{"id":57,"date":"2025-03-19T11:18:51","date_gmt":"2025-03-19T11:18:51","guid":{"rendered":"https:\/\/phr-resources.myservices.space\/?page_id=57"},"modified":"2025-03-19T11:18:51","modified_gmt":"2025-03-19T11:18:51","slug":"patient-information","status":"publish","type":"page","link":"https:\/\/phr-resources.myservices.space\/index.php\/patient-information\/","title":{"rendered":"Patient Information"},"content":{"rendered":"<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_6_container\" data-token=\"54cdacaaf019d673f369927c684e378e\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_js_validate  frm_ajax_submit  frm_pro_form \" id=\"form_new-patient-registration\" data-token=\"54cdacaaf019d673f369927c684e378e\">\n<div class=\"frm_form_fields  frm_page_num_1\">\n<fieldset>\n<legend class=\"frm_screen_reader\">New Patient Registration<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<div class=\"frm_rootline_group\" role=\"group\" tabindex=\"0\" aria-label=\"Page 1 of 4\" ><ul class=\"frm_page_bar frm_rootline_4 frm_progress frm_progress_line  frm_show_lines frm_show_titles\"><li class=\"frm_rootline_single frm_current_page\"><span class=\"frm_rootline_title\">Patient Information<\/span><input type=\"button\" value=\"1\" data-page=\"\" class=\" frm_page_1\" aria-disabled=\"true\" data-field=\"0\" aria-label=\"Patient Information\"  \/><\/li><li class=\"frm_rootline_single\"><span class=\"frm_rootline_title\">Next of Kin &#038; Emergency Contact Information<\/span><input type=\"button\" value=\"2\" data-page=\"25\" class=\"frm_page_skip frm_page_2\" data-field=\"30\" aria-label=\"Next of Kin &amp; Emergency Contact Information\"  \/><\/li><li class=\"frm_rootline_single\"><span class=\"frm_rootline_title\">Medical History<\/span><input type=\"button\" value=\"3\" data-page=\"44\" class=\"frm_page_skip frm_page_3\" data-field=\"38\" aria-label=\"Medical History\"  \/><\/li><li class=\"frm_rootline_single\"><span class=\"frm_rootline_title\">Health\/Lifestyle Habits<\/span><input type=\"button\" value=\"4\" data-page=\"67\" class=\"frm_page_skip frm_page_4\" data-field=\"47\" aria-label=\"Health\/Lifestyle Habits\"  \/><\/li><\/ul><div class=\"frm_percent_complete\">0% Complete<\/div><div class=\"frm_pages_complete\">1 of 4<\/div><div class=\"frm_clearfix\"><\/div><\/div><input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"6\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_6\" id=\"frm_hide_fields_6\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"new-patient-registration\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_6\" name=\"frm_submit_entry_6\" value=\"813ba9234b\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/57\" \/><div id=\"frm_field_16_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div id=\"field_fprs1_label\" class=\"frm_primary_label\">Patient Name\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_fprs1_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tPatient Name\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_16\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_16-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_fprs1_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_fprs1_first\" value=\"\" name=\"item_meta[16][first]\" autocomplete=\"given-name\" placeholder=\"John\" data-reqmsg=\"Patient Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient Name is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_16_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_16-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_fprs1_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_fprs1_last\" value=\"\" name=\"item_meta[16][last]\" autocomplete=\"family-name\" placeholder=\"Brown\" data-reqmsg=\"Patient Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient Name is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_16_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_17_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_dj3cq\" id=\"field_dj3cq_label\" class=\"frm_primary_label\">Gender\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[17]\" id=\"field_dj3cq\"  data-reqmsg=\"Gender cannot be blank.