-696-field_24_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_24_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-696-field_24_2\" name=\"wpforms[fields][24]\" value=\"Female\" aria-errormessage=\"wpforms-696-field_24_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_24_2\">Female<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_7\">Address<\/label><input type=\"text\" id=\"wpforms-696-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-696-field_7-error\" ><\/div><div id=\"wpforms-696-field_8-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_8\">City<\/label><input type=\"text\" id=\"wpforms-696-field_8\" class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-696-field_8-error\" ><\/div><div id=\"wpforms-696-field_21-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_21\">State<\/label><input type=\"text\" id=\"wpforms-696-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-696-field_21-error\" ><\/div><div id=\"wpforms-696-field_9-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_9\">ZIP CODE<\/label><input type=\"text\" id=\"wpforms-696-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-696-field_9-error\" ><\/div><div id=\"wpforms-696-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_3\">Name of the person referring <\/label><input type=\"text\" id=\"wpforms-696-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-696-field_3-error\" ><\/div><div id=\"wpforms-696-field_2-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"2\"><fieldset><legend class=\"wpforms-field-label\">How did you hear about Quality Physical Therapy and Rehabilitation <\/legend><ul id=\"wpforms-696-field_2\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_2_1\" name=\"wpforms[fields][2][]\" value=\"Friend\" aria-errormessage=\"wpforms-696-field_2_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_2_1\">Friend<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_2_2\" name=\"wpforms[fields][2][]\" value=\"Newspaper\" aria-errormessage=\"wpforms-696-field_2_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_2_2\">Newspaper<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_2_3\" name=\"wpforms[fields][2][]\" value=\"MD\" aria-errormessage=\"wpforms-696-field_2_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_2_3\">MD<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_2_4\" name=\"wpforms[fields][2][]\" value=\"Web\" aria-errormessage=\"wpforms-696-field_2_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_2_4\">Web<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_2_5\" name=\"wpforms[fields][2][]\" value=\"Other\" aria-errormessage=\"wpforms-696-field_2_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_2_5\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_11-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_11\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-696-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" spellcheck=\"false\" aria-errormessage=\"wpforms-696-field_11-error\" required><\/div><div id=\"wpforms-696-field_6-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_6\">Phone Number<\/label><input type=\"number\" id=\"wpforms-696-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" step=\"any\" aria-errormessage=\"wpforms-696-field_6-error\" ><\/div><div id=\"wpforms-696-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_18\">Date of Birth<\/label><input type=\"text\" id=\"wpforms-696-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" placeholder=\"Month-Date-Year\" aria-errormessage=\"wpforms-696-field_18-error\" ><\/div><div id=\"wpforms-696-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_10\">Last 4 digits of SSN<\/label><input type=\"text\" id=\"wpforms-696-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-696-field_10-error\" ><\/div><div id=\"wpforms-696-field_12-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Notification<\/legend><ul id=\"wpforms-696-field_12\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-696-field_12_1\" name=\"wpforms[fields][12]\" value=\"Email\" aria-errormessage=\"wpforms-696-field_12_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_12_1\">Email<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-696-field_12_2\" name=\"wpforms[fields][12]\" value=\"Phone- Call\" aria-errormessage=\"wpforms-696-field_12_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_12_2\">Phone- Call<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-696-field_12_3\" name=\"wpforms[fields][12]\" value=\"Phone Text\" aria-errormessage=\"wpforms-696-field_12_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_12_3\">Phone Text<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_19-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"19\"><fieldset><legend class=\"wpforms-field-label\">May we speak to your spouse about your medical Condition <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-696-field_19\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-696-field_19_1\" name=\"wpforms[fields][19]\" value=\"Not Married\" aria-errormessage=\"wpforms-696-field_19_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_19_1\">Not Married<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-696-field_19_2\" name=\"wpforms[fields][19]\" value=\"Yes\" aria-errormessage=\"wpforms-696-field_19_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_19_2\">Yes<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-696-field_19_3\" name=\"wpforms[fields][19]\" value=\"No\" aria-errormessage=\"wpforms-696-field_19_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_19_3\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_14\">Spouse Name<\/label><input type=\"text\" id=\"wpforms-696-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-696-field_14-error\" ><\/div><div id=\"wpforms-696-field_17-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_17\">Spouse Number<\/label><input type=\"number\" id=\"wpforms-696-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" step=\"any\" aria-errormessage=\"wpforms-696-field_17-error\" ><\/div><div id=\"wpforms-696-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_23\">Who else may we speak to concerning your medical condition?