{"id":4066,"date":"2020-03-23T11:06:53","date_gmt":"2020-03-23T18:06:53","guid":{"rendered":"http:\/\/www.pacificneurosurgery.com\/?page_id=4066"},"modified":"2021-08-23T11:10:14","modified_gmt":"2021-08-23T18:10:14","slug":"online-registration","status":"publish","type":"page","link":"http:\/\/www.pacificneurosurgery.com\/?page_id=4066","title":{"rendered":"Online Registration"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\"><div id=\"erf_form_container_4074\" class=\"erf-container erf-contact erf-label-top erf-layout-two-column erf-style-rounded-corner\">\n        \n    \n         \n                    <div class=\"erf-content-above\">\n                Please complete the information below and submit the form online, or if you prefer PDF versions of the paperwork are available for download and print.\u00a0This form contains confidential information and is delivered to your doctor through a secure Internet connection. We understand that filling out these forms can be time consuming; however, it's required by health insurance and enables us to provide the best possible care. Thank you ahead of time for your participation.            <\/div>\n            <form method=\"post\" enctype=\"multipart\/form-data\" class=\"erf-form erf-front-form\" data-parsley-validate=\"\" novalidate=\"true\" data-erf-submission-id=\"0\" data-erf-form-id=\"4074\">\n                <div class=\"erf-form-html\" id=\"erf_form_4074\">\n                    <div class=\"rendered-form\">\n                        <div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-c1Z3biQq' data-ref-id='ref-nxtxys7u' class='' >Patient Information<\/h1><\/div><div class=\"erf-text form-group field-text-5588508713 erf-element-width-12\"><label for=\"text-5588508713\" class=\"erf-text-label\">First Name<span class=\"erf-required\">*<\/span><\/label><input type='text' maxlength='50' required='required' class='form-control' name='text-5588508713' id='text-5588508713'  \/><\/div><div class=\"erf-text form-group field-text-170389416303 erf-element-width-12\"><label for=\"text-170389416303\" class=\"erf-text-label\">Last Name<span class=\"erf-required\">*<\/span><\/label><input type='text' required='required' maxlength='50' class='form-control' name='text-170389416303' id='text-170389416303'  \/><\/div><div class=\"erf-text form-group field-field-rNXJew88vLdA5Fl erf-element-width-12\"><label for=\"field-rNXJew88vLdA5Fl\" class=\"erf-text-label\">Date of Birth<\/label><input type='text' data-date-format='mm\/dd\/yy' class='form-control erf-date-field' name='field-rNXJew88vLdA5Fl' id='field-rNXJew88vLdA5Fl'  \/><\/div><div class=\"erf-text form-group field-field-3PxOQ9iiyyeYUYI erf-element-width-12\"><label for=\"field-3PxOQ9iiyyeYUYI\" class=\"erf-text-label\">Social Security Number<\/label><input type='text' class='form-control' name='field-3PxOQ9iiyyeYUYI' id='field-3PxOQ9iiyyeYUYI'  \/><\/div><div class=\"erf-checkbox-group form-group field-field-wQGW7G7rQ4tjRAG erf-element-width-12\"><label for=\"field-wQGW7G7rQ4tjRAG\" class=\"erf-checkbox-group-label\">Gender<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-wQGW7G7rQ4tjRAG-0\" name='field-wQGW7G7rQ4tjRAG[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"Male\" \/><label for=\"field-wQGW7G7rQ4tjRAG-0\">Male<\/label><\/div><div class=\"checkbox\"><input id=\"field-wQGW7G7rQ4tjRAG-1\" name='field-wQGW7G7rQ4tjRAG[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"Female\" \/><label for=\"field-wQGW7G7rQ4tjRAG-1\">Female<\/label><\/div><\/div><\/div><div class=\"erf-separator erf-element-width-12\"><div data-non-input='1' custom-type='spacer' class='spacer' data-ref-label='ref-COGPPfXz' data-ref-id='ref-yXguMdlx' >Separator<\/div><\/div><div class=\"erf-street1 form-group field-field-cBM6gRTB2rZ4uiq erf-element-width-12\"><label for=\"field-cBM6gRTB2rZ4uiq\" class=\"erf-street1-label\">Street Address1<\/label><input type='street1' class='form-control' name='field-cBM6gRTB2rZ4uiq' id='field-cBM6gRTB2rZ4uiq'  \/><\/div><div class=\"erf-street2 form-group field-field-J87d6rKkKLR3PpT erf-element-width-12\"><label for=\"field-J87d6rKkKLR3PpT\" class=\"erf-street2-label\">Street Address2<\/label><input type='street2' class='form-control' name='field-J87d6rKkKLR3PpT' id='field-J87d6rKkKLR3PpT'  \/><\/div><div class=\"erf-city form-group field-field-7ECDm4iioRvL3vk erf-element-width-12\"><label for=\"field-7ECDm4iioRvL3vk\" class=\"erf-city-label\">City<\/label><input type='city' class='form-control' name='field-7ECDm4iioRvL3vk' id='field-7ECDm4iioRvL3vk'  \/><\/div><div class=\"erf-select form-group field-field-sSd58KxBXSjH69u erf-element-width-12\"><label for=\"field-sSd58KxBXSjH69u\" class=\"erf-state-label\">State \/ Province<\/label><select class='form-control' name='field-sSd58KxBXSjH69u' id='field-sSd58KxBXSjH69u'  ><\/select><\/div><div class=\"erf-zip form-group field-field-BoqEPsOCTB2wAaF erf-element-width-12\"><label for=\"field-BoqEPsOCTB2wAaF\" class=\"erf-zip-label\">Postcode \/ Zip<\/label><input type='zip' class='form-control' name='field-BoqEPsOCTB2wAaF' id='field-BoqEPsOCTB2wAaF'  \/><\/div><div class=\"erf-separator erf-element-width-12\"><div data-non-input='1' custom-type='spacer' class='spacer' data-ref-label='ref-aimLin6e' data-ref-id='ref-Qjhe5u3E' >Separator<\/div><\/div><div class=\"erf-tel form-group field-field-1DXdcRJw90zdDeq erf-element-width-12\"><label for=\"field-1DXdcRJw90zdDeq\" class=\"erf-tel-label\">Home Phone Number<\/label><input type='tel' class='form-control' name='field-1DXdcRJw90zdDeq' enable-intl='1' id='field-1DXdcRJw90zdDeq'  \/><\/div><div class=\"erf-tel form-group field-field-ShZlOWiqmtL4wWl erf-element-width-12\"><label for=\"field-ShZlOWiqmtL4wWl\" class=\"erf-tel-label\">Cell Phone Number<\/label><input type='tel' class='form-control' name='field-ShZlOWiqmtL4wWl' enable-intl='1' id='field-ShZlOWiqmtL4wWl'  \/><\/div><div class=\"erf-email form-group field-text-29175458105 erf-element-width-12\"><label for=\"text-29175458105\" class=\"erf-email-label\">Email<\/label><input type='email' class='form-control' name='text-29175458105' id='text-29175458105'  \/><\/div><div class=\"erf-separator erf-element-width-12\"><div data-non-input='1' custom-type='spacer' class='spacer' data-ref-label='ref-eLZv6vuk' data-ref-id='ref-QZxgGNCl' >Separator<\/div><\/div><div class=\"erf-text form-group field-field-LL1sxCWq6zudwns erf-element-width-12\"><label for=\"field-LL1sxCWq6zudwns\" class=\"erf-text-label\">Employer<\/label><input type='text' class='form-control' name='field-LL1sxCWq6zudwns' id='field-LL1sxCWq6zudwns'  \/><\/div><div class=\"erf-text form-group field-field-behHkCBiBaFma20 erf-element-width-12\"><label for=\"field-behHkCBiBaFma20\" class=\"erf-text-label\">Occupation<\/label><input type='text' class='form-control' name='field-behHkCBiBaFma20' id='field-behHkCBiBaFma20'  \/><\/div><div class=\"erf-text form-group field-field-C96j3yQb1LT4xAg erf-element-width-12\"><label for=\"field-C96j3yQb1LT4xAg\" class=\"erf-text-label\">Referred By<\/label><input type='text' class='form-control' name='field-C96j3yQb1LT4xAg' id='field-C96j3yQb1LT4xAg'  \/><\/div><div class=\"erf-text form-group field-field-qqxQjxemi2HcIQZ erf-element-width-12\"><label for=\"field-qqxQjxemi2HcIQZ\" class=\"erf-text-label\">Primary Care Physician<\/label><input type='text' class='form-control' name='field-qqxQjxemi2HcIQZ' id='field-qqxQjxemi2HcIQZ'  \/><\/div><div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-b5ijOEO8' data-ref-id='ref-JGNJFMc7' class='' >Demographic Information<\/h1><\/div><div class=\"erf-text form-group field-field-03rvZzRZCDZXgbF erf-element-width-12\"><label for=\"field-03rvZzRZCDZXgbF\" class=\"erf-text-label\">Height<\/label><input type='text' class='form-control' name='field-03rvZzRZCDZXgbF' id='field-03rvZzRZCDZXgbF'  \/><\/div><div class=\"erf-text form-group field-field-Pg2ru6dpgboFgm8 erf-element-width-12\"><label for=\"field-Pg2ru6dpgboFgm8\" class=\"erf-text-label\">Weight<\/label><input type='text' class='form-control' name='field-Pg2ru6dpgboFgm8' id='field-Pg2ru6dpgboFgm8'  \/><\/div><div class=\"erf-select form-group field-field-dl3yVhDToIXa706 erf-element-width-12\"><label for=\"field-dl3yVhDToIXa706\" class=\"erf-select-label\">Preferred Language<\/label><select class='form-control' name='field-dl3yVhDToIXa706' id='field-dl3yVhDToIXa706'  ><option value=\"English\">English<\/option><option value=\"Spanish\">Spanish<\/option><option value=\"Chinese\">Chinese<\/option><option value=\"German\">German<\/option><option value=\"Other\">Other<\/option><option value=\"Decline\">Decline<\/option><\/select><\/div><div class=\"erf-select form-group field-field-joMehSvnw0TT5cb erf-element-width-12\"><label for=\"field-joMehSvnw0TT5cb\" class=\"erf-select-label\">Ethnicity<\/label><select class='form-control' name='field-joMehSvnw0TT5cb' id='field-joMehSvnw0TT5cb'  ><option value=\"Non-Hispanic or Latino\">Non-Hispanic or Latino<\/option><option value=\"Hispanic or Latino\">Hispanic or Latino<\/option><option value=\"Unknown\">Unknown<\/option><option value=\"Decline\">Decline<\/option><\/select><\/div><div class=\"erf-select form-group field-field-90S6n6icNZ4FvQf erf-element-width-12\"><label for=\"field-90S6n6icNZ4FvQf\" class=\"erf-select-label\">Race<\/label><select class='form-control' name='field-90S6n6icNZ4FvQf' id='field-90S6n6icNZ4FvQf'  ><option value=\"American Indian\/Alaska Native\">American Indian\/Alaska Native<\/option><option value=\"Asian\">Asian<\/option><option value=\"Black or African American\">Black or African American<\/option><option value=\"Decline\">Decline<\/option><option value=\"Native Hawaiian or Pacific Islander\">Native Hawaiian of Pacific Islander<\/option><option selected value=\"Other\">Other<\/option><option value=\"Unknown\">Unknown<\/option><option value=\"White\">White<\/option><\/select><\/div><div class=\"erf-select form-group field-field-eoRvXhi3pl3qSVG erf-element-width-12\"><label for=\"field-eoRvXhi3pl3qSVG\" class=\"erf-select-label\">Marital Status<\/label><select class='form-control' name='field-eoRvXhi3pl3qSVG' id='field-eoRvXhi3pl3qSVG'  ><option value=\"Single\">Single<\/option><option value=\"Married\">Married<\/option><option value=\"Widowed\">Widowed<\/option><option value=\"Separated\">Separated<\/option><option value=\"Divorced\">Divorced<\/option><\/select><\/div><div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-lWnL3bnr' data-ref-id='ref-VEwo6N0G' class='' >Emergency Contact Information<\/h1><\/div><div class=\"erf-text form-group field-field-AXafilILc9Ai6f9 erf-element-width-12\"><label for=\"field-AXafilILc9Ai6f9\" class=\"erf-text-label\">First Name<\/label><input type='text' class='form-control' name='field-AXafilILc9Ai6f9' id='field-AXafilILc9Ai6f9'  \/><\/div><div class=\"erf-text form-group field-field-AYsV5XPraq0dFaQ erf-element-width-12\"><label for=\"field-AYsV5XPraq0dFaQ\" class=\"erf-text-label\">Last Name<\/label><input type='text' class='form-control' name='field-AYsV5XPraq0dFaQ' id='field-AYsV5XPraq0dFaQ'  \/><\/div><div class=\"erf-tel form-group field-field-7Dj8UVHqEnJgEuA erf-element-width-12\"><label for=\"field-7Dj8UVHqEnJgEuA\" class=\"erf-tel-label\">Preferred Phone Number<\/label><input type='tel' class='form-control' name='field-7Dj8UVHqEnJgEuA' enable-intl='1' id='field-7Dj8UVHqEnJgEuA'  \/><\/div><div class=\"erf-text form-group field-field-Ss4HpOoKiZbZCAN erf-element-width-12\"><label for=\"field-Ss4HpOoKiZbZCAN\" class=\"erf-text-label\">Relationship to Patient<\/label><input type='text' class='form-control' name='field-Ss4HpOoKiZbZCAN' id='field-Ss4HpOoKiZbZCAN'  \/><\/div><div class=\"erf-separator erf-element-width-12\"><div data-non-input='1' custom-type='spacer' class='spacer' data-ref-label='ref-fO9luWgB' data-ref-id='ref-FvAUnAMU' >Separator<\/div><\/div><div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-PB9Zrgav' data-ref-id='ref-MGeFKEfV' class='' >Advanced Directive<\/h1><\/div><div class=\"erf-richtext erf-element-width-12\"><div data-non-input='1' data-ref-label='ref-4N1GT8QZ' data-ref-id='ref-IixcI2sS' class='erf-rich-text' ><p>An advanced directive is a document that you complete to be used in a situation when you can\u2019t speak for yourself and make your own decisions regarding the healthcare you want. It can do two things: (1) name the person you want to make decisions on your behalf when you can\u2019t and (2) provide that person and your health care team with information on the decision you would make if you could speak for yourself.<\/p><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-qwLXOD7e2FAM4q5 erf-element-width-12\"><label for=\"field-qwLXOD7e2FAM4q5\" class=\"erf-checkbox-group-label\">Do you have any type of Advanced Directive?<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-qwLXOD7e2FAM4q5-0\" name='field-qwLXOD7e2FAM4q5[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"Yes\" \/><label for=\"field-qwLXOD7e2FAM4q5-0\">Yes<\/label><\/div><div class=\"checkbox\"><input id=\"field-qwLXOD7e2FAM4q5-1\" name='field-qwLXOD7e2FAM4q5[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"No\" \/><label for=\"field-qwLXOD7e2FAM4q5-1\">No<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-YrNYixQ7q6Xhrgk erf-element-width-12\"><label for=\"field-YrNYixQ7q6Xhrgk\" class=\"erf-checkbox-group-label\">If yes, which type of Advanced Directive do you have:<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-YrNYixQ7q6Xhrgk-0\" name='field-YrNYixQ7q6Xhrgk[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"Durable Power of Attorney\" \/><label for=\"field-YrNYixQ7q6Xhrgk-0\">Durable Power of Attorney<\/label><\/div><div class=\"checkbox\"><input id=\"field-YrNYixQ7q6Xhrgk-1\" name='field-YrNYixQ7q6Xhrgk[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"Living Will\" \/><label for=\"field-YrNYixQ7q6Xhrgk-1\">Living Will<\/label><\/div><div class=\"checkbox\"><input id=\"field-YrNYixQ7q6Xhrgk-2\" name='field-YrNYixQ7q6Xhrgk[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"POLST\" \/><label for=\"field-YrNYixQ7q6Xhrgk-2\">POLST<\/label><\/div><\/div><\/div><div class=\"erf-separator erf-element-width-12\"><div data-non-input='1' custom-type='spacer' class='spacer' data-ref-label='ref-bA0B0vnZ' data-ref-id='ref-lMNLtJxQ' >Separator<\/div><\/div><div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-pKPrTD5L' data-ref-id='ref-KT9VELIt' class='' >Insurance Information<\/h1><\/div><div class=\"erf-richtext erf-element-width-12\"><div data-non-input='1' data-ref-label='ref-vTvamE12' data-ref-id='ref-ezq5ZtdA' class='erf-rich-text' ><p><strong>Please bring your insurance cards with you to your appointment.<\/strong><\/p><\/div><\/div><div class=\"erf-text form-group field-field-ffCuMrEVaPmLmQq erf-element-width-12\"><label for=\"field-ffCuMrEVaPmLmQq\" class=\"erf-text-label\">Primary Insurance Carrier Name<\/label><input type='text' class='form-control' name='field-ffCuMrEVaPmLmQq' id='field-ffCuMrEVaPmLmQq'  \/><\/div><div class=\"erf-text form-group field-field-oaZHmkJPq68bKuC erf-element-width-12\"><label for=\"field-oaZHmkJPq68bKuC\" class=\"erf-text-label\">Policy Number or Medicare ID Number<\/label><input type='text' class='form-control' name='field-oaZHmkJPq68bKuC' id='field-oaZHmkJPq68bKuC'  \/><\/div><div class=\"erf-text form-group field-field-BYmIQGtfPNTn4oI erf-element-width-12\"><label for=\"field-BYmIQGtfPNTn4oI\" class=\"erf-text-label\">Effective Date<\/label><input type='text' data-date-format='mm\/dd\/yy' class='form-control erf-date-field' name='field-BYmIQGtfPNTn4oI' id='field-BYmIQGtfPNTn4oI'  \/><\/div><div class=\"erf-checkbox-group form-group field-field-SxyY8fVTDwche4y erf-element-width-12\"><label for=\"field-SxyY8fVTDwche4y\" class=\"erf-checkbox-group-label\">Policy Type<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-SxyY8fVTDwche4y-0\" name='field-SxyY8fVTDwche4y[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"PPO\" \/><label for=\"field-SxyY8fVTDwche4y-0\">PPO<\/label><\/div><div class=\"checkbox\"><input id=\"field-SxyY8fVTDwche4y-1\" name='field-SxyY8fVTDwche4y[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"HMO\" \/><label