{"id":67,"date":"2016-05-19T16:24:27","date_gmt":"2016-05-19T16:24:27","guid":{"rendered":"http:\/\/www.mainefootcare.com\/?page_id=67"},"modified":"2023-03-29T17:12:35","modified_gmt":"2023-03-29T21:12:35","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/mainefootcare.com\/?page_id=67","title":{"rendered":"PATIENT FORMS"},"content":{"rendered":"\n<p class=\"has-vivid-cyan-blue-color has-text-color wp-block-paragraph\"><strong>PLEASE FILL OUT BOTH SECTIONS.  THERE WILL BE 2 SUBMISSIONS TO OUR SECURE EMAIL ADDRESS.<\/strong><\/p>\n\n\n<p>AUTHORIZATION FORM &nbsp; &nbsp;<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_3_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form \" id=\"form_ngab1\" data-frm-error-config=\"{&quot;includeAlertRole&quot;:false,&quot;focusFirstError&quot;:false,&quot;focusErrorSummary&quot;:true}\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_hidden\">AUTHORIZATION FORM - PODIATRY CARE OF MAINE<\/legend>\r\n<h3 class=\"frm_form_title\">AUTHORIZATION FORM - PODIATRY CARE OF MAINE<\/h3>\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"3\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_3\" id=\"frm_hide_fields_3\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"ngab1\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_3\" name=\"frm_submit_entry_3\" value=\"c586ec93ed\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F67\" \/><div id=\"frm_field_61_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_m5q8w\" class=\"frm_primary_label\">PATIENT NAME - PLEASE PRINT\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_m5q8w\" name=\"item_meta[61]\" value=\"\"  data-invmsg=\"PATIENT NAME - PLEASE PRINT is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_62_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_5x7xm\" class=\"frm_primary_label\">DATE OF BIRTH\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_5x7xm\" name=\"item_meta[62]\" value=\"\"  data-invmsg=\"DATE OF BIRTH is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_63_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_ttyfl\" class=\"frm_primary_label\">CONSENT OF TREATMENT\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[63]\" id=\"field_ttyfl\" rows=\"5\"  data-frmval=\"I authorize Podiatry Care of Maine, Robert B Taylor, DPM its health care practitioners, staff and other individuals involved in my care to examine me and perform any tests, procedures and\/or treatments that may be helpful.  I understand that the health care practitioner responsible for this care will explain any proposed procedures or treatments, including their usual and most common risks and hazards.  i also understand that I have the right to refuse any proposed procedure or treatment. \" data-invmsg=\"CONSENT OF TREATMENT is invalid\" aria-invalid=\"false\"  >I authorize Podiatry Care of Maine, Robert B Taylor, DPM its health care practitioners, staff and other individuals involved in my care to examine me and perform any tests, procedures and\/or treatments that may be helpful.  I understand that the health care practitioner responsible for this care will explain any proposed procedures or treatments, including their usual and most common risks and hazards.  i also understand that I have the right to refuse any proposed procedure or treatment. <\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_64_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_y2ssk\" class=\"frm_primary_label\">SIGNATURE OF PATIENT, PARENT OR LEGAL GUARDIAN\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_y2ssk\" name=\"item_meta[64]\" value=\"\"  data-invmsg=\"SIGNATURE OF PATIENT, PARENT OR LEGAL GUARDIAN is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_65_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_92lj6\" class=\"frm_primary_label\">DATE OF SIGNATURE\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_92lj6\" name=\"item_meta[65]\" value=\"\"  data-invmsg=\"DATE OF SIGNATURE is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_66_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_21vdp\" class=\"frm_primary_label\">AUTHORIZATION FOR BILLING AND PAYMENT\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[66]\" id=\"field_21vdp\" rows=\"5\"  data-frmval=\"I understand that I am responsible for paying all costs associated with my care and treatment.  If I have health insurance, I understand that I am financially responsible in the event that some or all payment is denied by my insurance carrier or other third party payer.  I am also responsible for charges not covered by my insurance, such as deductibles, copays or full payment for non covered services.  I authorize my health insurance carrier(s) or other third parties that are responsible for paying for my care to make payment directly to Podiatry Care of Maine. I authorize information to be sent to my insurance company.\r\n\r\nMedicare Patients:  I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Finance Administration or its intermediaries or Carriers any information needed for this or a related claim.  I permit a copy of this authorization to be use in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment.  Regulations pertaining to assignment of benefits apply.  \" data-invmsg=\"AUTHORIZATION FOR BILLING AND PAYMENT is invalid\" aria-invalid=\"false\"  >I understand that I am responsible for paying all costs associated with my care and treatment.  If I have health insurance, I understand that I am financially responsible in the event that some or all payment is denied by my insurance carrier or other third party payer.  I am also responsible for charges not covered by my insurance, such as deductibles, copays or full payment for non covered services.  I authorize my health insurance carrier(s) or other third parties that are responsible for paying for my care to make payment directly to Podiatry Care of Maine. I authorize information to be sent to my insurance company.\r\n\r\nMedicare Patients:  I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Finance Administration or its intermediaries or Carriers any information needed for this or a related claim.  I permit a copy of this authorization to be use in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment.  Regulations pertaining to assignment of benefits apply.  <\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_68_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_bmmg8\" class=\"frm_primary_label\">SIGNATURE OF PATIENT, PARENT OR LEGAL GUARDIAN\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_bmmg8\" name=\"item_meta[68]\" value=\"\"  data-invmsg=\"SIGNATURE OF PATIENT, PARENT OR LEGAL GUARDIAN is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_69_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_pbbdg\" class=\"frm_primary_label\">DATE OF SIGNATURE\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_pbbdg\" name=\"item_meta[69]\" value=\"\"  data-invmsg=\"DATE OF SIGNATURE is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_70_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_5i2l7\" class=\"frm_primary_label\">AUTHORIZATION TO DISCLOSE HEALTH CARE INFORMATION\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[70]\" id=\"field_5i2l7\" rows=\"5\"  data-frmval=\"Podiatry Care of Maine regards the safeguarding of your confidential health care information as an important duty.  The elements of this authorization to disclose are required by state law for your protection and to ensure your informed authorization to the disclosure of health care information necessary to support your relationship with your physician.\r\n\r\nI,  &quot;PATIENT, PARENT AND\/OR GUARDIAN&quot;, authorize Podiatry Care of Maine to disclose my health care information to health care practitioners and facilities that are involved in providing medical services to me.  I also authorize disclosure of my health information to my family and close friends who are providing me with emotional support as I receive health care services.  I understand that Podiatry Care of Maine will disclose such health care information which is necessary in the judgment of my physician for the legitimate needs of the recipient or for my general well being.  Also, I authorize Podiatry Care of Maine to disclose my health information to my health insurance carrier, utilization review organization or benefit manager or any other third party who may be responsible for payment for services rendered to me. \r\n\r\nMy health information, which is the subject of this authorization to disclose, includes demographic information; information about my physical or mental health or condition; information about the medical services provided to me, including payment information.  Depending upon the services I request from my physician, this information may include information about treatment for sexually transmitted disease, mental health or substance abuse.\r\n\r\nI understand that I have a right to restrict Podiatry Care of Maine use and disclosure of my health care information and that they are not obligated to agree to the requested restriction.  If they do agree, Podiatry Care of Maine will honor the restriction.  I may revoke this authorization at any time by providing a written, signed, and dated request to the attention of the medical records supervisor at Podiatry Care of Maine offices. The revocation will apply except to the extent where information has been released prior to receiving the written notice.  However, I understand that any restriction on the use and disclosure of protected health information or revocation of this authorization may result in improper diagnosis or treatment, a denial of coverage or a claim for health benefits or other insurance, or other adverse consequences. \r\n\r\nThis authorization to disclose will remain in effect for all subsequent exchanges of health care information for the limited purposes outlined above for 12 months from this authorization date, unless I revoke it in the manner described above.\r\n\r\nI understand that if I have any questions about this authorization or if I wish to have a copy of this form, I may ask the office staff.\r\n\" data-invmsg=\"AUTHORIZATION TO DISCLOSE HEALTH CARE INFORMATION is invalid\" aria-invalid=\"false\"  >Podiatry Care of Maine regards the safeguarding of your confidential health care information as an important duty.  The elements of this authorization to disclose are required by state law for your protection and to ensure your informed authorization to the disclosure of health care information necessary to support your relationship with your physician.