<\/label><input type=\"text\" id=\"wpforms-696-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" placeholder=\"Person Name\" aria-errormessage=\"wpforms-696-field_23-error\" ><\/div><div id=\"wpforms-696-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_25\">Phone Number<\/label><input type=\"text\" id=\"wpforms-696-field_25\" class=\"wpforms-field-medium\" name=\"wpforms[fields][25]\" aria-errormessage=\"wpforms-696-field_25-error\" ><\/div><div id=\"wpforms-696-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_26\">Employer<\/label><input type=\"text\" id=\"wpforms-696-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-696-field_26-error\" ><\/div><div id=\"wpforms-696-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_29\">Occupation<\/label><input type=\"text\" id=\"wpforms-696-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" aria-errormessage=\"wpforms-696-field_29-error\" ><\/div><div id=\"wpforms-696-field_27-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_27\">Address <\/label><input type=\"text\" id=\"wpforms-696-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\" aria-errormessage=\"wpforms-696-field_27-error\" ><\/div><div id=\"wpforms-696-field_28-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_28\">City\/ZIP\/State<\/label><input type=\"text\" id=\"wpforms-696-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-696-field_28-error\" ><\/div><div id=\"wpforms-696-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_30\">Diagnosis <\/label><input type=\"text\" id=\"wpforms-696-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" aria-errormessage=\"wpforms-696-field_30-error\" ><\/div><div id=\"wpforms-696-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_32\">Referring Physician&#039;s Name<\/label><input type=\"text\" id=\"wpforms-696-field_32\" class=\"wpforms-field-medium\" name=\"wpforms[fields][32]\" aria-errormessage=\"wpforms-696-field_32-error\" ><\/div><div id=\"wpforms-696-field_34-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_34\">Physician Address<\/label><textarea id=\"wpforms-696-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" placeholder=\"Please include ZIP,State and city\" aria-errormessage=\"wpforms-696-field_34-error\" ><\/textarea><\/div><div id=\"wpforms-696-field_35-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_35\">Physician \/ Office Phone Number<\/label><input type=\"text\" id=\"wpforms-696-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\" aria-errormessage=\"wpforms-696-field_35-error\" ><\/div><div id=\"wpforms-696-field_36-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_36\">Single Line Text<\/label><input type=\"text\" id=\"wpforms-696-field_36\" class=\"wpforms-field-medium\" name=\"wpforms[fields][36]\" aria-errormessage=\"wpforms-696-field_36-error\" ><\/div><div id=\"wpforms-696-field_38-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"38\"><fieldset><legend class=\"wpforms-field-label\">Insurance Type <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-696-field_38\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_38_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][38][]\" value=\"Private\" aria-errormessage=\"wpforms-696-field_38_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_38_1\">Private<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_38_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][38][]\" value=\"Workers Comp\" aria-errormessage=\"wpforms-696-field_38_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_38_2\">Workers Comp<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_38_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][38][]\" value=\"Auto\" aria-errormessage=\"wpforms-696-field_38_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_38_3\">Auto<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_38_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][38][]\" value=\"Medicare\" aria-errormessage=\"wpforms-696-field_38_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_38_4\">Medicare<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_38_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][38][]\" value=\"Other\" aria-errormessage=\"wpforms-696-field_38_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_38_5\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_39-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_39\">If injury is due to accident, DATE OF INJURY <\/label><input type=\"text\" id=\"wpforms-696-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" aria-errormessage=\"wpforms-696-field_39-error\" aria-describedby=\"wpforms-696-field_39-description\" ><div id=\"wpforms-696-field_39-description\" class=\"wpforms-field-description\">MM\/DD\/YYYY<\/div><\/div><div id=\"wpforms-696-field_40-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_40\">CLAIM ID<\/label><input type=\"text\" id=\"wpforms-696-field_40\" class=\"wpforms-field-medium\" name=\"wpforms[fields][40]\" aria-errormessage=\"wpforms-696-field_40-error\" ><\/div><div id=\"wpforms-696-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_42\">Adjustor Handling claim<\/label><input type=\"text\" id=\"wpforms-696-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" aria-errormessage=\"wpforms-696-field_42-error\" ><\/div><div id=\"wpforms-696-field_43-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_43\">Adjustor Phone<\/label><input type=\"text\" id=\"wpforms-696-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-696-field_43-error\" ><\/div><div id=\"wpforms-696-field_44-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_44\">Insurance Company Name<\/label><input type=\"text\" id=\"wpforms-696-field_44\" class=\"wpforms-field-medium\" name=\"wpforms[fields][44]\" aria-errormessage=\"wpforms-696-field_44-error\" ><\/div><div id=\"wpforms-696-field_45-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_45\">Insured Name:<\/label><input type=\"text\" id=\"wpforms-696-field_45\" class=\"wpforms-field-medium\" name=\"wpforms[fields][45]\" aria-errormessage=\"wpforms-696-field_45-error\" ><\/div><div id=\"wpforms-696-field_46-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_46\">Relationship to Patient <\/label><input type=\"text\" id=\"wpforms-696-field_46\" class=\"wpforms-field-medium\" name=\"wpforms[fields][46]\" aria-errormessage=\"wpforms-696-field_46-error\" ><\/div><div id=\"wpforms-696-field_47-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_47\">Members ID #<\/label><input type=\"text\" id=\"wpforms-696-field_47\" class=\"wpforms-field-medium\" name=\"wpforms[fields][47]\" aria-errormessage=\"wpforms-696-field_47-error\" ><\/div><div id=\"wpforms-696-field_48-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_48\">Group #<\/label><input type=\"text\" id=\"wpforms-696-field_48\" class=\"wpforms-field-medium\" name=\"wpforms[fields][48]\" aria-errormessage=\"wpforms-696-field_48-error\" ><\/div><div id=\"wpforms-696-field_49-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_49\">Phone Number<\/label><input type=\"text\" id=\"wpforms-696-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-696-field_49-error\" ><\/div><div id=\"wpforms-696-field_60-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"60\"><fieldset><legend class=\"wpforms-field-label\">PATIENT MEDICAL INFORMATION<\/legend><ul id=\"wpforms-696-field_60\"><li class=\"choice-3 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-696-field_60_3\" name=\"wpforms[fields][60][]\" value=\"Name\" aria-errormessage=\"wpforms-696-field_60_3-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_60_3\">Name<\/label><\/li><li class=\"choice-5 