for=\"field-SxyY8fVTDwche4y-1\">HMO<\/label><\/div><\/div><\/div><div class=\"erf-select form-group field-field-yoC8kyB5qVT9qbf erf-element-width-12\"><label for=\"field-yoC8kyB5qVT9qbf\" class=\"erf-select-label\">Relationship to Subscriber<\/label><select class='form-control' name='field-yoC8kyB5qVT9qbf' id='field-yoC8kyB5qVT9qbf'  ><option value=\"Value\">Self<\/option><option value=\"Value\">Spouse<\/option><option value=\"Value\">Dependent<\/option><option value=\"Value\">Other<\/option><\/select><\/div><div class=\"erf-text form-group field-field-94aWP8RRjYumY6v erf-element-width-12\"><label for=\"field-94aWP8RRjYumY6v\" class=\"erf-text-label\">Name of Subscriber (If Different from Patient)<\/label><input type='text' class='form-control' name='field-94aWP8RRjYumY6v' id='field-94aWP8RRjYumY6v'  \/><\/div><div class=\"erf-text form-group field-field-AV2OS7VVzEbiAJA erf-element-width-12\"><label for=\"field-AV2OS7VVzEbiAJA\" class=\"erf-text-label\">Subscriber Date of Birth (If Different from Patient)<\/label><input type='text' data-date-format='mm\/dd\/yy' class='form-control erf-date-field' name='field-AV2OS7VVzEbiAJA' id='field-AV2OS7VVzEbiAJA'  \/><\/div><div class=\"erf-separator erf-element-width-12\"><div data-non-input='1' custom-type='spacer' class='spacer' data-ref-label='ref-4vTSrL5A' data-ref-id='ref-YiadSa44' >Separator<\/div><\/div><div class=\"erf-text form-group field-field-aT1xsuDrx4yKwOs erf-element-width-12\"><label for=\"field-aT1xsuDrx4yKwOs\" class=\"erf-text-label\">Secondary Insurance Carrier Name (If Applicable)<\/label><input type='text' class='form-control' name='field-aT1xsuDrx4yKwOs' id='field-aT1xsuDrx4yKwOs'  \/><\/div><div class=\"erf-text form-group field-field-Txn3xF0LWtocEuf erf-element-width-12\"><label for=\"field-Txn3xF0LWtocEuf\" class=\"erf-text-label\">Policy Number or Medicare ID Number<\/label><input type='text' class='form-control' name='field-Txn3xF0LWtocEuf' id='field-Txn3xF0LWtocEuf'  \/><\/div><div class=\"erf-text form-group field-field-2lsIuGEBKAiP9WI erf-element-width-12\"><label for=\"field-2lsIuGEBKAiP9WI\" class=\"erf-text-label\">Effective Date<\/label><input type='text' data-date-format='mm\/dd\/yy' class='form-control erf-date-field' name='field-2lsIuGEBKAiP9WI' id='field-2lsIuGEBKAiP9WI'  \/><\/div><div class=\"erf-checkbox-group form-group field-field-y3SQAGjVCO9rQSh erf-element-width-12\"><label for=\"field-y3SQAGjVCO9rQSh\" class=\"erf-checkbox-group-label\">Policy Type<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-y3SQAGjVCO9rQSh-0\" name='field-y3SQAGjVCO9rQSh[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"PPO\" \/><label for=\"field-y3SQAGjVCO9rQSh-0\">PPO<\/label><\/div><div class=\"checkbox\"><input id=\"field-y3SQAGjVCO9rQSh-1\" name='field-y3SQAGjVCO9rQSh[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"HMO\" \/><label for=\"field-y3SQAGjVCO9rQSh-1\">HMO<\/label><\/div><\/div><\/div><div class=\"erf-select form-group field-field-63OlLfsqqZ0kW1Y erf-element-width-12\"><label for=\"field-63OlLfsqqZ0kW1Y\" class=\"erf-select-label\">Relationship to Subscriber<\/label><select class='form-control' name='field-63OlLfsqqZ0kW1Y' id='field-63OlLfsqqZ0kW1Y'  ><option value=\"Value\">Self<\/option><option value=\"Value\">Spouse<\/option><option value=\"Value\">Dependent<\/option><option value=\"Value\">Other<\/option><\/select><\/div><div class=\"erf-text form-group field-field-VZeIikxMw7e0sz4 erf-element-width-12\"><label for=\"field-VZeIikxMw7e0sz4\" class=\"erf-text-label\">Name of Subscriber (If Different from Patient)<\/label><input type='text' class='form-control' name='field-VZeIikxMw7e0sz4' id='field-VZeIikxMw7e0sz4'  \/><\/div><div class=\"erf-text form-group field-field-nA6pPMNNOZG3dOG erf-element-width-12\"><label for=\"field-nA6pPMNNOZG3dOG\" class=\"erf-text-label\">Subscriber Date of Birth (If Different from Patient)<\/label><input type='text' data-date-format='mm\/dd\/yy' class='form-control erf-date-field' name='field-nA6pPMNNOZG3dOG' id='field-nA6pPMNNOZG3dOG'  \/><\/div><div class=\"erf-separator erf-element-width-12\"><div data-non-input='1' custom-type='spacer' class='spacer' data-ref-label='ref-Kqb2QIb7' data-ref-id='ref-3brjNHAS' >Separator<\/div><\/div><div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-vPGEuaw3' data-ref-id='ref-moKnsT33' class='' >Authorization<\/h1><\/div><div class=\"erf-richtext erf-element-width-12\"><div data-non-input='1' data-ref-label='ref-LhkEKryy' data-ref-id='ref-2djusuLf' class='erf-rich-text' ><p>I hereby authorize Pacific Neurosurgery to furnish information to insurance carriers concerning this illness\/accident, and hereby irrevocably assign to the doctors all payments for medical services rendered. I understand that I will be responsible for any legal costs and attorney\u2019s fees incurred for collection of any past due account. I further understand that I am financially responsible for all charges whether or not covered by insurance.<\/p><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-dzNsUzfEYLgaYSV erf-element-width-12\"><label for=\"field-dzNsUzfEYLgaYSV\" class=\"erf-checkbox-group-label\">I agree<span class=\"erf-required\">*<\/span><\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-dzNsUzfEYLgaYSV-0\" name='field-dzNsUzfEYLgaYSV[]' required='required' class='form-control' multiple='1'  type=\"checkbox\" value=\"I agree\" \/><label for=\"field-dzNsUzfEYLgaYSV-0\"><\/label><\/div><\/div><\/div><div class=\"erf-splitter erf-element-width-12\"><div data-non-input='1' custom-type='page-break' class='' data-ref-label='ref-ieVIrwBB' data-ref-id='ref-3hRYnNxa' >Splitter<\/div><\/div><div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-tKVydMk5' data-ref-id='ref-mKW1pZlC' class='' >Medical History<\/h1><\/div><div class=\"erf-textarea form-group field-field-FLXDZGU03mPD0Ea erf-element-width-12\"><label for=\"field-FLXDZGU03mPD0Ea\" class=\"erf-textarea-label\">Current Medication & Dosage (mg)<\/label><textarea class='form-control' name='field-FLXDZGU03mPD0Ea' id='field-FLXDZGU03mPD0Ea' ><\/textarea><\/div><div class=\"erf-textarea form-group field-field-LGBj0YIKLHJcgxB erf-element-width-12\"><label for=\"field-LGBj0YIKLHJcgxB\" class=\"erf-textarea-label\">Allergies (Drug and\/or Medical)<\/label><textarea class='form-control' name='field-LGBj0YIKLHJcgxB' id='field-LGBj0YIKLHJcgxB' ><\/textarea><\/div><div class=\"erf-textarea form-group field-field-PljEDYlHbrERxZ7 erf-element-width-12\"><label for=\"field-PljEDYlHbrERxZ7\" class=\"erf-textarea-label\">Previous Surgical Procedures & Approx. Dates<\/label><textarea class='form-control' name='field-PljEDYlHbrERxZ7' id='field-PljEDYlHbrERxZ7' ><\/textarea><\/div><div class=\"erf-textarea form-group field-field-fF76QNBe8RSqu1l erf-element-width-12\"><label for=\"field-fF76QNBe8RSqu1l\" class=\"erf-textarea-label\">Previous Significant Injuries & Approx. Dates<\/label><textarea class='form-control' name='field-fF76QNBe8RSqu1l' id='field-fF76QNBe8RSqu1l' ><\/textarea><\/div><div class=\"erf-checkbox-group form-group field-field-7EgtNdIEJ6BKNyC erf-element-width-12\"><label for=\"field-7EgtNdIEJ6BKNyC\" class=\"erf-checkbox-group-label\">Do You Drink Alcohol?<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-7EgtNdIEJ6BKNyC-0\" name='field-7EgtNdIEJ6BKNyC[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"Yes\" \/><label for=\"field-7EgtNdIEJ6BKNyC-0\">Yes<\/label><\/div><div class=\"checkbox\"><input id=\"field-7EgtNdIEJ6BKNyC-1\" name='field-7EgtNdIEJ6BKNyC[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"No\" \/><label for=\"field-7EgtNdIEJ6BKNyC-1\">No<\/label><\/div><div class=\"checkbox\"><input id=\"field-7EgtNdIEJ6BKNyC-2\" name='field-7EgtNdIEJ6BKNyC[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"Occasionally\" \/><label for=\"field-7EgtNdIEJ6BKNyC-2\">Occasionally<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-8TBhKyKhudLKv2v erf-element-width-12\"><label for=\"field-8TBhKyKhudLKv2v\" class=\"erf-checkbox-group-label\">Do You Smoke?