\r\n\r\nI,  \"PATIENT, PARENT AND\/OR GUARDIAN\", authorize Podiatry Care of Maine to disclose my health care information to health care practitioners and facilities that are involved in providing medical services to me.  I also authorize disclosure of my health information to my family and close friends who are providing me with emotional support as I receive health care services.  I understand that Podiatry Care of Maine will disclose such health care information which is necessary in the judgment of my physician for the legitimate needs of the recipient or for my general well being.  Also, I authorize Podiatry Care of Maine to disclose my health information to my health insurance carrier, utilization review organization or benefit manager or any other third party who may be responsible for payment for services rendered to me. \r\n\r\nMy health information, which is the subject of this authorization to disclose, includes demographic information; information about my physical or mental health or condition; information about the medical services provided to me, including payment information.  Depending upon the services I request from my physician, this information may include information about treatment for sexually transmitted disease, mental health or substance abuse.\r\n\r\nI understand that I have a right to restrict Podiatry Care of Maine use and disclosure of my health care information and that they are not obligated to agree to the requested restriction.  If they do agree, Podiatry Care of Maine will honor the restriction.  I may revoke this authorization at any time by providing a written, signed, and dated request to the attention of the medical records supervisor at Podiatry Care of Maine offices. The revocation will apply except to the extent where information has been released prior to receiving the written notice.  However, I understand that any restriction on the use and disclosure of protected health information or revocation of this authorization may result in improper diagnosis or treatment, a denial of coverage or a claim for health benefits or other insurance, or other adverse consequences. \r\n\r\nThis authorization to disclose will remain in effect for all subsequent exchanges of health care information for the limited purposes outlined above for 12 months from this authorization date, unless I revoke it in the manner described above.\r\n\r\nI understand that if I have any questions about this authorization or if I wish to have a copy of this form, I may ask the office staff.\r\n<\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_71_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_glk4v\" class=\"frm_primary_label\">SIGNATURE OF PATIENT, PARENT OR LEGAL GUARDIAN\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_glk4v\" name=\"item_meta[71]\" value=\"\"  data-invmsg=\"SIGNATURE OF PATIENT, PARENT OR LEGAL GUARDIAN is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_72_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_snxus\" class=\"frm_primary_label\">DATE OF SIGNATURE\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_snxus\" name=\"item_meta[72]\" value=\"\"  data-invmsg=\"DATE OF SIGNATURE is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_74_container\" class=\"frm_form_field form-field \">\n\t<div class=\"frm_submit\">\r\n\r\n<input type=\"submit\" value=\"Submit\"  \/>\r\n<img data-recalc-dims=\"1\" decoding=\"async\" class=\"frm_ajax_loading\" src=\"https:\/\/i0.wp.com\/mainefootcare.com\/wp-content\/plugins\/formidable\/images\/ajax_loader.gif?ssl=1\" alt=\"Sending\"\/>\r\n\r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_75_container\">\n\t\t\t<label for=\"field_dwrad\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_dwrad\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[75]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"Gb2duk9lxArDsV8Vr3WhsaQ+FGouMAKuCIyd0ThIrm8=\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"213\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><\/form>\n<\/div>\n<\/p>\n<p>NEW PATIENT INFORMATION FORM &nbsp;<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_2_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form \" id=\"form_1qxr7\" data-frm-error-config=\"{&quot;includeAlertRole&quot;:false,&quot;focusFirstError&quot;:false,&quot;focusErrorSummary&quot;:true}\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_hidden\">New Patient Information <\/legend>\r\n<h3 class=\"frm_form_title\">New Patient Information <\/h3>\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"2\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_2\" id=\"frm_hide_fields_2\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"1qxr7\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_2\" name=\"frm_submit_entry_2\" value=\"c586ec93ed\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F67\" \/><div id=\"frm_field_12_container\" class=\"frm_form_field form-field  frm_none_container\">\r\n    <label for=\"field_yrnrf\" class=\"frm_primary_label\">Single Line Text\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_yrnrf\" name=\"item_meta[12]\" value=\"THANK YOU FOR CHOOSING PODIATRY CARE OF MAINE\"  data-frmval=\"THANK YOU FOR CHOOSING PODIATRY CARE OF MAINE\" data-invmsg=\"Single Line Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_13_container\" class=\"frm_form_field form-field  frm_none_container\">\r\n    <label for=\"field_luljz\" class=\"frm_primary_label\">Single Line Text\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_luljz\" name=\"item_meta[13]\" value=\"PATIENT INFORMATION --PLEASE FILL OUT ALL INFORMATION BELOW AND SUBMIT TO OUR OFFICE.   \"  data-frmval=\"PATIENT INFORMATION --PLEASE FILL OUT ALL INFORMATION BELOW AND SUBMIT TO OUR OFFICE.   \" data-invmsg=\"Single Line Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_14_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_ygxlk\" class=\"frm_primary_label\">TODAY'S DATE\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ygxlk\" name=\"item_meta[14]\" value=\"\"  data-invmsg=\"TODAY&#039;S DATE is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_15_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_fvcfj\" class=\"frm_primary_label\">PATIENT NAME\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_fvcfj\" name=\"item_meta[15]\" value=\"          \"  data-frmval=\"          \" data-invmsg=\"PATIENT NAME is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_16_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_yulix\" class=\"frm_primary_label\">ADDRESS\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_yulix\" name=\"item_meta[16]\" value=\"\"  data-invmsg=\"ADDRESS is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_17_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_z72i8\" class=\"frm_primary_label\">CITY\/ STATE AND ZIP CODE\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_z72i8\" name=\"item_meta[17]\" value=\"                                                                                          \"  data-frmval=\"                                                                                          \" data-invmsg=\"CITY\/ STATE AND ZIP CODE is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_18_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_3p75a\" class=\"frm_primary_label\">HOME PHONE\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_3p75a\" name=\"item_meta[18]\" value=\"\"  data-invmsg=\"HOME PHONE is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_58_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_5v5ma\" class=\"frm_primary_label\">WORK PHONE\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_5v5ma\" name=\"item_meta[58]\" value=\"\"  data-invmsg=\"WORK PHONE is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_57_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_2oe1b\" class=\"frm_primary_label\">CELL PHONE\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_2oe1b\" name=\"item_meta[57]\" value=\"\"  data-invmsg=\"CELL PHONE is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_51_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_s2jz4\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_s2jz4\" name=\"item_meta[51]\" value=\"\"  data-invmsg=\"Email Address is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_19_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_7fu5r\" class=\"frm_primary_label\">DATE OF BIRTH\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_7fu5r\" name=\"item_meta[19]\" value=\"                                                                                           \"  data-frmval=\"                                                                                           \" data-invmsg=\"DATE OF BIRTH is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_59_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_sfv5o\" class=\"frm_primary_label\">SOCIAL SECURITY NUMBER\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_sfv5o\" name=\"item_meta[59]\" value=\"\"  data-invmsg=\"SOCIAL SECURITY NUMBER is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_52_container\" class=\"frm_form_field form-field  frm_none_container vertical_radio\">\r\n    <label  class=\"frm_primary_label\">Checkboxes\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_52-0\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[52][]\" id=\"field_278da-0\" value=\"MALE\"  data-invmsg=\"Checkboxes is invalid\"   \/> MALE<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_52-1\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[52][]\" id=\"field_278da-1\" value=\"FEMALE\"  data-invmsg=\"Checkboxes is invalid\"   \/> FEMALE<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_52-2\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[52][]\" id=\"field_278da-2\" value=\"\" checked=\"checked\"  data-invmsg=\"Checkboxes is invalid\"   \/> <\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_20_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_tm26o\" class=\"frm_primary_label\">OCCUPATION\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_tm26o\" name=\"item_meta[20]\" value=\"                                                                                            \"  data-frmval=\"                                                                                            \" data-invmsg=\"OCCUPATION is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_60_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_k0dur\" class=\"frm_primary_label\">EMPLOYER\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_k0dur\" name=\"item_meta[60]\" value=\"\"  