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-696-field_60_5\" name=\"wpforms[fields][60][]\" value=\"AGE\" aria-errormessage=\"wpforms-696-field_60_5-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_60_5\">AGE<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_59-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_59\">Patient Name<\/label><input type=\"text\" id=\"wpforms-696-field_59\" class=\"wpforms-field-medium\" name=\"wpforms[fields][59]\" aria-errormessage=\"wpforms-696-field_59-error\" ><\/div><div id=\"wpforms-696-field_61-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_61\">Patient Age<\/label><input type=\"text\" id=\"wpforms-696-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\" aria-errormessage=\"wpforms-696-field_61-error\" ><\/div><div id=\"wpforms-696-field_76-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"76\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_76\">Patient Height <\/label><input type=\"text\" id=\"wpforms-696-field_76\" class=\"wpforms-field-medium\" name=\"wpforms[fields][76]\" aria-errormessage=\"wpforms-696-field_76-error\" ><\/div><div id=\"wpforms-696-field_77-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_77\">Patient Weight <\/label><input type=\"text\" id=\"wpforms-696-field_77\" class=\"wpforms-field-medium\" name=\"wpforms[fields][77]\" aria-errormessage=\"wpforms-696-field_77-error\" ><\/div><div id=\"wpforms-696-field_62-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_62\">Referring Physician<\/label><input type=\"text\" id=\"wpforms-696-field_62\" class=\"wpforms-field-medium\" name=\"wpforms[fields][62]\" aria-errormessage=\"wpforms-696-field_62-error\" ><\/div><div id=\"wpforms-696-field_63-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_63\">Primary Care Physician<\/label><input type=\"text\" id=\"wpforms-696-field_63\" class=\"wpforms-field-medium\" name=\"wpforms[fields][63]\" aria-errormessage=\"wpforms-696-field_63-error\" ><\/div><div id=\"wpforms-696-field_64-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_64\">Problems to be Treated<\/label><input type=\"text\" id=\"wpforms-696-field_64\" class=\"wpforms-field-large\" name=\"wpforms[fields][64]\" aria-errormessage=\"wpforms-696-field_64-error\" ><\/div><div id=\"wpforms-696-field_65-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"65\"><fieldset><legend class=\"wpforms-field-label\">Have you had treatment for this problem before?<\/legend><ul id=\"wpforms-696-field_65\"><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_65_3\" name=\"wpforms[fields][65][]\" value=\"Yes\" aria-errormessage=\"wpforms-696-field_65_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_65_3\">Yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_65_5\" name=\"wpforms[fields][65][]\" value=\"No\" aria-errormessage=\"wpforms-696-field_65_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_65_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_66-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_66\">If YES, state where and when<\/label><input type=\"text\" id=\"wpforms-696-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\" placeholder=\"Where, When(MM\/DD\/YYY)\" aria-errormessage=\"wpforms-696-field_66-error\" ><\/div><div id=\"wpforms-696-field_67-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"67\"><fieldset><legend class=\"wpforms-field-label\">CHECK ALL THAT APPLY<\/legend><ul id=\"wpforms-696-field_67\"><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_3\" name=\"wpforms[fields][67][]\" value=\"Allergies\" aria-errormessage=\"wpforms-696-field_67_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_3\">Allergies<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_5\" name=\"wpforms[fields][67][]\" value=\"Anemia\" aria-errormessage=\"wpforms-696-field_67_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_5\">Anemia<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_21\" name=\"wpforms[fields][67][]\" value=\"Anxiety\" aria-errormessage=\"wpforms-696-field_67_21-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_21\">Anxiety<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_20\" name=\"wpforms[fields][67][]\" value=\"Arthritis\" aria-errormessage=\"wpforms-696-field_67_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_20\">Arthritis<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_19\" name=\"wpforms[fields][67][]\" value=\"Asthma\" aria-errormessage=\"wpforms-696-field_67_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_19\">Asthma<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_18\" name=\"wpforms[fields][67][]\" value=\"Auto Immune Disorder\" aria-errormessage=\"wpforms-696-field_67_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_18\">Auto Immune Disorder<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_17\" name=\"wpforms[fields][67][]\" value=\"Cancer\" aria-errormessage=\"wpforms-696-field_67_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_17\">Cancer<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_16\" name=\"wpforms[fields][67][]\" value=\"Cardiac Conditions\" aria-errormessage=\"wpforms-696-field_67_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_16\">Cardiac Conditions<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_15\" name=\"wpforms[fields][67][]\" value=\"Cardiac Pacemaker\" aria-errormessage=\"wpforms-696-field_67_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_15\">Cardiac Pacemaker<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_14\" name=\"wpforms[fields][67][]\" value=\"Chemical Dependency\" aria-errormessage=\"wpforms-696-field_67_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_14\">Chemical Dependency<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_13\" name=\"wpforms[fields][67][]\" value=\"Circulation Problems\" aria-errormessage=\"wpforms-696-field_67_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_13\">Circulation Problems<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_12\" name=\"wpforms[fields][67][]\" value=\"Currently Pregnant\" aria-errormessage=\"wpforms-696-field_67_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_12\">Currently Pregnant<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_11\" name=\"wpforms[fields][67][]\" value=\"Depression\" aria-errormessage=\"wpforms-696-field_67_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_11\">Depression<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_10\" name=\"wpforms[fields][67][]\" value=\"Diabetes\" aria-errormessage=\"wpforms-696-field_67_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_10\">Diabetes<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_9\" name=\"wpforms[fields][67][]\" value=\"Dizzy Spells\" aria-errormessage=\"wpforms-696-field_67_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_9\">Dizzy