{"id":627,"date":"2018-03-23T00:19:47","date_gmt":"2018-03-23T00:19:47","guid":{"rendered":"\/?page_id=627"},"modified":"2018-03-24T23:38:00","modified_gmt":"2018-03-24T23:38:00","slug":"registration-form","status":"publish","type":"page","link":"https:\/\/www.washingtonnephrology.com\/index.php\/registration-form\/","title":{"rendered":"registration-form"},"content":{"rendered":"<div class=\"et_d4_element et_pb_section et_pb_section_0  et_pb_css_mix_blend_mode et_section_regular et_block_section\" >\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_d4_element et_pb_row et_pb_row_0 btn-inline  et_pb_css_mix_blend_mode et_block_row\">\n\t\t\t\t<div class=\"et_d4_element et_pb_column_4_4 et_pb_column et_pb_column_0  et_pb_css_mix_blend_mode et-last-child et_block_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t<div id=\"et_pb_contact_form_0\" class=\"et_pb_module et_d4_element et_pb_contact_form_0 et_pb_contact_form_container clearfix et_block_module\" data-form_unique_num=\"0\" data-form_unique_id=\"\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<h1 class=\"et_pb_contact_main_title\">Patient Registration Form <\/h1>\n\t\t\t\t<div class=\"et-pb-contact-message\"><\/div>\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_contact\">\n\t\t\t\t\t<form class=\"et_pb_contact_form clearfix\" method=\"post\" action=\"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/pages\/627\">\n\t\t\t\t\t\t<p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_0 et_pb_contact_field_last\" data-id=\"new_patient\/update\" data-type=\"radio\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_new_patient\/update_0\" class=\"et_pb_contact_form_label\">Choose One:<\/label>\n\t\t\t\t<span class=\"et_pb_contact_field_options_wrapper\">\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_title\">Choose One:<\/span>\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list\"><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_new_patient\/update_0_0_0\" class=\"input\" value=\"New Patient\" name=\"et_pb_contact_new_patient\/update_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"new_patient\/update\"  data-id=\"0\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_new_patient\/update_0_0_0\"><i><\/i>New Patient<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_new_patient\/update_0_0_1\" class=\"input\" value=\"Update\" name=\"et_pb_contact_new_patient\/update_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"new_patient\/update\"  data-id=\"1\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_new_patient\/update_0_0_1\"><i><\/i>Update<\/label>\n\t\t\t\t\t\t\t<\/span><\/span>\n\t\t\t\t\t<\/span>\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_1 et_pb_contact_field_last\" data-id=\"last_name\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_last_name_0\" class=\"et_pb_contact_form_label\">Last Name<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_last_name_0\" class=\"input\" value=\"\" name=\"et_pb_contact_last_name_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"last_name\" placeholder=\"Last Name\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_2 et_pb_contact_field_half\" data-id=\"first_name\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_first_name_0\" class=\"et_pb_contact_form_label\">First Name<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_first_name_0\" class=\"input\" value=\"\" name=\"et_pb_contact_first_name_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"first_name\" placeholder=\"First Name\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_3 et_pb_contact_field_half et_pb_contact_field_last\" data-id=\"middle_name\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_middle_name_0\" class=\"et_pb_contact_form_label\">Middle Name<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_middle_name_0\" class=\"input\" value=\"\" name=\"et_pb_contact_middle_name_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"middle_name\" placeholder=\"Middle Name\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_4 et_pb_contact_field_last\" data-id=\"also_known_as_last_name\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_also_known_as_last_name_0\" class=\"et_pb_contact_form_label\">AKA Last Name<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_also_known_as_last_name_0\" class=\"input\" value=\"\" name=\"et_pb_contact_also_known_as_last_name_0\" data-required_mark=\"not_required\" data-field_type=\"input\" data-original_id=\"also_known_as_last_name\" placeholder=\"AKA Last Name\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_5 et_pb_contact_field_half\" data-id=\"also_known_as_first_name\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_also_known_as_first_name_0\" class=\"et_pb_contact_form_label\">AKA First Name<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_also_known_as_first_name_0\" class=\"input\" value=\"\" name=\"et_pb_contact_also_known_as_first_name_0\" data-required_mark=\"not_required\" data-field_type=\"input\" data-original_id=\"also_known_as_first_name\" placeholder=\"AKA First Name\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_6 et_pb_contact_field_half et_pb_contact_field_last\" data-id=\"also_known_as_middle_name\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_also_known_as_middle_name_0\" class=\"et_pb_contact_form_label\">AKA Middle