<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-8TBhKyKhudLKv2v-0\" name='field-8TBhKyKhudLKv2v[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"Yes\" \/><label for=\"field-8TBhKyKhudLKv2v-0\">Yes<\/label><\/div><div class=\"checkbox\"><input id=\"field-8TBhKyKhudLKv2v-1\" name='field-8TBhKyKhudLKv2v[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"No\" \/><label for=\"field-8TBhKyKhudLKv2v-1\">No<\/label><\/div><div class=\"checkbox\"><input id=\"field-8TBhKyKhudLKv2v-2\" name='field-8TBhKyKhudLKv2v[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"I did smoke, but I do not smoke currently\" \/><label for=\"field-8TBhKyKhudLKv2v-2\">I did smoke, but I do not smoke currently<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-Pb46b9cItp7wr3B erf-element-width-12\"><label for=\"field-Pb46b9cItp7wr3B\" class=\"erf-checkbox-group-label\">Do You Experience Any of the Following?<\/label><div class=\"checkbox-group\"><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-0\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"BACK PAIN\" \/><label for=\"field-Pb46b9cItp7wr3B-0\">Back Pain<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-1\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"NECK STIFFNESS\" \/><label for=\"field-Pb46b9cItp7wr3B-1\">Neck Stiffness<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-2\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"HEART PROBLEMS\" \/><label for=\"field-Pb46b9cItp7wr3B-2\">Heart Problems<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-3\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"ASTHMA\" \/><label for=\"field-Pb46b9cItp7wr3B-3\">Asthma<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-4\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"CANCER\/MALIGNANCY\" \/><label for=\"field-Pb46b9cItp7wr3B-4\">Cancer\/Malignancy<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-5\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"ALCOHOL\/DRUG ADDICTION\" \/><label for=\"field-Pb46b9cItp7wr3B-5\">Alcohol\/Drug Addiction<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-6\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"STD\" \/><label for=\"field-Pb46b9cItp7wr3B-6\">STD<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-7\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"BLOOD CLOTS\" \/><label for=\"field-Pb46b9cItp7wr3B-7\">Blood Clots<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-8\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"THYROID PROBLEMS\" \/><label for=\"field-Pb46b9cItp7wr3B-8\">Thyroid Problems<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-9\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"SEIZURE\/EPILEPSY\" \/><label for=\"field-Pb46b9cItp7wr3B-9\">Seizure\/Epilepsy<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-10\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"TUBERCULOSIS\" \/><label for=\"field-Pb46b9cItp7wr3B-10\">Tuberculosis<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-11\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"HIGH BLOOD PRESSURE\" \/><label for=\"field-Pb46b9cItp7wr3B-11\">High Blood Pressure<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-12\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"IRREGULAR PULSE\" \/><label for=\"field-Pb46b9cItp7wr3B-12\">Irregular Pulse<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-13\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"CHEST PAIN\/ANGINA\" \/><label for=\"field-Pb46b9cItp7wr3B-13\">Chest Pain\/Angina<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-14\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"ULCERS\" \/><label for=\"field-Pb46b9cItp7wr3B-14\">Ulcers<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-15\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"BLEEDING PROBLEMS\" \/><label for=\"field-Pb46b9cItp7wr3B-15\">Bleeding Problems<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-16\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"DIABETES\" \/><label for=\"field-Pb46b9cItp7wr3B-16\">Diabetes<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-17\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"KIDNEY PROBLEMS\" \/><label for=\"field-Pb46b9cItp7wr3B-17\">Kidney Problems<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-18\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"HEPATITUS\/JAUNDICE\" \/><label for=\"field-Pb46b9cItp7wr3B-18\">Hepatitis\/Jaundice<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-19\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"HEARTBURN\" \/><label for=\"field-Pb46b9cItp7wr3B-19\">Heartburn<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-20\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"TRANSFUSIONS\" \/><label for=\"field-Pb46b9cItp7wr3B-20\">Tranfusions<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-21\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"ANEMIA\" \/><label for=\"field-Pb46b9cItp7wr3B-21\">Anemia<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-22\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"DIFFICULTY URINATING\" \/><label for=\"field-Pb46b9cItp7wr3B-22\">Difficulty Urinating<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-23\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"ARTHRITIS\" \/><label for=\"field-Pb46b9cItp7wr3B-23\">Arthritis<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-24\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"STROKE\" \/><label for=\"field-Pb46b9cItp7wr3B-24\">Stroke<\/label><\/div><div class=\"checkbox-inline\"><input id=\"field-Pb46b9cItp7wr3B-25\" name='field-Pb46b9cItp7wr3B[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"HIV POSITIVE\/RISK\" \/><label for=\"field-Pb46b9cItp7wr3B-25\">HIV Positive\/Risk<\/label><\/div><\/div><\/div><div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-AvelVqY1' data-ref-id='ref-Y6tO1CBw' class='' >Review of Systems<\/h1><\/div><div class=\"erf-richtext erf-element-width-12\"><div data-non-input='1' data-ref-label='ref-NzhIeECx' data-ref-id='ref-IR7sf7d9' class='erf-rich-text' ><p>Below, please indicate any symptoms you are currently experiencing (within the last month):<\/p><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-MFUZ9kEUlEBwLRL erf-element-width-12\"><label for=\"field-MFUZ9kEUlEBwLRL\" class=\"erf-checkbox-group-label\">General, Constitutional<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-MFUZ9kEUlEBwLRL-0\" name='field-MFUZ9kEUlEBwLRL[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"GOOD GENERAL HEALTH LATELY\" \/><label for=\"field-MFUZ9kEUlEBwLRL-0\">Good general health lately<\/label><\/div><div class=\"checkbox\"><input id=\"field-MFUZ9kEUlEBwLRL-1\" name='field-MFUZ9kEUlEBwLRL[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"FEVER\" \/><label for=\"field-MFUZ9kEUlEBwLRL-1\">Fever<\/label><\/div><div class=\"checkbox\"><input id=\"field-MFUZ9kEUlEBwLRL-2\" name='field-MFUZ9kEUlEBwLRL[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"FATIGUE\" \/><label for=\"field-MFUZ9kEUlEBwLRL-2\">Fatigue<\/label><\/div><div class=\"checkbox\"><input id=\"field-MFUZ9kEUlEBwLRL-3\" name='field-MFUZ9kEUlEBwLRL[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"RECENT WEIGHT CHANGE\" \/><label for=\"field-MFUZ9kEUlEBwLRL-3\">Recent weight change<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-RUHw93vIP1VbY7p erf-element-width-12\"><label for=\"field-RUHw93vIP1VbY7p\" class=\"erf-checkbox-group-label\">Psychiatric<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-RUHw93vIP1VbY7p-0\" name='field-RUHw93vIP1VbY7p[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"NERVOUSNESS\" \/><label for=\"field-RUHw93vIP1VbY7p-0\">Nervousness<\/label><\/div><div class=\"checkbox\"><input id=\"field-RUHw93vIP1VbY7p-1\" name='field-RUHw93vIP1VbY7p[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"DEPRESSION\" \/><label for=\"field-RUHw93vIP1VbY7p-1\">Depression<\/label><\/div><div class=\"checkbox\"><input id=\"field-RUHw93vIP1VbY7p-2\" name='field-RUHw93vIP1VbY7p[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"ANXIETY\/PANIC ATTACKS\" \/><label for=\"field-RUHw93vIP1VbY7p-2\">Anxiety\/Panic