Spells<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_8\" name=\"wpforms[fields][67][]\" value=\"Emphysema\/Bronchitis\" aria-errormessage=\"wpforms-696-field_67_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_8\">Emphysema\/Bronchitis<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_7\" name=\"wpforms[fields][67][]\" value=\"Fibromyalgia\" aria-errormessage=\"wpforms-696-field_67_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_7\">Fibromyalgia<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_6\" name=\"wpforms[fields][67][]\" value=\"Fractures\" aria-errormessage=\"wpforms-696-field_67_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_6\">Fractures<\/label><\/li><li class=\"choice-31 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_31\" name=\"wpforms[fields][67][]\" value=\"Gallbladder Problems\" aria-errormessage=\"wpforms-696-field_67_31-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_31\">Gallbladder Problems<\/label><\/li><li class=\"choice-30 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_30\" name=\"wpforms[fields][67][]\" value=\"Headaches\" aria-errormessage=\"wpforms-696-field_67_30-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_30\">Headaches<\/label><\/li><li class=\"choice-29 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_29\" name=\"wpforms[fields][67][]\" value=\"Hearing Impairment\" aria-errormessage=\"wpforms-696-field_67_29-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_29\">Hearing Impairment<\/label><\/li><li class=\"choice-28 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_28\" name=\"wpforms[fields][67][]\" value=\"Hepatitis\" aria-errormessage=\"wpforms-696-field_67_28-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_28\">Hepatitis<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_27\" name=\"wpforms[fields][67][]\" value=\"High Cholesterol\" aria-errormessage=\"wpforms-696-field_67_27-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_27\">High Cholesterol<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_26\" name=\"wpforms[fields][67][]\" value=\"High\/Low blood pressure\" aria-errormessage=\"wpforms-696-field_67_26-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_26\">High\/Low blood pressure<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_25\" name=\"wpforms[fields][67][]\" value=\"HIV\/AIDS\" aria-errormessage=\"wpforms-696-field_67_25-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_25\">HIV\/AIDS<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_24\" name=\"wpforms[fields][67][]\" value=\"Incontinence\" aria-errormessage=\"wpforms-696-field_67_24-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_24\">Incontinence<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_23\" name=\"wpforms[fields][67][]\" value=\"Kidney problems\" aria-errormessage=\"wpforms-696-field_67_23-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_23\">Kidney problems<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_22\" name=\"wpforms[fields][67][]\" value=\"Metal Implants\" aria-errormessage=\"wpforms-696-field_67_22-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_22\">Metal Implants<\/label><\/li><li class=\"choice-37 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_37\" name=\"wpforms[fields][67][]\" value=\"MRSA\" aria-errormessage=\"wpforms-696-field_67_37-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_37\">MRSA<\/label><\/li><li class=\"choice-36 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_36\" name=\"wpforms[fields][67][]\" value=\"Multiple Sclerosis\" aria-errormessage=\"wpforms-696-field_67_36-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_36\">Multiple Sclerosis<\/label><\/li><li class=\"choice-35 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_35\" name=\"wpforms[fields][67][]\" value=\"Muscular Disease\" aria-errormessage=\"wpforms-696-field_67_35-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_35\">Muscular Disease<\/label><\/li><li class=\"choice-34 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_34\" name=\"wpforms[fields][67][]\" value=\"Osteoporosis\" aria-errormessage=\"wpforms-696-field_67_34-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_34\">Osteoporosis<\/label><\/li><li class=\"choice-33 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_33\" name=\"wpforms[fields][67][]\" value=\"Parkinson&#039;s\" aria-errormessage=\"wpforms-696-field_67_33-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_33\">Parkinson's<\/label><\/li><li class=\"choice-32 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_32\" name=\"wpforms[fields][67][]\" value=\"Rheumatoid Arthritis\" aria-errormessage=\"wpforms-696-field_67_32-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_32\">Rheumatoid Arthritis<\/label><\/li><li class=\"choice-42 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_42\" name=\"wpforms[fields][67][]\" value=\"Seizures\" aria-errormessage=\"wpforms-696-field_67_42-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_42\">Seizures<\/label><\/li><li class=\"choice-41 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_41\" name=\"wpforms[fields][67][]\" value=\"Smoking\" aria-errormessage=\"wpforms-696-field_67_41-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_41\">Smoking<\/label><\/li><li class=\"choice-40 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_40\" name=\"wpforms[fields][67][]\" value=\"Speech Problems\" aria-errormessage=\"wpforms-696-field_67_40-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_40\">Speech Problems<\/label><\/li><li class=\"choice-39 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_39\" name=\"wpforms[fields][67][]\" value=\"Strokes\" aria-errormessage=\"wpforms-696-field_67_39-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_39\">Strokes<\/label><\/li><li class=\"choice-38 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_38\" name=\"wpforms[fields][67][]\" value=\"Thyroid Disease\" aria-errormessage=\"wpforms-696-field_67_38-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_38\">Thyroid Disease<\/label><\/li><li class=\"choice-48 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_48\" name=\"wpforms[fields][67][]\" value=\"Tuberculosis\" aria-errormessage=\"wpforms-696-field_67_48-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_48\">Tuberculosis<\/label><\/li><li class=\"choice-47 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_67_47\" name=\"wpforms[fields][67][]\" value=\"Vision Problems\" aria-errormessage=\"wpforms-696-field_67_47-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_67_47\">Vision Problems<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_68-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_68\">If any conditions checked above, please explain and give approximate dates. Describe any other conditions.