Name<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_also_known_as_middle_name_0\" class=\"input\" value=\"\" name=\"et_pb_contact_also_known_as_middle_name_0\" data-required_mark=\"not_required\" data-field_type=\"input\" data-original_id=\"also_known_as_middle_name\" placeholder=\"AKA Middle Name\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_7 et_pb_contact_field_last\" data-id=\"home_street_address\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_home_street_address_0\" class=\"et_pb_contact_form_label\">Street Address<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_home_street_address_0\" class=\"input\" value=\"\" name=\"et_pb_contact_home_street_address_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"home_street_address\" placeholder=\"Street Address\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_8 et_pb_contact_field_half\" data-id=\"home_city\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_home_city_0\" class=\"et_pb_contact_form_label\">City<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_home_city_0\" class=\"input\" value=\"\" name=\"et_pb_contact_home_city_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"home_city\" placeholder=\"City\" pattern=\"[A-Za-z\\s\\-]*\" title=\"Only letters allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_9 et_pb_contact_field_half et_pb_contact_field_last\" data-id=\"home_state\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_home_state_0\" class=\"et_pb_contact_form_label\">State<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_home_state_0\" class=\"input\" value=\"\" name=\"et_pb_contact_home_state_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"home_state\" placeholder=\"State\" pattern=\"[A-Za-z\\s\\-]*\" title=\"Only letters allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_10 et_pb_contact_field_half\" data-id=\"home_zip_code\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_home_zip_code_0\" class=\"et_pb_contact_form_label\">Zip Code<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_home_zip_code_0\" class=\"input\" value=\"\" name=\"et_pb_contact_home_zip_code_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"home_zip_code\" placeholder=\"Zip Code\" pattern=\"[0-9\\s\\-]*\" title=\"Only numbers allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_11 et_pb_contact_field_half et_pb_contact_field_last\" data-id=\"dob\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_dob_0\" class=\"et_pb_contact_form_label\">DOB<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_dob_0\" class=\"input\" value=\"\" name=\"et_pb_contact_dob_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"dob\" placeholder=\"DOB\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_12 et_pb_contact_field_half\" data-id=\"ssn\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_ssn_0\" class=\"et_pb_contact_form_label\">SSN<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_ssn_0\" class=\"input\" value=\"\" name=\"et_pb_contact_ssn_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"ssn\" placeholder=\"SSN\" pattern=\"[0-9\\s\\-]*\" title=\"Only numbers allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_13 et_pb_contact_field_half et_pb_contact_field_last\" data-id=\"home_phone_number\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_home_phone_number_0\" class=\"et_pb_contact_form_label\">Home Phone Number<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_home_phone_number_0\" class=\"input\" value=\"\" name=\"et_pb_contact_home_phone_number_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"home_phone_number\" placeholder=\"Home Phone Number\" pattern=\"[0-9\\s\\-]*\" title=\"Only numbers allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_14 et_pb_contact_field_half\" data-id=\"cell_phone_number\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_cell_phone_number_0\" class=\"et_pb_contact_form_label\">Cell Phone Number<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_cell_phone_number_0\" class=\"input\" value=\"\" name=\"et_pb_contact_cell_phone_number_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"cell_phone_number\" placeholder=\"Cell Phone Number\" pattern=\"[0-9\\s\\-]*\" title=\"Only numbers allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_15 et_pb_contact_field_half et_pb_contact_field_last\" data-id=\"work_phone_number\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_work_phone_number_0\" class=\"et_pb_contact_form_label\">Work Phone Number<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_work_phone_number_0\" class=\"input\" value=\"\" name=\"et_pb_contact_work_phone_number_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"work_phone_number\" placeholder=\"Work Phone Number\" pattern=\"[0-9\\s\\-]*\" title=\"Only numbers allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_16 et_pb_contact_field_half\" data-id=\"email_address\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_email_address_0\" class=\"et_pb_contact_form_label\">eMail Address<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_email_address_0\" class=\"input\" value=\"\" name=\"et_pb_contact_email_address_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"email_address\" placeholder=\"eMail Address\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_17 