\" aria-required=\"true\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"Male\">Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_18_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_g0ft9\" id=\"field_g0ft9_label\" class=\"frm_primary_label\">Patient Date of Birth\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_g0ft9\" name=\"item_meta[18]\" value=\"\"  maxlength=\"10\" data-reqmsg=\"Patient Date of Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient Date of Birth is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_19_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_winse\" id=\"field_winse_label\" class=\"frm_primary_label\">Patient Email\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"email\" id=\"field_winse\" name=\"item_meta[19]\" value=\"\"  autocomplete=\"email\"  placeholder=\"myemail@gmail.com\" data-reqmsg=\"Patient Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient Email is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_20_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_abf5g\" id=\"field_abf5g_label\" class=\"frm_primary_label\">Patient Phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_abf5g\" name=\"item_meta[20]\" value=\"\"  data-frmmask=\"(999) 999-9999\" data-reqmsg=\"Patient Phone cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient Phone is invalid\" aria-invalid=\"false\" pattern=\"\\(\\d\\d\\d\\) \\d\\d\\d-\\d\\d\\d\\d$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_21_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div id=\"field_xpdr6_label\" class=\"frm_primary_label\">Unit Preference for Patient Details?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_21-0\">\t\t\t<label  for=\"field_xpdr6-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[21]\" id=\"field_xpdr6-0\" value=\"Imperial\"\n\t\t data-reqmsg=\"Unit Preference for Patient Details? cannot be blank.\" data-invmsg=\"Unit Preference for Patient Details? is invalid\"   \/> Imperial<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_21-1\">\t\t\t<label  for=\"field_xpdr6-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[21]\" id=\"field_xpdr6-1\" value=\"Metric\"\n\t\t data-reqmsg=\"Unit Preference for Patient Details? cannot be blank.\" data-invmsg=\"Unit Preference for Patient Details? is invalid\"   \/> Metric<\/label><\/div>\n<\/div>\r\n\t<div class=\"frm_description\" id=\"frm_desc_field_xpdr6\">Please choose the unit preference for entering the patient&#8217;s weight and height.<\/div>\r\n\t\r\n<\/div>\n<div id=\"frm_field_22_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_hoanw\" id=\"field_hoanw_label\" class=\"frm_primary_label\">Patient Height (Feet\/Inches)\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[22]\" id=\"field_hoanw\"  data-reqmsg=\"Patient Height (Feet\/Inches) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient Height (Feet\/Inches) is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"4 ft 0 in\">4 ft 0 in<\/option><option  value=\"4 ft 1 in\">4 ft 1 in<\/option><option  value=\"4 ft 2 in\">4 ft 2 in<\/option><option  value=\"4 ft 3 in\">4 ft 3 in<\/option><option  value=\"4 ft 4 in\">4 ft 4 in<\/option><option  value=\"4 ft 5 in\">4 ft 5 in<\/option><option  value=\"4 ft 6 in\">4 ft 6 in<\/option><option  value=\"4 ft 7 in\">4 ft 7 in<\/option><option  value=\"4 ft 8 in\">4 ft 8 in<\/option><option  value=\"4 ft 9 in\">4 ft 9 in<\/option><option  value=\"4 ft 10 in\">4 ft 10 in<\/option><option  value=\"4 ft 11 in\">4 ft 11 in<\/option><option  value=\"5 ft 0 in\">5 ft 0 in<\/option><option  value=\"4 ft 0 in\">4 ft 0 in<\/option><option  value=\"4 ft 1 in\">4 ft 1 in<\/option><option  value=\"4 ft 2 in\">4 ft 2 in<\/option><option  value=\"4 ft 3 in\">4 ft 3 in<\/option><option  value=\"4 ft 4 in\">4 ft 4 in<\/option><option  value=\"4 ft 5 in\">4 ft 5 in<\/option><option  value=\"4 ft 6 in\">4 ft 6 in<\/option><option  value=\"4 ft 7 in\">4 ft 7 in<\/option><option  value=\"4 ft 8 in\">4 