<\/label><textarea id=\"wpforms-696-field_68\" class=\"wpforms-field-medium\" name=\"wpforms[fields][68]\" aria-errormessage=\"wpforms-696-field_68-error\" ><\/textarea><\/div><div id=\"wpforms-696-field_69-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"69\"><fieldset><legend class=\"wpforms-field-label\">FALL HISTORY <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-696-field_69\" class=\"wpforms-field-required\"><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_69_3\" name=\"wpforms[fields][69][]\" value=\"Injury as a result of fall in past year?\" aria-errormessage=\"wpforms-696-field_69_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_69_3\">Injury as a result of fall in past year?<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_69_5\" name=\"wpforms[fields][69][]\" value=\"Two or more falls in the last year?\" aria-errormessage=\"wpforms-696-field_69_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_69_5\">Two or more falls in the last year?<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_69_4\" name=\"wpforms[fields][69][]\" value=\"Patient at risk for falls?\" aria-errormessage=\"wpforms-696-field_69_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_69_4\">Patient at risk for falls?<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_69_6\" name=\"wpforms[fields][69][]\" value=\"N\/A\" aria-errormessage=\"wpforms-696-field_69_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_69_6\">N\/A<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_106-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"106\"><fieldset><legend class=\"wpforms-field-label\">SURGICAL HISTORY 1<\/legend><ul id=\"wpforms-696-field_106\"><li class=\"choice-3 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-696-field_106_3\" name=\"wpforms[fields][106]\" value=\"Surgical History1\" aria-errormessage=\"wpforms-696-field_106_3-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_106_3\">Surgical History1<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_108-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"108\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_108\">1.Body Region<\/label><input type=\"text\" id=\"wpforms-696-field_108\" class=\"wpforms-field-medium\" name=\"wpforms[fields][108]\" aria-errormessage=\"wpforms-696-field_108-error\" ><\/div><div id=\"wpforms-696-field_109-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"109\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_109\">1.Surgery Type<\/label><input type=\"text\" id=\"wpforms-696-field_109\" class=\"wpforms-field-medium\" name=\"wpforms[fields][109]\" aria-errormessage=\"wpforms-696-field_109-error\" ><\/div>\t\t<div id=\"wpforms-696-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-696-field_1\" >City\/ZIP\/State and Certification<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-696-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-696-field_110-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"110\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_110\">1.DATE<\/label><input type=\"text\" id=\"wpforms-696-field_110\" class=\"wpforms-field-medium\" name=\"wpforms[fields][110]\" aria-errormessage=\"wpforms-696-field_110-error\" ><\/div><div id=\"wpforms-696-field_107-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"107\"><fieldset><legend class=\"wpforms-field-label\">SURGICAL HISTORY 2 <\/legend><ul id=\"wpforms-696-field_107\"><li class=\"choice-3 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-696-field_107_3\" name=\"wpforms[fields][107]\" value=\"Surgical History2\" aria-errormessage=\"wpforms-696-field_107_3-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_107_3\">Surgical History2<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_111-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"111\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_111\">2.Body Region <\/label><input type=\"text\" id=\"wpforms-696-field_111\" class=\"wpforms-field-medium\" name=\"wpforms[fields][111]\" aria-errormessage=\"wpforms-696-field_111-error\" ><\/div><div id=\"wpforms-696-field_112-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"112\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_112\">2.Surgery Type<\/label><input type=\"text\" id=\"wpforms-696-field_112\" class=\"wpforms-field-medium\" name=\"wpforms[fields][112]\" aria-errormessage=\"wpforms-696-field_112-error\" ><\/div><div id=\"wpforms-696-field_113-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"113\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_113\">2.DATE<\/label><input type=\"text\" id=\"wpforms-696-field_113\" class=\"wpforms-field-medium\" name=\"wpforms[fields][113]\" aria-errormessage=\"wpforms-696-field_113-error\" ><\/div><div id=\"wpforms-696-field_72-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"72\"><fieldset><legend class=\"wpforms-field-label\">Currently taking Medication ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-696-field_72\" class=\"wpforms-field-required\"><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_72_3\" name=\"wpforms[fields][72][]\" value=\"YES\" aria-errormessage=\"wpforms-696-field_72_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_72_3\">YES<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_72_4\" name=\"wpforms[fields][72][]\" value=\"NO\" aria-errormessage=\"wpforms-696-field_72_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_72_4\">NO<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_88-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"88\"><fieldset><legend class=\"wpforms-field-label\">LIST OF MEDICATIONS TO BE SCANNED IF TAKING MORE THAN 4 <\/legend><ul id=\"wpforms-696-field_88\"><li class=\"choice-3 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-696-field_88_3\" name=\"wpforms[fields][88]\" value=\"DRUG 1\" aria-errormessage=\"wpforms-696-field_88_3-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_88_3\">DRUG 1<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_89-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"89\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_89\">1.Drug Name<\/label><input type=\"text\" id=\"wpforms-696-field_89\" class=\"wpforms-field-medium\" name=\"wpforms[fields][89]\" aria-errormessage=\"wpforms-696-field_89-error\" ><\/div><div id=\"wpforms-696-field_90-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"90\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_90\">1.Dosage<\/label><input type=\"text\" id=\"wpforms-696-field_90\" class=\"wpforms-field-medium\" name=\"wpforms[fields][90]\" aria-errormessage=\"wpforms-696-field_90-error\" ><\/div><div id=\"wpforms-696-field_91-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"91\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_91\">1.Frequency <\/label><input type=\"text\" id=\"wpforms-696-field_91\" class=\"wpforms-field-medium\" name=\"wpforms[fields][91]\" aria-errormessage=\"wpforms-696-field_91-error\" ><\/div><div id=\"wpforms-696-field_92-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"92\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_92\">1.Route<\/label><input