data-invmsg=\"EMPLOYER is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_21_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_m36lq\" class=\"frm_primary_label\">PRIMARY PHYSICIAN\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_m36lq\" name=\"item_meta[21]\" value=\"\"  data-invmsg=\"PRIMARY PHYSICIAN is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_56_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <label  class=\"frm_primary_label\">MARITAL STATUS\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_56-0\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[56][]\" id=\"field_vzh8o-0\" value=\"SINGLE\"  data-invmsg=\"MARITAL STATUS is invalid\"   \/> SINGLE<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_56-1\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[56][]\" id=\"field_vzh8o-1\" value=\"MARRIED\"  data-invmsg=\"MARITAL STATUS is invalid\"   \/> MARRIED<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_56-2\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[56][]\" id=\"field_vzh8o-2\" value=\"DIVORCED\"  data-invmsg=\"MARITAL STATUS is invalid\"   \/> DIVORCED<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_56-3\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[56][]\" id=\"field_vzh8o-3\" value=\"WIDOWED\"  data-invmsg=\"MARITAL STATUS is invalid\"   \/> WIDOWED<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_22_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_29cox\" class=\"frm_primary_label\">SPOUSE\/ GUARDIAN\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_29cox\" name=\"item_meta[22]\" value=\"                                                                                               \"  data-frmval=\"                                                                                               \" data-invmsg=\"SPOUSE\/ GUARDIAN is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_rea79\" class=\"frm_primary_label\">IF NOT REFERRED, HOW DID YOU HEAR OF OUR OFFICE?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_rea79\" name=\"item_meta[23]\" value=\"\"  data-invmsg=\"IF NOT REFERRED, HOW DID YOU HEAR OF OUR OFFICE? is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_24_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_aqw6f\" class=\"frm_primary_label\">PERSON TO NOTIFY IN EMERGENCY\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_aqw6f\" name=\"item_meta[24]\" value=\"                                                                                                 RELATIONSHIP\"  data-frmval=\"                                                                                                 RELATIONSHIP\" data-invmsg=\"PERSON TO NOTIFY IN EMERGENCY is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_25_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_kh9w5\" class=\"frm_primary_label\">EMERGENCY CONTACT'S PHONE NUMBER\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_kh9w5\" name=\"item_meta[25]\" value=\"\"  data-invmsg=\"EMERGENCY CONTACT&#039;S PHONE NUMBER is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_none_container\">\r\n    <label for=\"field_tly20\" class=\"frm_primary_label\">Single Line Text\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_tly20\" name=\"item_meta[26]\" value=\"INSURANCE INFORMATION\"  data-frmval=\"INSURANCE INFORMATION\" data-invmsg=\"Single Line Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_27_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_cyxbd\" class=\"frm_primary_label\">INSURANCE COMPANY\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_cyxbd\" name=\"item_meta[27]\" value=\"\"  data-invmsg=\"INSURANCE COMPANY is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_28_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_8l36i\" class=\"frm_primary_label\">MEMBER ID OR INSURED ID#\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_8l36i\" name=\"item_meta[28]\" value=\"\"  data-invmsg=\"MEMBER ID OR INSURED ID# is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_30_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_t5q9z\" class=\"frm_primary_label\">SECONDARY INSURANCE NAME:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_t5q9z\" name=\"item_meta[30]\" value=\"\"  data-invmsg=\"SECONDARY INSURANCE NAME: is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_29_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_2g8wh\" class=\"frm_primary_label\">SECONDARY INSURANCE MEMBER OR ID#\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_2g8wh\" name=\"item_meta[29]\" value=\"\"  data-invmsg=\"SECONDARY INSURANCE MEMBER OR ID# is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_31_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_ojqw6\" class=\"frm_primary_label\">NAME OF PERSON INSURANCE ISSUED UNDER\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ojqw6\" name=\"item_meta[31]\" value=\"\"  data-invmsg=\"NAME OF PERSON INSURANCE ISSUED UNDER is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_35_container\" class=\"frm_form_field form-field  frm_none_container\">\r\n    <label for=\"field_ydw6q\" class=\"frm_primary_label\">Paragraph Text\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[35]\" id=\"field_ydw6q\" rows=\"5\"  data-frmval=\"SIGNATURE ON FILE AUTHORIZATION:  I hereby authorize Podiatry Care of Maine to furnish information to insurance carrier concerning this illness\/accident, and I hereby irrevocably assign to the doctor all payments for medical services rendered.  