et_pb_contact_field_last\" data-id=\"preferred_method_of_communication\" data-type=\"select\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_preferred_method_of_communication_0\" class=\"et_pb_contact_form_label\">Preferred Method of Communication<\/label>\n\t\t\t\t<select id=\"et_pb_contact_preferred_method_of_communication_0\" class=\"et_pb_contact_select input\" name=\"et_pb_contact_preferred_method_of_communication_0\" data-required_mark=\"required\" data-field_type=\"select\" data-original_id=\"preferred_method_of_communication\">\n\t\t\t\t\t\t<option value=\"\">Preferred Method of Communication<\/option><option value=\"Cell Number\">Cell Number<\/option><option value=\"Texting\">Texting<\/option><option value=\"Home Number\">Home Number<\/option><option value=\"eMail\">eMail<\/option><option value=\"Work Number\">Work Number<\/option>\n\t\t\t\t\t<\/select>\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_18 et_pb_contact_field_half\" data-id=\"gender\" data-type=\"radio\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_gender_0\" class=\"et_pb_contact_form_label\">Gender<\/label>\n\t\t\t\t<span class=\"et_pb_contact_field_options_wrapper\">\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_title\">Gender<\/span>\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list\"><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_gender_0_18_0\" class=\"input\" value=\"Male\" name=\"et_pb_contact_gender_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"gender\"  data-id=\"0\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_gender_0_18_0\"><i><\/i>Male<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_gender_0_18_1\" class=\"input\" value=\"Female\" name=\"et_pb_contact_gender_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"gender\"  data-id=\"1\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_gender_0_18_1\"><i><\/i>Female<\/label>\n\t\t\t\t\t\t\t<\/span><\/span>\n\t\t\t\t\t<\/span>\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_19 et_pb_contact_field_half et_pb_contact_field_last\" data-id=\"marital_status\" data-type=\"radio\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_marital_status_0\" class=\"et_pb_contact_form_label\">Marital Status:<\/label>\n\t\t\t\t<span class=\"et_pb_contact_field_options_wrapper\">\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_title\">Marital Status:<\/span>\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list\"><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_marital_status_0_19_0\" class=\"input\" value=\"Single\" name=\"et_pb_contact_marital_status_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"marital_status\"  data-id=\"0\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_marital_status_0_19_0\"><i><\/i>Single<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_marital_status_0_19_1\" class=\"input\" value=\"Married\" name=\"et_pb_contact_marital_status_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"marital_status\"  data-id=\"1\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_marital_status_0_19_1\"><i><\/i>Married<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_marital_status_0_19_2\" class=\"input\" value=\"Divorced\" name=\"et_pb_contact_marital_status_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"marital_status\"  data-id=\"2\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_marital_status_0_19_2\"><i><\/i>Divorced<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_marital_status_0_19_3\" class=\"input\" value=\"Separated\" name=\"et_pb_contact_marital_status_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"marital_status\"  data-id=\"3\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_marital_status_0_19_3\"><i><\/i>Separated<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_marital_status_0_19_4\" class=\"input\" value=\"Widowed\" name=\"et_pb_contact_marital_status_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"marital_status\"  data-id=\"4\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_marital_status_0_19_4\"><i><\/i>Widowed<\/label>\n\t\t\t\t\t\t\t<\/span><\/span>\n\t\t\t\t\t<\/span>\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_20 et_pb_contact_field_half\" data-id=\"ethnicity\" data-type=\"radio\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_ethnicity_0\" class=\"et_pb_contact_form_label\">Ethnicy<\/label>\n\t\t\t\t<span class=\"et_pb_contact_field_options_wrapper\">\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_title\">Ethnicy<\/span>\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list\"><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_ethnicity_0_20_0\" class=\"input\" value=\"Hispanic\/Latino\" name=\"et_pb_contact_ethnicity_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"ethnicity\"  data-id=\"0\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_ethnicity_0_20_0\"><i><\/i>Hispanic\/Latino<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_ethnicity_0_20_1\" class=\"input\" value=\"Not Hispanic\/Latino\" name=\"et_pb_contact_ethnicity_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"ethnicity\"  data-id=\"1\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_ethnicity_0_20_1\"><i><\/i>Not Hispanic\/Latino<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_ethnicity_0_20_2\" class=\"input\" value=\"Declined\" name=\"et_pb_contact_ethnicity_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"ethnicity\"  