ft 8 in<\/option><option  value=\"4 ft 9 in\">4 ft 9 in<\/option><option  value=\"4 ft 10 in\">4 ft 10 in<\/option><option  value=\"4 ft 11 in\">4 ft 11 in<\/option><option  value=\"5 ft 0 in\">5 ft 0 in<\/option><option  value=\"5 ft 1 in\">5 ft 1 in<\/option><option  value=\"5 ft 2 in\">5 ft 2 in<\/option><option  value=\"5 ft 3 in\">5 ft 3 in<\/option><option  value=\"5 ft 4 in\">5 ft 4 in<\/option><option  value=\"5 ft 5 in\">5 ft 5 in<\/option><option  value=\"5 ft 6 in\">5 ft 6 in<\/option><option  value=\"5 ft 7 in\">5 ft 7 in<\/option><option  value=\"5 ft 8 in\">5 ft 8 in<\/option><option  value=\"5 ft 9 in\">5 ft 9 in<\/option><option  value=\"5 ft 10 in\">5 ft 10 in<\/option><option  value=\"5 ft 11 in\">5 ft 11 in<\/option><option  value=\"6 ft 0 in\">6 ft 0 in<\/option><option  value=\"6 ft 1 in\">6 ft 1 in<\/option><option  value=\"6 ft 2 in\">6 ft 2 in<\/option><option  value=\"6 ft 3 in\">6 ft 3 in<\/option><option  value=\"6 ft 4 in\">6 ft 4 in<\/option><option  value=\"6 ft 5 in\">6 ft 5 in<\/option><option  value=\"6 ft 6 in\">6 ft 6 in<\/option><option  value=\"6 ft 7 in\">6 ft 7 in<\/option><option  value=\"6 ft 8 in\">6 ft 8 in<\/option><option  value=\"6 ft 9 in\">6 ft 9 in<\/option><option  value=\"6 ft 10 in\">6 ft 10 in<\/option><option  value=\"6 ft 11 in\">6 ft 11 in<\/option><option  value=\"7 ft 0 in\">7 ft 0 in<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_5ded5\" id=\"field_5ded5_label\" class=\"frm_primary_label\">Patient Weight (Pounds)\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[23]\" id=\"field_5ded5\"  data-reqmsg=\"Patient Weight (Pounds) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient Weight (Pounds) is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"100 lbs\">100 lbs<\/option><option  value=\"110 lbs\">110 lbs<\/option><option  value=\"120 lbs\">120 lbs<\/option><option  value=\"130 lbs\">130 lbs<\/option><option  value=\"140 lbs\">140 lbs<\/option><option  value=\"150 lbs\">150 lbs<\/option><option  value=\"160 lbs\">160 lbs<\/option><option  value=\"170 lbs\">170 lbs<\/option><option  value=\"180 lbs\">180 lbs<\/option><option  value=\"190 lbs\">190 lbs<\/option><option  value=\"200 lbs\">200 lbs<\/option><option  value=\"210 lbs\">210 lbs<\/option><option  value=\"220 lbs\">220 lbs<\/option><option  value=\"230 lbs\">230 lbs<\/option><option  value=\"240 lbs\">240 lbs<\/option><option  value=\"250 lbs\">250 lbs<\/option><option  value=\"260 lbs\">260 lbs<\/option><option  value=\"270 lbs\">270 lbs<\/option><option  value=\"280 lbs\">280 lbs<\/option><option  value=\"290 lbs\">290 lbs<\/option><option  value=\"300 lbs\">300 lbs<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_24_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_gbaw3\" id=\"field_gbaw3_label\" class=\"frm_primary_label\">Patient Height (Centimeters)\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[24]\" id=\"field_gbaw3\"  data-reqmsg=\"Patient Height (Centimeters) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient Height (Centimeters) is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"121.92 cm\">121.92 cm<\/option><option  value=\"124.46 cm\">124.46 cm<\/option><option  value=\"127 cm\">127 cm<\/option><option  value=\"129.54 cm\">129.54 cm<\/option><option  value=\"132.08 cm\">132.08 cm<\/option><option  value=\"134.62 cm\">134.62 cm<\/option><option  value=\"137.16 cm\">137.16 cm<\/option><option  value=\"139.7 cm\">139.7 cm<\/option><option  value=\"142.24 cm\">142.24 cm<\/option><option  value=\"144.78 cm\">144.78 cm<\/option><option  value=\"147.32 cm\">147.32 cm<\/option><option  value=\"149.86 cm\">149.86 cm<\/option><option  value=\"152.4 cm\">152.4 cm<\/option><option  value=\"121.92 cm\">121.92 cm<\/option><option  value=\"124.46 cm\">124.46 cm<\/option><option  value=\"127 cm\">127 cm<\/option><option  value=\"129.54 cm\">129.54 cm<\/option><option  value=\"132.08 cm\">132.08 cm<\/option><option  value=\"134.62 cm\">134.62 cm<\/option><option  value=\"137.16 cm\">137.16 cm<\/option><option  value=\"139.7 cm\">139.7 