I understand that I am financially responsible for all charges whether or not covered by insurance.  \r\n\r\n__________________________________________________________\r\nSignature of Responsible Person\" data-invmsg=\"Paragraph Text is invalid\" aria-invalid=\"false\"  >SIGNATURE ON FILE AUTHORIZATION:  I hereby authorize Podiatry Care of Maine to furnish information to insurance carrier concerning this illness\/accident, and I hereby irrevocably assign to the doctor all payments for medical services rendered.  I understand that I am financially responsible for all charges whether or not covered by insurance.  \r\n\r\n__________________________________________________________\r\nSignature of Responsible Person<\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_36_container\" class=\"frm_form_field form-field  frm_none_container\">\r\n    <label for=\"field_ct56b\" class=\"frm_primary_label\">Paragraph Text\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[36]\" id=\"field_ct56b\" rows=\"5\"  data-frmval=\"STATE IN YOUR OWN WORDS YOUR MEDICAL REASON FOR COMING TO OUR OFFICE:\" data-invmsg=\"Paragraph Text is invalid\" aria-invalid=\"false\"  >STATE IN YOUR OWN WORDS YOUR MEDICAL REASON FOR COMING TO OUR OFFICE:<\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_37_container\" class=\"frm_form_field form-field  frm_none_container\">\r\n    <label for=\"field_qr52n\" class=\"frm_primary_label\">Paragraph Text\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[37]\" id=\"field_qr52n\" rows=\"5\"  data-frmval=\"WHAT PROFESSIONAL OR SELF TREATMENT HAS BEEN ATTEMPTED FOR THE ABOVE CONDITION:\" data-invmsg=\"Paragraph Text is invalid\" aria-invalid=\"false\"  >WHAT PROFESSIONAL OR SELF TREATMENT HAS BEEN ATTEMPTED FOR THE ABOVE CONDITION:<\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_38_container\" class=\"frm_form_field form-field  frm_none_container\">\r\n    <label for=\"field_43i3y\" class=\"frm_primary_label\">Single Line Text\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_43i3y\" name=\"item_meta[38]\" value=\"PREVIOUS INJURY OR X-RAYS RELATED TO THIS PROBLEM?\"  data-frmval=\"PREVIOUS INJURY OR X-RAYS RELATED TO THIS PROBLEM?\" data-invmsg=\"Single Line Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_39_container\" class=\"frm_form_field form-field  frm_none_container vertical_radio\">\r\n    <label  class=\"frm_primary_label\">PAST MEDICAL HISTORY:  PLEASE CHECK ALL THAT APPLY\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-0\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xrfzp-0\" value=\"HIGH BLOOD PRESSURE\"  data-invmsg=\"PAST MEDICAL HISTORY:  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> HIGH BLOOD PRESSURE<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-1\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xrfzp-1\" value=\"HEART DISEASE\"  data-invmsg=\"PAST MEDICAL HISTORY:  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> HEART DISEASE<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-2\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xrfzp-2\" value=\"KIDNEY DISEASE\"  data-invmsg=\"PAST MEDICAL HISTORY:  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> KIDNEY DISEASE<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-3\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xrfzp-3\" value=\"HISTORY OF STROKE OR HEART ATTACK\"  data-invmsg=\"PAST MEDICAL HISTORY:  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> HISTORY OF STROKE OR HEART ATTACK<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-4\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xrfzp-4\" value=\"LIVER DISEASE\"  data-invmsg=\"PAST MEDICAL HISTORY:  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> LIVER DISEASE<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-5\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xrfzp-5\" value=\"DIABETES\"  data-invmsg=\"PAST MEDICAL HISTORY:  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> DIABETES<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-6\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xrfzp-6\" value=\"ARTHRITIS\"  data-invmsg=\"PAST MEDICAL HISTORY:  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> ARTHRITIS<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-7\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xrfzp-7\" value=\"ASTHMA OR EMPHYSEMA\"  data-invmsg=\"PAST MEDICAL HISTORY:  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> ASTHMA OR EMPHYSEMA<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-8\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xrfzp-8\" value=\"CANCER\"  data-invmsg=\"PAST MEDICAL HISTORY:  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> CANCER<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-9\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xrfzp-9\" value=\"STOMACH\/INTESTINAL PROBLEMS\"  data-invmsg=\"PAST MEDICAL HISTORY:  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> STOMACH\/INTESTINAL PROBLEMS<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-10\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xrfzp-10\" value=\"OTHER\"  