data-id=\"2\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_ethnicity_0_20_2\"><i><\/i>Declined<\/label>\n\t\t\t\t\t\t\t<\/span><\/span>\n\t\t\t\t\t<\/span>\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_21 et_pb_contact_field_last\" data-id=\"primary_race\" data-type=\"select\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_primary_race_0\" class=\"et_pb_contact_form_label\">Primary Race:<\/label>\n\t\t\t\t<select id=\"et_pb_contact_primary_race_0\" class=\"et_pb_contact_select input\" name=\"et_pb_contact_primary_race_0\" data-required_mark=\"required\" data-field_type=\"select\" data-original_id=\"primary_race\">\n\t\t\t\t\t\t<option value=\"\">Primary Race:<\/option><option value=\"Asian\">Asian<\/option><option value=\"Black\/African American\">Black\/African American<\/option><option value=\"White\">White<\/option><option value=\"American Indian\/Alaska Native\">American Indian\/Alaska Native<\/option><option value=\"Pacific Islander\/Nativer Hawaiian\">Pacific Islander\/Nativer Hawaiian<\/option><option value=\"Other\">Other<\/option><option value=\"Declined\">Declined<\/option>\n\t\t\t\t\t<\/select>\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_22 et_pb_contact_field_half\" data-conditional-logic=\"[[&quot;primary_race&quot;,&quot;is&quot;,&quot;Other&quot;]]\" data-conditional-relation=\"any\" data-id=\"other_race\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_other_race_0\" class=\"et_pb_contact_form_label\">Other Race: Please specify<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_other_race_0\" class=\"input\" value=\"\" name=\"et_pb_contact_other_race_0\" data-required_mark=\"not_required\" data-field_type=\"input\" data-original_id=\"other_race\" placeholder=\"Other Race: Please specify\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_23 et_pb_contact_field_last\" data-id=\"preferred_language\" data-type=\"radio\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_preferred_language_0\" class=\"et_pb_contact_form_label\">Preferred Language:<\/label>\n\t\t\t\t<span class=\"et_pb_contact_field_options_wrapper\">\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_title\">Preferred Language:<\/span>\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list\"><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_preferred_language_0_23_0\" class=\"input\" value=\"English\" name=\"et_pb_contact_preferred_language_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"preferred_language\"  data-id=\"0\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_preferred_language_0_23_0\"><i><\/i>English<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_preferred_language_0_23_1\" class=\"input\" value=\"Spanish\" name=\"et_pb_contact_preferred_language_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"preferred_language\"  data-id=\"1\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_preferred_language_0_23_1\"><i><\/i>Spanish<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_preferred_language_0_23_2\" class=\"input\" value=\"Other\" name=\"et_pb_contact_preferred_language_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"preferred_language\"  data-id=\"2\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_preferred_language_0_23_2\"><i><\/i>Other<\/label>\n\t\t\t\t\t\t\t<\/span><\/span>\n\t\t\t\t\t<\/span>\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_24 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;preferred_language&quot;,&quot;is&quot;,&quot;Other&quot;]]\" data-conditional-relation=\"any\" data-id=\"preferred_language_other\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_preferred_language_other_0\" class=\"et_pb_contact_form_label\">Other Language: Please Spicify<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_preferred_language_other_0\" class=\"input\" value=\"\" name=\"et_pb_contact_preferred_language_other_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"preferred_language_other\" placeholder=\"Other Language: Please Spicify\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_25 et_pb_contact_field_last\" data-id=\"are_you_currently?\" data-type=\"radio\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_are_you_currently?_0\" class=\"et_pb_contact_form_label\">Are You Currently?<\/label>\n\t\t\t\t<span class=\"et_pb_contact_field_options_wrapper\">\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_title\">Are You Currently?<\/span>\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list\"><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_are_you_currently?_0_25_0\" class=\"input\" value=\"Employed\" name=\"et_pb_contact_are_you_currently?_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"are_you_currently?\"  data-id=\"\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_are_you_currently?_0_25_0\"><i><\/i>Employed<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_are_you_currently?_0_25_1\" class=\"input\" value=\"Going to School\" name=\"et_pb_contact_are_you_currently?_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"are_you_currently?\"  data-id=\"\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_are_you_currently?_0_25_1\"><i><\/i>Going to School<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_are_you_currently?_0_25_2\" class=\"input\" value=\"Both\" name=\"et_pb_contact_are_you_currently?_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"are_you_currently?