Attacks<\/label><\/div><div class=\"checkbox\"><input id=\"field-RUHw93vIP1VbY7p-3\" name='field-RUHw93vIP1VbY7p[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"SLEEP PROBLEMS\" \/><label for=\"field-RUHw93vIP1VbY7p-3\">Sleep problems<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-qz9ltV37ufjxLxN erf-element-width-12\"><label for=\"field-qz9ltV37ufjxLxN\" class=\"erf-checkbox-group-label\">Musculoskeletal<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-qz9ltV37ufjxLxN-0\" name='field-qz9ltV37ufjxLxN[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"JOINT STIFFNESS AND SWELLING\" \/><label for=\"field-qz9ltV37ufjxLxN-0\">Joint stiffness &amp; swelling<\/label><\/div><div class=\"checkbox\"><input id=\"field-qz9ltV37ufjxLxN-1\" name='field-qz9ltV37ufjxLxN[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"MUSCLE PAIN OR CRAMPS\" \/><label for=\"field-qz9ltV37ufjxLxN-1\">Muscle pain or cramps<\/label><\/div><div class=\"checkbox\"><input id=\"field-qz9ltV37ufjxLxN-2\" name='field-qz9ltV37ufjxLxN[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"NECK PAIN\" \/><label for=\"field-qz9ltV37ufjxLxN-2\">Neck pain (muscular)<\/label><\/div><div class=\"checkbox\"><input id=\"field-qz9ltV37ufjxLxN-3\" name='field-qz9ltV37ufjxLxN[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"WEAKNESS OF MUSCLE\/JOINTS\" \/><label for=\"field-qz9ltV37ufjxLxN-3\">Weakness of muscle\/joints<\/label><\/div><div class=\"checkbox\"><input id=\"field-qz9ltV37ufjxLxN-4\" name='field-qz9ltV37ufjxLxN[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"LOWER BACK PAIN\" \/><label for=\"field-qz9ltV37ufjxLxN-4\">Lower back pain<\/label><\/div><div class=\"checkbox\"><input id=\"field-qz9ltV37ufjxLxN-5\" name='field-qz9ltV37ufjxLxN[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"DIFFICULTY WALKING\" \/><label for=\"field-qz9ltV37ufjxLxN-5\">Difficulty walking<\/label><\/div><div class=\"checkbox\"><input id=\"field-qz9ltV37ufjxLxN-6\" name='field-qz9ltV37ufjxLxN[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"COLD EXTREMETIES\" \/><label for=\"field-qz9ltV37ufjxLxN-6\">Cold extremities<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-bGhOoKz3WP8F0D9 erf-element-width-12\"><label for=\"field-bGhOoKz3WP8F0D9\" class=\"erf-checkbox-group-label\">Ear, Nose & Throat<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-bGhOoKz3WP8F0D9-0\" name='field-bGhOoKz3WP8F0D9[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"RINGING IN EARS\" \/><label for=\"field-bGhOoKz3WP8F0D9-0\">Ringing in ears<\/label><\/div><div class=\"checkbox\"><input id=\"field-bGhOoKz3WP8F0D9-1\" name='field-bGhOoKz3WP8F0D9[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"EAR ACHES\/DRAINAGE\" \/><label for=\"field-bGhOoKz3WP8F0D9-1\">Ear aches\/drainage<\/label><\/div><div class=\"checkbox\"><input id=\"field-bGhOoKz3WP8F0D9-2\" name='field-bGhOoKz3WP8F0D9[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"SINUS PROBLEMS\" \/><label for=\"field-bGhOoKz3WP8F0D9-2\">Sinus problems<\/label><\/div><div class=\"checkbox\"><input id=\"field-bGhOoKz3WP8F0D9-3\" name='field-bGhOoKz3WP8F0D9[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"NOSE BLEEDS\" \/><label for=\"field-bGhOoKz3WP8F0D9-3\">Nose bleeds<\/label><\/div><div class=\"checkbox\"><input id=\"field-bGhOoKz3WP8F0D9-4\" name='field-bGhOoKz3WP8F0D9[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"HEARING LOSS\" \/><label for=\"field-bGhOoKz3WP8F0D9-4\">Hearing loss<\/label><\/div><div class=\"checkbox\"><input id=\"field-bGhOoKz3WP8F0D9-5\" name='field-bGhOoKz3WP8F0D9[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"SORE THROAT\/VOICE CHANGES\" \/><label for=\"field-bGhOoKz3WP8F0D9-5\">Sore throat\/voice changes<\/label><\/div><div class=\"checkbox\"><input id=\"field-bGhOoKz3WP8F0D9-6\" name='field-bGhOoKz3WP8F0D9[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"SWOLLEN GLANDS IN NECK\" \/><label for=\"field-bGhOoKz3WP8F0D9-6\">Swollen glands in neck<\/label><\/div><div class=\"checkbox\"><input id=\"field-bGhOoKz3WP8F0D9-7\" name='field-bGhOoKz3WP8F0D9[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"MOUTH SORES\" \/><label for=\"field-bGhOoKz3WP8F0D9-7\">Mouth sores<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-WHDAitw8r16dOpJ erf-element-width-12\"><label for=\"field-WHDAitw8r16dOpJ\" class=\"erf-checkbox-group-label\">Neurological<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-WHDAitw8r16dOpJ-0\" name='field-WHDAitw8r16dOpJ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"STROKE\" \/><label for=\"field-WHDAitw8r16dOpJ-0\">Stroke<\/label><\/div><div class=\"checkbox\"><input id=\"field-WHDAitw8r16dOpJ-1\" name='field-WHDAitw8r16dOpJ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"HEAD INJURY\" \/><label for=\"field-WHDAitw8r16dOpJ-1\">Head injury<\/label><\/div><div class=\"checkbox\"><input id=\"field-WHDAitw8r16dOpJ-2\" name='field-WHDAitw8r16dOpJ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"NUMBNESS\/TINGLING IN EXTREMETIES\" \/><label for=\"field-WHDAitw8r16dOpJ-2\">Numbness\/tingling in extremeties<\/label><\/div><div class=\"checkbox\"><input id=\"field-WHDAitw8r16dOpJ-3\" name='field-WHDAitw8r16dOpJ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"PARALYSIS\" \/><label for=\"field-WHDAitw8r16dOpJ-3\">Paralysis<\/label><\/div><div class=\"checkbox\"><input id=\"field-WHDAitw8r16dOpJ-4\" name='field-WHDAitw8r16dOpJ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"LIGHT HEADED\/DIZZY\" \/><label for=\"field-WHDAitw8r16dOpJ-4\">Light headed\/dizzy<\/label><\/div><div class=\"checkbox\"><input id=\"field-WHDAitw8r16dOpJ-5\" name='field-WHDAitw8r16dOpJ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"CONVULSIONS\/SEIZURES\" \/><label for=\"field-WHDAitw8r16dOpJ-5\">Convulsions\/Seizures<\/label><\/div><div class=\"checkbox\"><input id=\"field-WHDAitw8r16dOpJ-6\" name='field-WHDAitw8r16dOpJ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"MEMORY LOSS OR CONFUSION\" \/><label for=\"field-WHDAitw8r16dOpJ-6\">Memory loss or confusion<\/label><\/div><div class=\"checkbox\"><input id=\"field-WHDAitw8r16dOpJ-7\" name='field-WHDAitw8r16dOpJ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"MIGRAINES\" \/><label for=\"field-WHDAitw8r16dOpJ-7\">Migraines<\/label><\/div><div class=\"checkbox\"><input id=\"field-WHDAitw8r16dOpJ-8\" name='field-WHDAitw8r16dOpJ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"FREQUENT HEADACHES\/URINATION\" \/><label for=\"field-WHDAitw8r16dOpJ-8\">Frequent\/recurrent headaches<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-pKfJvOrYA06AnWX erf-element-width-12\"><label for=\"field-pKfJvOrYA06AnWX\" class=\"erf-checkbox-group-label\">Gastrointestinal<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-pKfJvOrYA06AnWX-0\" name='field-pKfJvOrYA06AnWX[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"PAINFUL BOWEL MOVEMENTS\" \/><label for=\"field-pKfJvOrYA06AnWX-0\">Painful bowel movements<\/label><\/div><div class=\"checkbox\"><input id=\"field-pKfJvOrYA06AnWX-1\" name='field-pKfJvOrYA06AnWX[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"CHANGE IN BOWEL MOVEMENTS\" \/><label for=\"field-pKfJvOrYA06AnWX-1\">Change in bowel movements<\/label><\/div><div class=\"checkbox\"><input id=\"field-pKfJvOrYA06AnWX-2\" name='field-pKfJvOrYA06AnWX[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"STOMACH PAIN\" \/><label for=\"field-pKfJvOrYA06AnWX-2\">Stomach pain<\/label><\/div><div class=\"checkbox\"><input id=\"field-pKfJvOrYA06AnWX-3\" name='field-pKfJvOrYA06AnWX[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"NAUSEA OR VOMITING\" \/><label for=\"field-pKfJvOrYA06AnWX-3\">Nausea or vomiting<\/label><\/div><div class=\"checkbox\"><input id=\"field-pKfJvOrYA06AnWX-4\" name='field-pKfJvOrYA06AnWX[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"CONSTIPATION\" \/><label for=\"field-pKfJvOrYA06AnWX-4\">Constipation<\/label><\/div><div class=\"checkbox\"><input id=\"field-pKfJvOrYA06AnWX-5\" name='field-pKfJvOrYA06AnWX[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"BLOOD