cm<\/option><option  value=\"142.24 cm\">142.24 cm<\/option><option  value=\"144.78 cm\">144.78 cm<\/option><option  value=\"147.32 cm\">147.32 cm<\/option><option  value=\"149.86 cm\">149.86 cm<\/option><option  value=\"152.4 cm\">152.4 cm<\/option><option  value=\"154.94 cm\">154.94 cm<\/option><option  value=\"157.48 cm\">157.48 cm<\/option><option  value=\"160.02 cm\">160.02 cm<\/option><option  value=\"162.56 cm\">162.56 cm<\/option><option  value=\"165.1 cm\">165.1 cm<\/option><option  value=\"167.64 cm\">167.64 cm<\/option><option  value=\"170.18 cm\">170.18 cm<\/option><option  value=\"172.72 cm\">172.72 cm<\/option><option  value=\"175.26 cm\">175.26 cm<\/option><option  value=\"177.8 cm\">177.8 cm<\/option><option  value=\"180.34 cm\">180.34 cm<\/option><option  value=\"182.88 cm\">182.88 cm<\/option><option  value=\"185.42 cm\">185.42 cm<\/option><option  value=\"187.96 cm\">187.96 cm<\/option><option  value=\"190.5 cm\">190.5 cm<\/option><option  value=\"193.04 cm\">193.04 cm<\/option><option  value=\"195.58 cm\">195.58 cm<\/option><option  value=\"198.12 cm\">198.12 cm<\/option><option  value=\"200.66 cm\">200.66 cm<\/option><option  value=\"203.2 cm\">203.2 cm<\/option><option  value=\"205.74 cm\">205.74 cm<\/option><option  value=\"208.28 cm\">208.28 cm<\/option><option  value=\"210.82 cm\">210.82 cm<\/option><option  value=\"213.36 cm\">213.36 cm<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_25_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_3gxji\" id=\"field_3gxji_label\" class=\"frm_primary_label\">Patient Weight (Kg)\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[25]\" id=\"field_3gxji\"  data-reqmsg=\"Patient Weight (Kg) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient Weight (Kg) is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"45.36 kg\">45.36 kg<\/option><option  value=\"49.90 kg\">49.90 kg<\/option><option  value=\"54.43 kg\">54.43 kg<\/option><option  value=\"58.97 kg\">58.97 kg<\/option><option  value=\"63.50 kg\">63.50 kg<\/option><option  value=\"68.04 kg\">68.04 kg<\/option><option  value=\"72.57 kg\">72.57 kg<\/option><option  value=\"77.11 kg\">77.11 kg<\/option><option  value=\"81.65 kg\">81.65 kg<\/option><option  value=\"86.18 kg\">86.18 kg<\/option><option  value=\"90.72 kg\">90.72 kg<\/option><option  value=\"95.25 kg\">95.25 kg<\/option><option  value=\"99.79 kg\">99.79 kg<\/option><option  value=\"104.33 kg\">104.33 kg<\/option><option  value=\"108.86 kg\">108.86 kg<\/option><option  value=\"113.40 kg\">113.40 kg<\/option><option  value=\"117.93 kg\">117.93 kg<\/option><option  value=\"122.47 kg\">122.47 kg<\/option><option  value=\"127.01 kg\">127.01 kg<\/option><option  value=\"131.54 kg\">131.54 kg<\/option><option  value=\"136.08 kg\">136.08 kg<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_e235m\" id=\"field_e235m_label\" class=\"frm_primary_label\">Reason For Seeing The Doctor?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_e235m\" name=\"item_meta[26]\" value=\"\"  placeholder=\"Example: Fever with a cough and joint pain\" data-reqmsg=\"Reason For Seeing The Doctor? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Reason For Seeing The Doctor? is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_e235m\" \/>\r\n\t<div class=\"frm_description\" id=\"frm_desc_field_e235m\">Please enter the symptoms you are experincing.<\/div>\r\n\t\r\n<\/div>\n<div id=\"frm_field_27_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_5i726\" id=\"field_5i726_label\" class=\"frm_primary_label\">Date\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_5i726\" name=\"item_meta[27]\" value=\"04\/12\/2026\"  readonly=\"readonly\"  maxlength=\"10\" data-frmval=\"04\/12\/2026\" data-reqmsg=\"Date cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_28_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div id=\"field_127rk_label\" class=\"frm_primary_label\">Do You Have Health Insurance\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_28-0\">\t\t\t<label  for=\"field_127rk-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[28]\" id=\"field_127rk-0\" value=\"Yes\"\n\t\t data-reqmsg=\"Do You Have Health Insurance cannot be blank.