\"  data-id=\"\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_are_you_currently?_0_25_2\"><i><\/i>Both<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_are_you_currently?_0_25_3\" class=\"input\" value=\"None of the above\" name=\"et_pb_contact_are_you_currently?_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"are_you_currently?\"  data-id=\"\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_are_you_currently?_0_25_3\"><i><\/i>None of the above<\/label>\n\t\t\t\t\t\t\t<\/span><\/span>\n\t\t\t\t\t<\/span>\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_26 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Employed&quot;],[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Both&quot;]]\" data-conditional-relation=\"any\" data-id=\"employer_name:\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_employer_name:_0\" class=\"et_pb_contact_form_label\">Employer Name:<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_employer_name:_0\" class=\"input\" value=\"\" name=\"et_pb_contact_employer_name:_0\" data-required_mark=\"not_required\" data-field_type=\"input\" data-original_id=\"employer_name:\" placeholder=\"Employer Name:\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_27 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Employed&quot;],[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Both&quot;]]\" data-conditional-relation=\"any\" data-id=\"employer&#039;s_street_address\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_employer&#039;s_street_address_0\" class=\"et_pb_contact_form_label\">Employer&#039;s Street Address<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_employer&#039;s_street_address_0\" class=\"input\" value=\"\" name=\"et_pb_contact_employer&#039;s_street_address_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"employer&#039;s_street_address\" placeholder=\"Employer&#039;s Street Address\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_28 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Employed&quot;],[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Both&quot;]]\" data-conditional-relation=\"any\" data-id=\"employer_city\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_employer_city_0\" class=\"et_pb_contact_form_label\">City<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_employer_city_0\" class=\"input\" value=\"\" name=\"et_pb_contact_employer_city_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"employer_city\" placeholder=\"City\" pattern=\"[A-Za-z\\s\\-]*\" title=\"Only letters allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_29 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Employed&quot;],[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Both&quot;]]\" data-conditional-relation=\"any\" data-id=\"employer_state\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_employer_state_0\" class=\"et_pb_contact_form_label\">State<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_employer_state_0\" class=\"input\" value=\"\" name=\"et_pb_contact_employer_state_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"employer_state\" placeholder=\"State\" pattern=\"[A-Za-z\\s\\-]*\" title=\"Only letters allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_30 et_pb_contact_field_half\" data-conditional-logic=\"[[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Employed&quot;],[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Both&quot;]]\" data-conditional-relation=\"any\" data-id=\"employer_zip_code\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_employer_zip_code_0\" class=\"et_pb_contact_form_label\">Zip Code<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_employer_zip_code_0\" class=\"input\" value=\"\" name=\"et_pb_contact_employer_zip_code_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"employer_zip_code\" placeholder=\"Zip Code\" pattern=\"[0-9\\s\\-]*\" title=\"Only numbers allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_31 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Going to School&quot;],[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Both&quot;]]\" data-conditional-relation=\"any\" data-id=\"school_name:\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_school_name:_0\" class=\"et_pb_contact_form_label\">School Name:<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_school_name:_0\" class=\"input\" value=\"\" name=\"et_pb_contact_school_name:_0\" data-required_mark=\"not_required\" data-field_type=\"input\" data-original_id=\"school_name:\" placeholder=\"School Name:\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_32 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Going to School&quot;],[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Both&quot;]]\" data-conditional-relation=\"any\" data-id=\"school_street_address\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_school_street_address_0\" class=\"et_pb_contact_form_label\">School Street Address<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_school_street_address_0\" class=\"input\" value=\"\" name=\"et_pb_contact_school_street_address_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"school_street_address\" placeholder=\"School Street Address\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_33 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Going to