IN STOOL\" \/><label for=\"field-pKfJvOrYA06AnWX-5\">Blood in stool<\/label><\/div><div class=\"checkbox\"><input id=\"field-pKfJvOrYA06AnWX-6\" name='field-pKfJvOrYA06AnWX[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"FREQUENT DIARRHEA\" \/><label for=\"field-pKfJvOrYA06AnWX-6\">Frequent diarrhea<\/label><\/div><div class=\"checkbox\"><input id=\"field-pKfJvOrYA06AnWX-7\" name='field-pKfJvOrYA06AnWX[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"LOSS OF APPETITE\" \/><label for=\"field-pKfJvOrYA06AnWX-7\">Loss of appetite<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-f0IYrzMaEPvOMlC erf-element-width-12\"><label for=\"field-f0IYrzMaEPvOMlC\" class=\"erf-checkbox-group-label\">Respiratory<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-f0IYrzMaEPvOMlC-0\" name='field-f0IYrzMaEPvOMlC[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"SPITTING UP BLOOD\" \/><label for=\"field-f0IYrzMaEPvOMlC-0\">Spitting up blood<\/label><\/div><div class=\"checkbox\"><input id=\"field-f0IYrzMaEPvOMlC-1\" name='field-f0IYrzMaEPvOMlC[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"FREQUENT COUGHING\" \/><label for=\"field-f0IYrzMaEPvOMlC-1\">Frequent coughing<\/label><\/div><div class=\"checkbox\"><input id=\"field-f0IYrzMaEPvOMlC-2\" name='field-f0IYrzMaEPvOMlC[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"SHORTNESS OF BREATH\" \/><label for=\"field-f0IYrzMaEPvOMlC-2\">Shortness of breath<\/label><\/div><div class=\"checkbox\"><input id=\"field-f0IYrzMaEPvOMlC-3\" name='field-f0IYrzMaEPvOMlC[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"ASTHMA OR WHEEZING\" \/><label for=\"field-f0IYrzMaEPvOMlC-3\">Asthma or wheezing<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-GerYLMCWOJ4zISZ erf-element-width-12\"><label for=\"field-GerYLMCWOJ4zISZ\" class=\"erf-checkbox-group-label\">Eyes & Visions<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-GerYLMCWOJ4zISZ-0\" name='field-GerYLMCWOJ4zISZ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"WEAR GLASSES OR CONTACTS\" \/><label for=\"field-GerYLMCWOJ4zISZ-0\">Wear glasses or contact lenses<\/label><\/div><div class=\"checkbox\"><input id=\"field-GerYLMCWOJ4zISZ-1\" name='field-GerYLMCWOJ4zISZ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"EYE DISEASES OR INJURY\" \/><label for=\"field-GerYLMCWOJ4zISZ-1\">Eye diseases or injury<\/label><\/div><div class=\"checkbox\"><input id=\"field-GerYLMCWOJ4zISZ-2\" name='field-GerYLMCWOJ4zISZ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"BLURRED OR DOUBLE VISION\" \/><label for=\"field-GerYLMCWOJ4zISZ-2\">Blurred or double vision<\/label><\/div><div class=\"checkbox\"><input id=\"field-GerYLMCWOJ4zISZ-3\" name='field-GerYLMCWOJ4zISZ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"GLAUCOMA\" \/><label for=\"field-GerYLMCWOJ4zISZ-3\">Glaucoma<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-sl0v03ILUcnRrKl erf-element-width-12\"><label for=\"field-sl0v03ILUcnRrKl\" class=\"erf-checkbox-group-label\">Genitourinary<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-sl0v03ILUcnRrKl-0\" name='field-sl0v03ILUcnRrKl[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"SEXUAL DIFFICULTY\" \/><label for=\"field-sl0v03ILUcnRrKl-0\">Sexual difficulty<\/label><\/div><div class=\"checkbox\"><input id=\"field-sl0v03ILUcnRrKl-1\" name='field-sl0v03ILUcnRrKl[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"BLOOD IN URINE\" \/><label for=\"field-sl0v03ILUcnRrKl-1\">Blood in urine<\/label><\/div><div class=\"checkbox\"><input id=\"field-sl0v03ILUcnRrKl-2\" name='field-sl0v03ILUcnRrKl[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"FREQUENT URINATION\" \/><label for=\"field-sl0v03ILUcnRrKl-2\">Frequent urination<\/label><\/div><div class=\"checkbox\"><input id=\"field-sl0v03ILUcnRrKl-3\" name='field-sl0v03ILUcnRrKl[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"KIDNEY STONES\" \/><label for=\"field-sl0v03ILUcnRrKl-3\">Kidney stones<\/label><\/div><div class=\"checkbox\"><input id=\"field-sl0v03ILUcnRrKl-4\" name='field-sl0v03ILUcnRrKl[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"STRAIN WITH URINATION\" \/><label for=\"field-sl0v03ILUcnRrKl-4\">Strain with urination<\/label><\/div><div class=\"checkbox\"><input id=\"field-sl0v03ILUcnRrKl-5\" name='field-sl0v03ILUcnRrKl[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"BURNING OR PAINFUL URINATION\" \/><label for=\"field-sl0v03ILUcnRrKl-5\">Burning or painful urination<\/label><\/div><div class=\"checkbox\"><input id=\"field-sl0v03ILUcnRrKl-6\" name='field-sl0v03ILUcnRrKl[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"INCONTINENCE\" \/><label for=\"field-sl0v03ILUcnRrKl-6\">Incontinence<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-nkqynvO6Byu8UOd erf-element-width-12\"><label for=\"field-nkqynvO6Byu8UOd\" class=\"erf-checkbox-group-label\">Endocrine<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-nkqynvO6Byu8UOd-0\" name='field-nkqynvO6Byu8UOd[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"THYROID DISEASE\" \/><label for=\"field-nkqynvO6Byu8UOd-0\">Thyroid disease<\/label><\/div><div class=\"checkbox\"><input id=\"field-nkqynvO6Byu8UOd-1\" name='field-nkqynvO6Byu8UOd[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"HEAT OR COLD INTOLERANCE\" \/><label for=\"field-nkqynvO6Byu8UOd-1\">Heat or cold intolerance<\/label><\/div><div class=\"checkbox\"><input id=\"field-nkqynvO6Byu8UOd-2\" name='field-nkqynvO6Byu8UOd[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"CHANGE IN SKIN COLOR\" \/><label for=\"field-nkqynvO6Byu8UOd-2\">Change in skin color<\/label><\/div><div class=\"checkbox\"><input id=\"field-nkqynvO6Byu8UOd-3\" name='field-nkqynvO6Byu8UOd[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"DIABETES\" \/><label for=\"field-nkqynvO6Byu8UOd-3\">Diabetes<\/label><\/div><div class=\"checkbox\"><input id=\"field-nkqynvO6Byu8UOd-4\" name='field-nkqynvO6Byu8UOd[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"GLANDULAR OR HORMONE PROBLEMS\" \/><label for=\"field-nkqynvO6Byu8UOd-4\">Glandular or hormone problems<\/label><\/div><div class=\"checkbox\"><input id=\"field-nkqynvO6Byu8UOd-5\" name='field-nkqynvO6Byu8UOd[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"EXCESSIVE THIRST OR URINATION\" \/><label for=\"field-nkqynvO6Byu8UOd-5\">Excessive thirst and\/or urination<\/label><\/div><div class=\"checkbox\"><input id=\"field-nkqynvO6Byu8UOd-6\" name='field-nkqynvO6Byu8UOd[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"RASH AND\/OR ITCHING\" \/><label for=\"field-nkqynvO6Byu8UOd-6\">Rash and\/or itching<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-YghoZ9mJTTSmUVr erf-element-width-12\"><label for=\"field-YghoZ9mJTTSmUVr\" class=\"erf-checkbox-group-label\">Skin & Breasts<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-YghoZ9mJTTSmUVr-0\" name='field-YghoZ9mJTTSmUVr[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"VARICOSE VEINS\" \/><label for=\"field-YghoZ9mJTTSmUVr-0\">Varicose veins<\/label><\/div><div class=\"checkbox\"><input id=\"field-YghoZ9mJTTSmUVr-1\" name='field-YghoZ9mJTTSmUVr[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"BREAST DISCHARGE\" \/><label for=\"field-YghoZ9mJTTSmUVr-1\">Breast discharge<\/label><\/div><div class=\"checkbox\"><input id=\"field-YghoZ9mJTTSmUVr-2\" name='field-YghoZ9mJTTSmUVr[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"BREAST PAIN\" \/><label for=\"field-YghoZ9mJTTSmUVr-2\">Breast pain<\/label><\/div><div class=\"checkbox\"><input id=\"field-YghoZ9mJTTSmUVr-3\" name='field-YghoZ9mJTTSmUVr[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"CHANGES IN HAIR AND\/OR NAILS\" \/><label for=\"field-YghoZ9mJTTSmUVr-3\">Changes in hair and\/or nails<\/label><\/div><div class=\"checkbox\"><input id=\"field-YghoZ9mJTTSmUVr-4\" name='field-YghoZ9mJTTSmUVr[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"BREAST LUMP\" \/><label for=\"field-YghoZ9mJTTSmUVr-4\">Breast lump<\/label><\/div><div class=\"checkbox\"><input id=\"field-YghoZ9mJTTSmUVr-5\" name='field-YghoZ9mJTTSmUVr[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"DRY