\" data-invmsg=\"Do You Have Health Insurance is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_28-1\">\t\t\t<label  for=\"field_127rk-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[28]\" id=\"field_127rk-1\" value=\"No\"\n\t\t data-reqmsg=\"Do You Have Health Insurance cannot be blank.\" data-invmsg=\"Do You Have Health Insurance is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_29_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_other_container\">\r\n\t<label for=\"field_gl8p8\" id=\"field_gl8p8_label\" class=\"frm_primary_label\">Select Your Health Insurance Provider\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[29]\" id=\"field_gl8p8\"  data-placeholder=\"Select an option\"  data-reqmsg=\"Select Your Health Insurance Provider cannot be blank.\" aria-required=\"true\" data-invmsg=\"Select Your Health Insurance Provider is invalid\" class=\"frm_slimselect\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"UnitedHealth Group\">UnitedHealth Group<\/option><option  value=\"Elevance Health Inc. (formerly Anthem)\">Elevance Health Inc. (formerly Anthem)<\/option><option  value=\"Centene Corp.\">Centene Corp.<\/option><option  value=\"Kaiser Foundation (Kaiser Permanente)\">Kaiser Foundation (Kaiser Permanente)<\/option><option  value=\"Humana\">Humana<\/option><option  value=\"CVS Health (including Aetna Health)\">CVS Health (including Aetna Health)<\/option><option  value=\"Health Care Services Corporation (HCSC)\">Health Care Services Corporation (HCSC)<\/option><option  value=\"Cigna Health\">Cigna Health<\/option><option  value=\"Molina Healthcare Inc.\">Molina Healthcare Inc.<\/option><option  value=\"GuideWell (including Florida Blue)\">GuideWell (including Florida Blue)<\/option><option  value=\"Blue Cross Blue Shield of Massachusetts\">Blue Cross Blue Shield of Massachusetts<\/option><option  value=\"Blue Cross Blue Shield of Michigan\">Blue Cross Blue Shield of Michigan<\/option><option  value=\"Independence Health Group\">Independence Health Group<\/option><option  value=\"Wellcare Health Plans\">Wellcare Health Plans<\/option><option  value=\"Highmark Group\">Highmark Group<\/option><option  value=\"CareSource\">CareSource<\/option><option  value=\"Medica Health Plans\">Medica Health Plans<\/option><option  value=\"UPMC Health Plan\">UPMC Health Plan<\/option><option  value=\"Excellus Health Plan Inc.\">Excellus Health Plan Inc.<\/option><option  value=\"Amerigroup\">Amerigroup<\/option><option  value=\"MetroPlus Health Plan\">MetroPlus Health Plan<\/option><option  value=\"Fidelis Care\">Fidelis Care<\/option><option  value=\"Priority Health\">Priority Health<\/option><option  value=\"Independence Blue Cross\">Independence Blue Cross<\/option><option  value=\"Tufts Health Plan\">Tufts Health Plan<\/option><option  value=\"Community Health Choice\">Community Health Choice<\/option><option  value=\"Geisinger Health Plan\">Geisinger Health Plan<\/option><option  value=\"Oscar Health\">Oscar Health<\/option><option  value=\"HealthPartners\">HealthPartners<\/option><option  value=\"Harvard Pilgrim Health Care\">Harvard Pilgrim Health Care<\/option><option  value=\"Horizon Blue Cross Blue Shield of New Jersey\">Horizon Blue Cross Blue Shield of New Jersey<\/option><option  value=\"Molina Healthcare of California\">Molina Healthcare of California<\/option><option  value=\"MVP Health Care\">MVP Health Care<\/option><option  value=\"Bright HealthCare\">Bright HealthCare<\/option><option  value=\"Capital District Physicians\u2019 Health Plan (CDPHP)\">Capital District Physicians\u2019 Health Plan (CDPHP)<\/option><option  value=\"Wellmark Blue Cross Blue Shield\">Wellmark Blue Cross Blue Shield<\/option><option  value=\"AllWays Health Partners\">AllWays Health Partners<\/option><option  value=\"Inter Valley Health Plan\">Inter Valley Health Plan<\/option><option  value=\"Group Health Cooperative of Eau Claire\">Group Health Cooperative of Eau Claire<\/option><option  