type=\"text\" id=\"wpforms-696-field_92\" class=\"wpforms-field-medium\" name=\"wpforms[fields][92]\" aria-errormessage=\"wpforms-696-field_92-error\" ><\/div><div id=\"wpforms-696-field_93-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"93\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_93\">1.Reason Taking<\/label><input type=\"text\" id=\"wpforms-696-field_93\" class=\"wpforms-field-medium\" name=\"wpforms[fields][93]\" aria-errormessage=\"wpforms-696-field_93-error\" ><\/div><div id=\"wpforms-696-field_84-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"84\"><fieldset><legend class=\"wpforms-field-label\">LIST OF MEDICATIONS TO BE SCANNED IF TAKING MORE THAN 4<\/legend><ul id=\"wpforms-696-field_84\"><li class=\"choice-3 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-696-field_84_3\" name=\"wpforms[fields][84]\" value=\"DRUG 2\" aria-errormessage=\"wpforms-696-field_84_3-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_84_3\">DRUG 2<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_78-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_78\">2.Drug Name<\/label><input type=\"text\" id=\"wpforms-696-field_78\" class=\"wpforms-field-medium\" name=\"wpforms[fields][78]\" aria-errormessage=\"wpforms-696-field_78-error\" ><\/div><div id=\"wpforms-696-field_80-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_80\">2.Dosage<\/label><input type=\"text\" id=\"wpforms-696-field_80\" class=\"wpforms-field-medium\" name=\"wpforms[fields][80]\" aria-errormessage=\"wpforms-696-field_80-error\" ><\/div><div id=\"wpforms-696-field_79-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_79\">2.Frequency <\/label><input type=\"text\" id=\"wpforms-696-field_79\" class=\"wpforms-field-medium\" name=\"wpforms[fields][79]\" aria-errormessage=\"wpforms-696-field_79-error\" ><\/div><div id=\"wpforms-696-field_85-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"85\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_85\">2.Route<\/label><input type=\"text\" id=\"wpforms-696-field_85\" class=\"wpforms-field-medium\" name=\"wpforms[fields][85]\" aria-errormessage=\"wpforms-696-field_85-error\" ><\/div><div id=\"wpforms-696-field_86-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"86\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_86\">2.Reason Taking<\/label><input type=\"text\" id=\"wpforms-696-field_86\" class=\"wpforms-field-medium\" name=\"wpforms[fields][86]\" aria-errormessage=\"wpforms-696-field_86-error\" ><\/div><div id=\"wpforms-696-field_99-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"99\"><fieldset><legend class=\"wpforms-field-label\">LIST OF MEDICATIONS TO BE SCANNED IF TAKING MORE THAN 4 <\/legend><ul id=\"wpforms-696-field_99\"><li class=\"choice-3 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-696-field_99_3\" name=\"wpforms[fields][99]\" value=\"DRUG 3\" aria-errormessage=\"wpforms-696-field_99_3-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_99_3\">DRUG 3<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_98-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"98\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_98\">3.Drug Name <\/label><input type=\"text\" id=\"wpforms-696-field_98\" class=\"wpforms-field-medium\" name=\"wpforms[fields][98]\" aria-errormessage=\"wpforms-696-field_98-error\" ><\/div><div id=\"wpforms-696-field_97-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"97\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_97\">3.Dosage <\/label><input type=\"text\" id=\"wpforms-696-field_97\" class=\"wpforms-field-medium\" name=\"wpforms[fields][97]\" aria-errormessage=\"wpforms-696-field_97-error\" ><\/div><div id=\"wpforms-696-field_96-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"96\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_96\">3.Frequency  <\/label><input type=\"text\" id=\"wpforms-696-field_96\" class=\"wpforms-field-medium\" name=\"wpforms[fields][96]\" aria-errormessage=\"wpforms-696-field_96-error\" ><\/div><div id=\"wpforms-696-field_95-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"95\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_95\">3.Route <\/label><input type=\"text\" id=\"wpforms-696-field_95\" class=\"wpforms-field-medium\" name=\"wpforms[fields][95]\" aria-errormessage=\"wpforms-696-field_95-error\" ><\/div><div id=\"wpforms-696-field_94-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"94\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_94\">3.Reason Taking <\/label><input type=\"text\" id=\"wpforms-696-field_94\" class=\"wpforms-field-medium\" name=\"wpforms[fields][94]\" aria-errormessage=\"wpforms-696-field_94-error\" ><\/div><div id=\"wpforms-696-field_105-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"105\"><fieldset><legend class=\"wpforms-field-label\">LIST OF MEDICATIONS TO BE SCANNED IF TAKING MORE THAN 4  <\/legend><ul id=\"wpforms-696-field_105\"><li class=\"choice-3 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-696-field_105_3\" name=\"wpforms[fields][105]\" value=\"DRUG 4\" aria-errormessage=\"wpforms-696-field_105_3-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_105_3\">DRUG 4<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_104-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"104\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_104\">4.Drug Name <\/label><input type=\"text\" id=\"wpforms-696-field_104\" class=\"wpforms-field-medium\" name=\"wpforms[fields][104]\" aria-errormessage=\"wpforms-696-field_104-error\" ><\/div><div id=\"wpforms-696-field_103-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"103\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_103\">4.Dosage<\/label><input type=\"text\" id=\"wpforms-696-field_103\" class=\"wpforms-field-medium\" name=\"wpforms[fields][103]\" aria-errormessage=\"wpforms-696-field_103-error\" ><\/div><div id=\"wpforms-696-field_102-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"102\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_102\">4.Frequency <\/label><input type=\"text\" id=\"wpforms-696-field_102\" class=\"wpforms-field-medium\" name=\"wpforms[fields][102]\" aria-errormessage=\"wpforms-696-field_102-error\" ><\/div><div id=\"wpforms-696-field_101-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"101\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_101\">4.Route<\/label><input type=\"text\" id=\"wpforms-696-field_101\" class=\"wpforms-field-medium\" name=\"wpforms[fields][101]\" aria-errormessage=\"wpforms-696-field_101-error\" ><\/div><div id=\"wpforms-696-field_100-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"100\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_100\">4.Reason Taking <\/label><input type=\"text\" id=\"wpforms-696-field_100\" class=\"wpforms-field-medium\" name=\"wpforms[fields][100]\" aria-errormessage=\"wpforms-696-field_100-error\" ><\/div><div id=\"wpforms-696-field_51-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"51\"><fieldset><legend class=\"wpforms-field-label\">Authorization for Treatment <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-696-field_51\" class=\"wpforms-field-required\"><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_51_3\" name=\"wpforms[fields][51][]\" value=\"I hereby authorize and consent to rehabilitation services provided by Quality Physical Therapy &amp; Rehabilitation, P.C, including any procedures which may be performed during this visit for Patient mentioned above.