School&quot;],[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Both&quot;]]\" data-conditional-relation=\"any\" data-id=\"school_city\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_school_city_0\" class=\"et_pb_contact_form_label\">City<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_school_city_0\" class=\"input\" value=\"\" name=\"et_pb_contact_school_city_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"school_city\" placeholder=\"City\" pattern=\"[A-Za-z\\s\\-]*\" title=\"Only letters allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_34 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Going to School&quot;],[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Both&quot;]]\" data-conditional-relation=\"any\" data-id=\"school_state\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_school_state_0\" class=\"et_pb_contact_form_label\">State<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_school_state_0\" class=\"input\" value=\"\" name=\"et_pb_contact_school_state_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"school_state\" placeholder=\"State\" pattern=\"[A-Za-z\\s\\-]*\" title=\"Only letters allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_35 et_pb_contact_field_half\" data-conditional-logic=\"[[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Going to School&quot;],[&quot;are_you_currently?&quot;,&quot;is&quot;,&quot;Both&quot;]]\" data-conditional-relation=\"any\" data-id=\"school_zip_code\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_school_zip_code_0\" class=\"et_pb_contact_form_label\">Zip Code<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_school_zip_code_0\" class=\"input\" value=\"\" name=\"et_pb_contact_school_zip_code_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"school_zip_code\" placeholder=\"Zip Code\" pattern=\"[0-9\\s\\-]*\" title=\"Only numbers allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_36 et_pb_contact_field_last\" data-id=\"are_you_financially_responsible_for_your_medical_bills?\" data-type=\"radio\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_are_you_financially_responsible_for_your_medical_bills?_0\" class=\"et_pb_contact_form_label\">Are you Financially Responsible for Your Medical Bills?<\/label>\n\t\t\t\t<span class=\"et_pb_contact_field_options_wrapper\">\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_title\">Are you Financially Responsible for Your Medical Bills?<\/span>\n\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list\"><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_are_you_financially_responsible_for_your_medical_bills?_0_36_0\" class=\"input\" value=\"Yes\" name=\"et_pb_contact_are_you_financially_responsible_for_your_medical_bills?_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"are_you_financially_responsible_for_your_medical_bills?\"  data-id=\"0\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_are_you_financially_responsible_for_your_medical_bills?_0_36_0\"><i><\/i>Yes<\/label>\n\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_radio\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_are_you_financially_responsible_for_your_medical_bills?_0_36_1\" class=\"input\" value=\"No\" name=\"et_pb_contact_are_you_financially_responsible_for_your_medical_bills?_0\" data-required_mark=\"required\" data-field_type=\"radio\" data-original_id=\"are_you_financially_responsible_for_your_medical_bills?\"  data-id=\"1\">\n\t\t\t\t\t\t\t\t<label for=\"et_pb_contact_are_you_financially_responsible_for_your_medical_bills?_0_36_1\"><i><\/i>No<\/label>\n\t\t\t\t\t\t\t<\/span><\/span>\n\t\t\t\t\t<\/span>\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_37 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_financially_responsible_for_your_medical_bills?&quot;,&quot;is&quot;,&quot;No&quot;]]\" data-conditional-relation=\"any\" data-id=\"responsible_last_name\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_responsible_last_name_0\" class=\"et_pb_contact_form_label\">Last Name Of Financially Responsible Person<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_responsible_last_name_0\" class=\"input\" value=\"\" name=\"et_pb_contact_responsible_last_name_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"responsible_last_name\" placeholder=\"Last Name Of Financially Responsible Person\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_38 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_financially_responsible_for_your_medical_bills?&quot;,&quot;is&quot;,&quot;No&quot;]]\" data-conditional-relation=\"all\" data-id=\"responsible_first_name\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_responsible_first_name_0\" class=\"et_pb_contact_form_label\">First Name<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_responsible_first_name_0\" class=\"input\" value=\"\" name=\"et_pb_contact_responsible_first_name_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"responsible_first_name\" placeholder=\"First Name\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_39 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_financially_responsible_for_your_medical_bills?