data-invmsg=\"PAST MEDICAL HISTORY:  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> OTHER<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field form-field  frm_none_container\">\r\n    <label for=\"field_c49ck\" class=\"frm_primary_label\">Paragraph Text\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[41]\" id=\"field_c49ck\" rows=\"5\"  data-frmval=\"SURGERIES:  PLEASE LIST SURGERY AND DATE PERFORMED\r\n_____________________________________________________________\r\n_____________________________________________________________\r\n_____________________________________________________________\r\n_____________________________________________________________\" data-invmsg=\"Paragraph Text is invalid\" aria-invalid=\"false\"  >SURGERIES:  PLEASE LIST SURGERY AND DATE PERFORMED\r\n_____________________________________________________________\r\n_____________________________________________________________\r\n_____________________________________________________________\r\n_____________________________________________________________<\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_44_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_av26s\" class=\"frm_primary_label\">PLEASE LIST ALL MEDICATIONS:       LIST MEDICATION NAME, DOSAGE AND FREQUENCY\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[44]\" id=\"field_av26s\" rows=\"5\"  data-invmsg=\"PLEASE LIST ALL MEDICATIONS:       LIST MEDICATION NAME, DOSAGE AND FREQUENCY is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_47_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <label  class=\"frm_primary_label\">ALLERGIES\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_47-0\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[47][]\" id=\"field_svgi3-0\" value=\"ALLERGIES TO MEDICATIONS\"  data-invmsg=\"ALLERGIES is invalid\"   \/> ALLERGIES TO MEDICATIONS<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_47-1\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[47][]\" id=\"field_svgi3-1\" value=\"OTHER\"  data-invmsg=\"ALLERGIES is invalid\"   \/> OTHER<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_47-2\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[47][]\" id=\"field_svgi3-2\" value=\"No Known Drug Allergies\"  data-invmsg=\"ALLERGIES is invalid\"   \/> No Known Drug Allergies<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_53_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_wv5id\" class=\"frm_primary_label\">IF YES TO ALLERGIES, PLEASE LIST BELOW\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[53]\" id=\"field_wv5id\" rows=\"5\"  data-invmsg=\"IF YES TO ALLERGIES, PLEASE LIST BELOW is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_48_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <label  class=\"frm_primary_label\">SUBSTANCE USE\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-0\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_q9u4l-0\" value=\"DO YOU USE TOBACCO?\"  data-invmsg=\"SUBSTANCE USE is invalid\"   \/> DO YOU USE TOBACCO?<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-1\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_q9u4l-1\" value=\"DO YOU USE ALCOHOL?\"  data-invmsg=\"SUBSTANCE USE is invalid\"   \/> DO YOU USE ALCOHOL?<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-2\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_q9u4l-2\" value=\"DO YOU RECREATIONAL DRUGS?\"  data-invmsg=\"SUBSTANCE USE is invalid\"   \/> DO YOU RECREATIONAL DRUGS?<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_54_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_9atym\" class=\"frm_primary_label\">IF YES TO ANY OF THE ABOVE, PLEASE DESCRIBE SUBSTANCE, FREQUENCY OF USE, AND NUMBER OF USE PER DAY\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[54]\" id=\"field_9atym\" rows=\"5\"  data-invmsg=\"IF YES TO ANY OF THE ABOVE, PLEASE DESCRIBE SUBSTANCE, FREQUENCY OF USE, AND NUMBER OF USE PER DAY is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_49_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <label  class=\"frm_primary_label\">FAMILY MEDICAL HISTORY  PLEASE CHECK ALL THAT APPLY\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_49-0\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[49][]\" id=\"field_2sj6a-0\" value=\"ANY HISTORY OF DIABETES MELLITUS?\"  data-invmsg=\"FAMILY MEDICAL HISTORY  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> ANY HISTORY OF DIABETES MELLITUS?<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_49-1\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[49][]\" id=\"field_2sj6a-1\" value=\"ANY HISTORY OF FOOT DEFORMITIES?\"  data-invmsg=\"FAMILY MEDICAL HISTORY  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> ANY HISTORY OF FOOT DEFORMITIES?<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_49-2\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[49][]\" id=\"field_2sj6a-2\" value=\"ANY HISTORY OF HEART DISEASE?\"  data-invmsg=\"FAMILY MEDICAL HISTORY  PLEASE CHECK ALL THAT APPLY is invalid\"   \/> ANY HISTORY OF HEART DISEASE?<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_49-3\">\t\t\t<label >\n\t\t\t<input type=\"checkbox\" name=\"item_meta[49][]\" id=\"field_2sj6a-3\" value=\"OTHER\"  data-invmsg=\"FAMILY 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