value=\"SummaCare\">SummaCare<\/option><option  value=\"SelectHealth\">SelectHealth<\/option><option  value=\"Blue Shield of California\">Blue Shield of California<\/option><option  value=\"Neighborhood Health Plan of Rhode Island\">Neighborhood Health Plan of Rhode Island<\/option><option  value=\"Security Health Plan of Wisconsin\">Security Health Plan of Wisconsin<\/option><option  value=\"AvMed Health Plans\">AvMed Health Plans<\/option><option  value=\"Fallon Community Health Plan\">Fallon Community Health Plan<\/option><option  value=\"ConnectiCare\">ConnectiCare<\/option><option  value=\"Presbyterian Healthcare Services\">Presbyterian Healthcare Services<\/option><option  value=\"Rocky Mountain Health Plans\">Rocky Mountain Health Plans<\/option><option  value=\"Scott and White Health Plan\">Scott and White Health Plan<\/option><option  value=\"Other\" class=\"frm_other_trigger\">Other<\/option>\t<\/select>\n\t<label for=\"field_gl8p8-otext\" class=\"frm_screen_reader frm_hidden\">Select Your Health Insurance Provider<\/label><input type=\"text\" id=\"field_gl8p8-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][29]\" value=\"\" \/>\r\n\t\r\n\t\r\n<\/div>\n<input type=\"hidden\" name=\"frm_page_order_6\" id=\"frm_page_order_6\" value=\"25\" \/><input type=\"hidden\" name=\"item_meta[31]\" id=\"field_sx9jm\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[32]\" id=\"field_ghxdq\" value=\"\"  autocomplete=\"email\"     \/>\n<input type=\"hidden\" name=\"item_meta[33]\" id=\"field_fyuy2\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[34]\" id=\"field_9kp6r\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[35]\" id=\"field_lx680-0\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[36]\" id=\"field_at1xu\" value=\"\" \/>\n\t\t\t<input type=\"hidden\" name=\"item_meta[37]\" id=\"field_t950i\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[38]\" id=\"field_kk1si\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[39]\" id=\"field_7zwn1-0\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[40]\" id=\"field_7xlhg\" value=\"\" \/>\n\t\t\t<input type=\"hidden\" name=\"item_meta[41]\" id=\"field_8lj3j\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[42]\" id=\"field_6mbdu-0\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[43]\" id=\"field_s2nn2\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[44]\" id=\"field_pajzl-0\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[45]\" id=\"field_f43c7\" value=\"\" \/>\n\t\t\t<input type=\"hidden\" name=\"item_meta[46]\" id=\"field_tbccy\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[47]\" id=\"field_ms0vk\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[48]\" id=\"field_v7kpz-0\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[49]\" id=\"field_usg2k-0\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[50]\" id=\"field_pq773-0\" value=\"\"     \/>\n<input type=\"hidden\" name=\"item_meta[51]\" 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formnovalidate=\"formnovalidate\">Next<\/button>\r\n\r\n\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-57","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/phr-resources.myservices.space\/index.php\/wp-json\/wp\/v2\/pages\/57","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/phr-resources.myservices.space\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/phr-resources.myservices.space\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/phr-resources.myservices.space\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/phr-resources.myservices.space\/index.php\/wp-json\/wp\/v2\/comments?post=57"}],"version-history":[{"count":1,"href":"https:\/\/phr-resources.myservices.space\/index.php\/wp-json\/wp\/v2\/pages\/57\/revisions"}],"predecessor-version":[{"id":59,"href":"https:\/\/phr-resources.myservices.space\/index.php\/wp-json\/wp\/v2\/pages\/57\/revisions\/59"}],"wp:attachment":[{"href":"https:\/\/phr-resources.myservices.space\/index.php\/wp-json\/wp\/v2\/media?parent=57"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}