\" aria-errormessage=\"wpforms-696-field_51_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_51_3\">I hereby authorize and consent to rehabilitation services provided by Quality Physical Therapy &amp; Rehabilitation, P.C, including any procedures which may be performed during this visit for Patient mentioned above.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_52-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"52\"><fieldset><legend class=\"wpforms-field-label\">Assignment of Insurance Benefits and Release of Information <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-696-field_52\" class=\"wpforms-field-required\"><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_52_3\" name=\"wpforms[fields][52][]\" value=\"I hereby assign and authorize direct payment to Quality Physical Therapy and Rehabilitation, P.C. of all insurance benefits payable to me under the terms of any insurance policy for the services rendered, but not to exceed the regular charge for services received. I authorize any holder of medical information about me or any information needed to determine benefits payable for related services to be released to my insurance carrier, third party payor, and managed care organization or to any other insurance carrier, including worker&#039;s compensation claims. I authorize a copy of the authorization to be used in place of the original.\" aria-errormessage=\"wpforms-696-field_52_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_52_3\">I hereby assign and authorize direct payment to Quality Physical Therapy and Rehabilitation, P.C. of all insurance benefits payable to me under the terms of any insurance policy for the services rendered, but not to exceed the regular charge for services received. I authorize any holder of medical information about me or any information needed to determine benefits payable for related services to be released to my insurance carrier, third party payor, and managed care organization or to any other insurance carrier, including worker's compensation claims. I authorize a copy of the authorization to be used in place of the original.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_53-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label\">Medical Patient Certification  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-696-field_53\" class=\"wpforms-field-required\"><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_53_3\" name=\"wpforms[fields][53][]\" value=\"I certify that the information given by me in applying for payment under Title XVIII or Title XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I permit a copy of the authorization to be used in place of the original and request payment of authorized benefits to be made on my behalf.\" aria-errormessage=\"wpforms-696-field_53_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_53_3\">I certify that the information given by me in applying for payment under Title XVIII or Title XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I permit a copy of the authorization to be used in place of the original and request payment of authorized benefits to be made on my behalf.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_54-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"54\"><fieldset><legend class=\"wpforms-field-label\">Medicaid Authorization and Assignment <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-696-field_54\" class=\"wpforms-field-required\"><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_54_3\" name=\"wpforms[fields][54][]\" value=\"I request that payment of authorized Medicaid, Medigap or other Medical Assistance programs be made on my behalf to the above provider for services furnished to me by the provider\/supplier. I authorize any holder of medical information about me or any information needed to determine benefits payable to be released to my insurance carrier. My signature certifies that I have received a service beginning with the date below. I understand that payment for this service will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal and State Law.\" aria-errormessage=\"wpforms-696-field_54_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_54_3\">I request that payment of authorized Medicaid, Medigap or other Medical Assistance programs be made on my behalf to the above provider for services furnished to me by the provider\/supplier. I authorize any holder of medical information about me or any information needed to determine benefits payable to be released to my insurance carrier. My signature certifies that I have received a service beginning with the date below. I understand that payment for this service will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal and State Law.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_55-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"55\"><fieldset><legend class=\"wpforms-field-label\">Personal Valuables\/Dependents\/Visitors <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-696-field_55\" class=\"wpforms-field-required\"><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_55_3\" name=\"wpforms[fields][55][]\" value=\"It is understood and agreed that Quality Physical Therapy and Rehabilitation , P.C. is not responsible for loss or damage to any personal valuables or properties. In order to maximize safety, small children will not be allowed in the treatment area of the clinic. If older children are present, please keep them off the exercise equipment in order to prevent injuries. There may be exceptions, please ask if you have any concerns or questions. We will do everything possible to accommodate your schedule if you are a caretaker of small children.\" aria-errormessage=\"wpforms-696-field_55_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_55_3\">It is understood and agreed that Quality Physical Therapy and Rehabilitation , P.C. is not responsible for loss or damage to any personal valuables or properties. In order to maximize safety, small children will not be allowed in the treatment area of the clinic. If older children are present, please keep them off the exercise equipment in order to prevent injuries. There may be exceptions, please ask if you have any concerns or questions. We will do everything possible to accommodate your schedule if you are a caretaker of small children.