SKIN\" \/><label for=\"field-YghoZ9mJTTSmUVr-5\">Dry skin<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-bUtSMiNzcMCqwhw erf-element-width-12\"><label for=\"field-bUtSMiNzcMCqwhw\" class=\"erf-checkbox-group-label\">Hematologic\/Lymphatic<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-bUtSMiNzcMCqwhw-0\" name='field-bUtSMiNzcMCqwhw[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"EASILY BRUISE OR BLEED\" \/><label for=\"field-bUtSMiNzcMCqwhw-0\">Easily bruise or bleed<\/label><\/div><div class=\"checkbox\"><input id=\"field-bUtSMiNzcMCqwhw-1\" name='field-bUtSMiNzcMCqwhw[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"HISTORY OF TRANSFUSION\" \/><label for=\"field-bUtSMiNzcMCqwhw-1\">History of transfusion<\/label><\/div><div class=\"checkbox\"><input id=\"field-bUtSMiNzcMCqwhw-2\" name='field-bUtSMiNzcMCqwhw[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"ANEMIA\" \/><label for=\"field-bUtSMiNzcMCqwhw-2\">Anemia<\/label><\/div><div class=\"checkbox\"><input id=\"field-bUtSMiNzcMCqwhw-3\" name='field-bUtSMiNzcMCqwhw[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"SLOW TO HEAL AFTER CUTS\" \/><label for=\"field-bUtSMiNzcMCqwhw-3\">Slow to heal after cuts<\/label><\/div><div class=\"checkbox\"><input id=\"field-bUtSMiNzcMCqwhw-4\" name='field-bUtSMiNzcMCqwhw[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"PHLEBITIS\" \/><label for=\"field-bUtSMiNzcMCqwhw-4\">Phlebitis<\/label><\/div><div class=\"checkbox\"><input id=\"field-bUtSMiNzcMCqwhw-5\" name='field-bUtSMiNzcMCqwhw[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"SWOLLEN GLANDS\" \/><label for=\"field-bUtSMiNzcMCqwhw-5\">Swollen glands<\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-bT9sNpOnCEZTwRd erf-element-width-12\"><label for=\"field-bT9sNpOnCEZTwRd\" class=\"erf-checkbox-group-label\">Heart & Cardiovascular<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-bT9sNpOnCEZTwRd-0\" name='field-bT9sNpOnCEZTwRd[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"CHEST PAIN\" \/><label for=\"field-bT9sNpOnCEZTwRd-0\">Chest pain<\/label><\/div><div class=\"checkbox\"><input id=\"field-bT9sNpOnCEZTwRd-1\" name='field-bT9sNpOnCEZTwRd[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"SUDDEN HEARTBEAT CHANGES\" \/><label for=\"field-bT9sNpOnCEZTwRd-1\">Sudden heartbeat changes<\/label><\/div><div class=\"checkbox\"><input id=\"field-bT9sNpOnCEZTwRd-2\" name='field-bT9sNpOnCEZTwRd[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"SWELLING OF FEET, ANKLES AND\/OR HANDS\" \/><label for=\"field-bT9sNpOnCEZTwRd-2\">Swelling of feet, ankles and\/or hands<\/label><\/div><\/div><\/div><div class=\"erf-textarea form-group field-field-cLhAaYM9PhwYPy5 erf-element-width-12\"><label for=\"field-cLhAaYM9PhwYPy5\" class=\"erf-textarea-label\">Is there anything else you would like to add?<\/label><textarea class='form-control' name='field-cLhAaYM9PhwYPy5' id='field-cLhAaYM9PhwYPy5' ><\/textarea><\/div><div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-l95Tvh7z' data-ref-id='ref-olb0CGd9' class='' >Family History<\/h1><\/div><div class=\"erf-richtext erf-element-width-12\"><div data-non-input='1' data-ref-label='ref-ggDiKykE' data-ref-id='ref-GZZunZp9' class='erf-rich-text' ><p>Has any family member experienced the following?<\/p><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-osU6D8crhiR7kQU erf-element-width-12\"><label for=\"field-osU6D8crhiR7kQU\" class=\"erf-checkbox-group-label\">Had cancer?<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-osU6D8crhiR7kQU-0\" name='field-osU6D8crhiR7kQU[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"NO\" \/><label for=\"field-osU6D8crhiR7kQU-0\">No<\/label><\/div><div class=\"checkbox\"><input id=\"field-osU6D8crhiR7kQU-1\" name='field-osU6D8crhiR7kQU[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"YES\" \/><label for=\"field-osU6D8crhiR7kQU-1\">Yes<\/label><\/div><\/div><\/div><div class=\"erf-text form-group field-field-ZR1WCLiobBp4KO6 erf-element-width-12\"><label for=\"field-ZR1WCLiobBp4KO6\" class=\"erf-text-label\">If yes, please indicate who:<\/label><input type='text' class='form-control' name='field-ZR1WCLiobBp4KO6' id='field-ZR1WCLiobBp4KO6'  \/><\/div><div class=\"erf-checkbox-group form-group field-field-WJCRs2bFWMbtzBX erf-element-width-12\"><label for=\"field-WJCRs2bFWMbtzBX\" class=\"erf-checkbox-group-label\">Is or has been an alcoholic?<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-WJCRs2bFWMbtzBX-0\" name='field-WJCRs2bFWMbtzBX[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"YES\" \/><label for=\"field-WJCRs2bFWMbtzBX-0\">Yes<\/label><\/div><div class=\"checkbox\"><input id=\"field-WJCRs2bFWMbtzBX-1\" name='field-WJCRs2bFWMbtzBX[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"NO\" \/><label for=\"field-WJCRs2bFWMbtzBX-1\">No<\/label><\/div><\/div><\/div><div class=\"erf-text form-group field-field-W8jyjxt2tVopeJO erf-element-width-12\"><label for=\"field-W8jyjxt2tVopeJO\" class=\"erf-text-label\">If yes, please indicate who:<\/label><input type='text' class='form-control' name='field-W8jyjxt2tVopeJO' id='field-W8jyjxt2tVopeJO'  \/><\/div><div class=\"erf-checkbox-group form-group field-field-GdwunLUjqk41SsG erf-element-width-12\"><label for=\"field-GdwunLUjqk41SsG\" class=\"erf-checkbox-group-label\">Is or has been a drug addict?<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-GdwunLUjqk41SsG-0\" name='field-GdwunLUjqk41SsG[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"YES\" \/><label for=\"field-GdwunLUjqk41SsG-0\">Yes<\/label><\/div><div class=\"checkbox\"><input id=\"field-GdwunLUjqk41SsG-1\" name='field-GdwunLUjqk41SsG[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"NO\" \/><label for=\"field-GdwunLUjqk41SsG-1\">No<\/label><\/div><\/div><\/div><div class=\"erf-text form-group field-field-mhpz3GVKfvravem erf-element-width-12\"><label for=\"field-mhpz3GVKfvravem\" class=\"erf-text-label\">If yes, please indicate who:<\/label><input type='text' class='form-control' name='field-mhpz3GVKfvravem' id='field-mhpz3GVKfvravem'  \/><\/div><div class=\"erf-checkbox-group form-group field-field-fNJ1sVfm4SmnKjo erf-element-width-12\"><label for=\"field-fNJ1sVfm4SmnKjo\" class=\"erf-checkbox-group-label\">Had unusual bleeding tendencies?<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-fNJ1sVfm4SmnKjo-0\" name='field-fNJ1sVfm4SmnKjo[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"YES\" \/><label for=\"field-fNJ1sVfm4SmnKjo-0\">Yes<\/label><\/div><div class=\"checkbox\"><input id=\"field-fNJ1sVfm4SmnKjo-1\" name='field-fNJ1sVfm4SmnKjo[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"NO\" \/><label for=\"field-fNJ1sVfm4SmnKjo-1\">No<\/label><\/div><\/div><\/div><div class=\"erf-text form-group field-field-VTnTeRosffTMpQI erf-element-width-12\"><label for=\"field-VTnTeRosffTMpQI\" class=\"erf-text-label\">If yes, please indicate who:<\/label><input type='text' class='form-control' name='field-VTnTeRosffTMpQI' id='field-VTnTeRosffTMpQI'  \/><\/div><div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-7BipmhpW' data-ref-id='ref-iRAcFbRx' class='' >Comments<\/h1><\/div><div class=\"erf-textarea form-group field-field-Ek5pG2KmXfihbQB erf-element-width-12\"><label for=\"field-Ek5pG2KmXfihbQB\" class=\"erf-textarea-label\">If you have any additional comments, please enter them here:<\/label><textarea class='form-control' name='field-Ek5pG2KmXfihbQB' id='field-Ek5pG2KmXfihbQB' ><\/textarea><\/div><div class=\"erf-splitter erf-element-width-12\"><div data-non-input='1' custom-type='page-break' class='' data-ref-label='ref-DWRoIZBI' data-ref-id='ref-hdZL7kv3' >Splitter<\/div><\/div><div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-tMansrwH' data-ref-id='ref-jHMyn2tJ' class='' >Pacific Neurosurgery Office &amp; Financial Policy<\/h1><\/div><div class=\"erf-richtext erf-element-width-12\"><div data-non-input='1' data-ref-label='ref-FowqS3sY' data-ref-id='ref-bORufwvP' class='erf-rich-text' ><p>I agree that in return for services provided to me by Pacific Neurosurgery, I will pay any account balances at the time of service or will make financial arrangements with Pacific Neurosurgery. If co-payments, deductibles, out-of-network balances, non-covered services and\/or past balances are designated by my health plan, I agree to pay those balances directly to Pacific Neurosurgery. I understand that if my account is delinquent and all efforts to collect any balances have been exhausted, it may be turned over to a collection agency.