&quot;,&quot;is&quot;,&quot;No&quot;]]\" data-conditional-relation=\"any\" data-id=\"responsible_middle_name\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_responsible_middle_name_0\" class=\"et_pb_contact_form_label\">Middle Name<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_responsible_middle_name_0\" class=\"input\" value=\"\" name=\"et_pb_contact_responsible_middle_name_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"responsible_middle_name\" placeholder=\"Middle Name\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_40 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_financially_responsible_for_your_medical_bills?&quot;,&quot;is&quot;,&quot;No&quot;]]\" data-conditional-relation=\"any\" data-id=\"responsible_home_street_address\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_responsible_home_street_address_0\" class=\"et_pb_contact_form_label\">Street Address<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_responsible_home_street_address_0\" class=\"input\" value=\"\" name=\"et_pb_contact_responsible_home_street_address_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"responsible_home_street_address\" placeholder=\"Street Address\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_41 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_financially_responsible_for_your_medical_bills?&quot;,&quot;is&quot;,&quot;No&quot;]]\" data-conditional-relation=\"any\" data-id=\"responsible_home_city\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_responsible_home_city_0\" class=\"et_pb_contact_form_label\">City<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_responsible_home_city_0\" class=\"input\" value=\"\" name=\"et_pb_contact_responsible_home_city_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"responsible_home_city\" placeholder=\"City\" pattern=\"[A-Za-z\\s\\-]*\" title=\"Only letters allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_42 et_pb_contact_field_last\" data-conditional-logic=\"[[&quot;are_you_financially_responsible_for_your_medical_bills?&quot;,&quot;is&quot;,&quot;No&quot;]]\" data-conditional-relation=\"any\" data-id=\"responsible_home_state\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_responsible_home_state_0\" class=\"et_pb_contact_form_label\">State<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_responsible_home_state_0\" class=\"input\" value=\"\" name=\"et_pb_contact_responsible_home_state_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"responsible_home_state\" placeholder=\"State\" pattern=\"[A-Za-z\\s\\-]*\" title=\"Only letters allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_43 et_pb_contact_field_half\" data-conditional-logic=\"[[&quot;are_you_financially_responsible_for_your_medical_bills?&quot;,&quot;is&quot;,&quot;No&quot;]]\" data-conditional-relation=\"any\" data-id=\"responsible_home_zip_code\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_responsible_home_zip_code_0\" class=\"et_pb_contact_form_label\">Zip Code<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_responsible_home_zip_code_0\" class=\"input\" value=\"\" name=\"et_pb_contact_responsible_home_zip_code_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"responsible_home_zip_code\" placeholder=\"Zip Code\" pattern=\"[0-9\\s\\-]*\" title=\"Only numbers allowed.\">\n\t\t\t<\/p><p class=\"et_d4_element et_pb_contact_field et_pb_contact_field_44 et_pb_contact_field_half et_pb_contact_field_last\" data-id=\"field_0_44\" data-type=\"input\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<label for=\"et_pb_contact_field_0_44_0\" class=\"et_pb_contact_form_label\">New Field<\/label>\n\t\t\t\t<input type=\"text\" id=\"et_pb_contact_field_0_44_0\" class=\"input\" value=\"\" name=\"et_pb_contact_field_0_44_0\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"field_0_44\" placeholder=\"New Field\">\n\t\t\t<\/p>\n\t\t\t\t\t\t<input type=\"hidden\" value=\"et_contact_proccess\" name=\"et_pb_contactform_submit_0\"\/>\n\t\t\t\t\t\t<div class=\"et_contact_bottom_container\">\n\t\t\t\t\t\t\t\n\t\t\t<div class=\"et_pb_contact_right et_pb_contact_field\">\n\t\t\t\t<p class=\"clearfix\">\n\t\t\t\t\t<span class=\"et_pb_contact_captcha_question\">2 + 4<\/span> = <input type=\"text\" size=\"2\" class=\"input et_pb_contact_captcha\" data-first_digit=\"2\" data-second_digit=\"4\" value=\"\" name=\"et_pb_contact_captcha_0\" data-required_mark=\"required\" autocomplete=\"off\">\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t<button type=\"submit\" name=\"et_builder_submit_button\" class=\"et_pb_contact_submit et_pb_button\">Submit<\/button>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<input type=\"hidden\" id=\"_wpnonce-et-pb-contact-form-submitted-0\" name=\"_wpnonce-et-pb-contact-form-submitted-0\" value=\"158d48cd9f\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/627\" \/>\n\t\t\t\t\t<\/form>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"et_pb_module et_d4_element et_pb_code et_pb_code_0\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_code_inner\">[print_link]<\/div>\n\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t\n\t\t\t<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_monsterinsights_skip_tracking":false,"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-627","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/pages\/627","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/comments?post=627"}],"version-history":[{"count":0,"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/pages\/627\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/media?parent=627"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}