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_56-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"56\"><fieldset><legend class=\"wpforms-field-label\">Financial Agreement, Guarantee of Account <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-696-field_56\" class=\"wpforms-field-required\"><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_56_3\" name=\"wpforms[fields][56][]\" value=\"I, the undersigned agree whether I sign as parent, guardian, spouse, agent, guarantor or as patient, that in consideration of the services to be rendered to the patient, I hereby individually obligate myself to pay the account of Quality Physical Therapy and Rehabilitation, P.C. in accordance with the regular rates and terms of the Facility. I understand that therapy services are rendered and charged to the patient and not to the insurance company, and the facility cannot accept total responsibility for collection of claims nor for egotiating a disputed settlement. I agree to be responsible for al deductibles, coinsurance and noncovered portions of service erformed. I understand that Quality Physical Therapy and Rehabilitation , P.C. is not a party to any lawsuit I may have due to litigation. I furthe understand that although information will be provided to my attorney, I am fully responsible to the provider for payment in full under the regular terms of the practice. Should the account be referred to an agency or attorney for collection, I shall pay actual attorney&#039;s fees, 35% collection expense, and 24% annual interest rate. There is a $25 charge for cancellation without proper notice. This charge will not be covered by insurance and will have to be paid by me personally.\" aria-errormessage=\"wpforms-696-field_56_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_56_3\">I, the undersigned agree whether I sign as parent, guardian, spouse, agent, guarantor or as patient, that in consideration of the services to be rendered to the patient, I hereby individually obligate myself to pay the account of Quality Physical Therapy and Rehabilitation, P.C. in accordance with the regular rates and terms of the Facility. I understand that therapy services are rendered and charged to the patient and not to the insurance company, and the facility cannot accept total responsibility for collection of claims nor for egotiating a disputed settlement. I agree to be responsible for al deductibles, coinsurance and noncovered portions of service erformed. I understand that Quality Physical Therapy and Rehabilitation , P.C. is not a party to any lawsuit I may have due to litigation. I furthe understand that although information will be provided to my attorney, I am fully responsible to the provider for payment in full under the regular terms of the practice. Should the account be referred to an agency or attorney for collection, I shall pay actual attorney's fees, 35% collection expense, and 24% annual interest rate. There is a $25 charge for cancellation without proper notice. This charge will not be covered by insurance and will have to be paid by me personally.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_57-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"57\"><fieldset><legend class=\"wpforms-field-label\">Notice of Privacy Practices <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-696-field_57\" class=\"wpforms-field-required\"><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-696-field_57_3\" name=\"wpforms[fields][57][]\" value=\"Our Notice of Privacy Practices provides information about how we may use and disclose medical information about you. As indicated in our notice, the terms of our notice may change. If we change our notice, you may request a revised copy. By signing below, you are stating that you have reviewed the Notice of Privacy Practices. Our Notice of Privacy Practices is posted in the waiting area, but you may request a written copy of the Notice at any time. You may also ask any questions about the Notice at any time.\" aria-errormessage=\"wpforms-696-field_57_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-696-field_57_3\">Our Notice of Privacy Practices provides information about how we may use and disclose medical information about you. As indicated in our notice, the terms of our notice may change. If we change our notice, you may request a revised copy. By signing below, you are stating that you have reviewed the Notice of Privacy Practices. Our Notice of Privacy Practices is posted in the waiting area, but you may request a written copy of the Notice at any time. You may also ask any questions about the Notice at any time.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-696-field_114-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"114\"><label class=\"wpforms-field-label\" for=\"wpforms-696-field_114\">Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-696-field_114\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][114]\" aria-errormessage=\"wpforms-696-field_114-error\" aria-describedby=\"wpforms-696-field_114-description\" required><div id=\"wpforms-696-field_114-description\" class=\"wpforms-field-description\">Type Full Name<\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-696-field_1-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-696-field_1-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-696-field_1-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"696\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/deerfieldpt.com\/index.php?rest_route=\/wp\/v2\/pages\/717\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-696\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/deerfieldpt.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-d323f91 e-con-full e-flex e-con e-child\" data-id=\"d323f91\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Patient Info and Medical History FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. How did you hear about Quality Physical Therapy and Rehabilitation Friend Newspaper MD Web Other Name of the person referring Patient&#039;s Legal name * FirstLast Gender * Male Female AddressCityStateZIP CODEEmail [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"nf_dc_page":"","footnotes":""},"class_list":["post-717","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/deerfieldpt.com\/index.php?rest_route=\/wp\/v2\/pages\/717","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/deerfieldpt.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/deerfieldpt.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/deerfieldpt.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/deerfieldpt.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=717"}],"version-history":[{"count":5,"href":"https:\/\/deerfieldpt.com\/index.php?rest_route=\/wp\/v2\/pages\/717\/revisions"}],"predecessor-version":[{"id":729,"href":"https:\/\/deerfieldpt.com\/index.php?rest_route=\/wp\/v2\/pages\/717\/revisions\/729"}],"wp:attachment":[{"href":"https:\/\/deerfieldpt.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=717"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}