<\/p>\n<p><br \/><strong>Non-Participating Insurance Accounts<\/strong> A patient who is insured by an insurance carrier with which the practice does not participate, is considered a self-pay patient. It is the patient's responsibility to inform the practice of any insurance coverage changes, to confirm the practice's participation and to verify their eligibility before each visit. I understand and agree that I am obligated to pay the full charge(s) of all services rendered to me by Pacific Neurosurgery if I belong to a plan in which Pacific Neurosurgery does not participate.<\/p>\n<p><br \/><strong>Self-Pay Patients<\/strong> Self-pay patients are those who are covered by an insurance carrier with which the practice does not participate or patients without insurance at the time of service. I understand and agree that, as a self pay patient, I am individual responsible to pay the full charges at the time of service.<\/p>\n<p><br \/><strong>HMO Referrals and Authorizations<\/strong> If your insurance is an HMO (has a designated primary care physician), you are required to inform the office of this at the time of scheduling your appointment so an authorization may be obtained. If this information is not provided at the time of scheduling, you will be asked to reschedule your appointment.<\/p>\n<p><br \/><strong>Non-Covered Services<\/strong> I understand that my insurance plan may not pay for all of my medical services and costs. Some items and services are not considered \u201ccovered benefits\u201d under your health insurance plan and as such, your insurance will not pay for these services. It is the patients responsibility to understand what your plan covers and does not cover. You will be responsible for all non-covered charges\/services.<\/p>\n<p><br \/><strong>Missed Appointments<\/strong> Failure to arrive for a scheduled appointment and\/or failure to cancel an appointment within 24 hours will result in a missed appointment fee of $50 for each occurrence. The patient is fully responsible for this payment.<\/p><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-AVNrVbNB8lYR550 erf-element-width-12\"><label for=\"field-AVNrVbNB8lYR550\" class=\"erf-checkbox-group-label\">I have read and understand the policies written above:<span class=\"erf-required\">*<\/span><\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-AVNrVbNB8lYR550-0\" name='field-AVNrVbNB8lYR550[]' required='required' class='form-control' multiple='1'  type=\"checkbox\" value=\"I HAVE READ AND UNDERSTAND THE POLICIES WRITTEN ABOVE\" \/><label for=\"field-AVNrVbNB8lYR550-0\"><\/label><\/div><\/div><\/div><div class=\"erf-splitter erf-element-width-12\"><div data-non-input='1' custom-type='page-break' class='' data-ref-label='ref-WJ5Cx6ne' data-ref-id='ref-gaTUwEP1' >Splitter<\/div><\/div><div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-VBwOK3KA' data-ref-id='ref-HdRJ2Ysw' class='' >Credit Card on File Policy<\/h1><\/div><div class=\"erf-richtext erf-element-width-12\"><div data-non-input='1' data-ref-label='ref-3AKxj7Zh' data-ref-id='ref-KPSEWybp' class='erf-rich-text' ><p>Pacific Neurosurgery requires that all patients keep a credit card or debit card on file as a convenient way to pay for any outstanding patient balances. This is due to an increasing amount of deductibles and co-payments required by insurance companies, and to decrease the number of delinquent accounts.<\/p>\n<p>We will bill your credit card <strong>ONLY<\/strong>\u00a0in the following situations:<\/p>\n<p>1. Your balance is 90+ days old and\/or we have sent you at least 3 statements<\/p>\n<p>2. You instruct us to bill your credit card for any outstanding balance<\/p>\n<p>3. If you set up a payment plan with us<\/p>\n<p><strong>Should you decline to provide a credit card or debit card number, you will be responsible for paying any outstanding balance upon receiving a billing statement. Should you not pay your balance due after three statements, your balance will be sent to collections without further notice and you will no longer be able to receive services by Pacific Neurosurgery until this balance is paid in full.<\/strong><\/p>\n<p>Your credit card information is kept confidential and secure, and payments to your card are processed only after the claim has been processed by your insurance company, and the insurance portion of your claim has been paid and posted to your account.<\/p>\n<p>I authorize Pacific Neurosurgery to charge the portion of my bill that is my financial responsibility to the following credit card or debit card:<\/p><\/div><\/div><div class=\"erf-text form-group field-field-7cHpkdk1y9KBWCv erf-element-width-12\"><label for=\"field-7cHpkdk1y9KBWCv\" class=\"erf-text-label\">Credit Card Number<\/label><input type='text' class='form-control' name='field-7cHpkdk1y9KBWCv' id='field-7cHpkdk1y9KBWCv'  \/><\/div><div class=\"erf-text form-group field-field-mhPvrBXNnGFBhs1 erf-element-width-12\"><label for=\"field-mhPvrBXNnGFBhs1\" class=\"erf-text-label\">Expiration Date (MMYY)<\/label><input type='text' class='form-control' name='field-mhPvrBXNnGFBhs1' id='field-mhPvrBXNnGFBhs1'  \/><\/div><div class=\"erf-text form-group field-field-ejtTl0OmqsIbFsq erf-element-width-12\"><label for=\"field-ejtTl0OmqsIbFsq\" class=\"erf-text-label\">CVV<\/label><input type='text' class='form-control' name='field-ejtTl0OmqsIbFsq' id='field-ejtTl0OmqsIbFsq'  \/><\/div><div class=\"erf-text form-group field-field-c9nQMNerAIXqt6S erf-element-width-12\"><label for=\"field-c9nQMNerAIXqt6S\" class=\"erf-text-label\">Cardholder Name (If different from patient)<\/label><input type='text' class='form-control' name='field-c9nQMNerAIXqt6S' id='field-c9nQMNerAIXqt6S'  \/><\/div><div class=\"erf-text form-group field-field-YKUUoOEtYznBNbi erf-element-width-12\"><label for=\"field-YKUUoOEtYznBNbi\" class=\"erf-text-label\">Billing Zip Code<\/label><input type='text' class='form-control' name='field-YKUUoOEtYznBNbi' id='field-YKUUoOEtYznBNbi'  \/><\/div><div class=\"erf-richtext erf-element-width-12\"><div data-non-input='1' data-ref-label='ref-Fw972UQZ' data-ref-id='ref-cejDSXUs' class='erf-rich-text' ><p>I (we), the undersigned, authorize and request Pacific Neurosurgery to charge my credit card, indicated above, for balances due for services rendered that my insurance company identifies as my financial responsibility. The authorization relates to all payments not covered by my insurance company for services provided to my by Pacific Neurosurgery. This authorization will remain in effect until I (we) cancel this authorization. To cancel, I (we) must give a 60 day notification to Pacific Neurosurgery in writing and the account must be in good standing.<\/p><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-4JQagKqLcuJ96KM erf-element-width-12\"><label for=\"field-4JQagKqLcuJ96KM\" class=\"erf-checkbox-group-label\">I agree<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-4JQagKqLcuJ96KM-0\" name='field-4JQagKqLcuJ96KM[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"I AGREE\" \/><label for=\"field-4JQagKqLcuJ96KM-0\"><\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-gvY1IrB3qdOZhAq erf-element-width-12\"><label for=\"field-gvY1IrB3qdOZhAq\" class=\"erf-checkbox-group-label\">I decline to provide a credit card and understand the above policy<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-gvY1IrB3qdOZhAq-0\" name='field-gvY1IrB3qdOZhAq[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"DECLINE CREDIT CARD\" \/><label for=\"field-gvY1IrB3qdOZhAq-0\"><\/label><\/div><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-f3BsQcYPga3uee6 erf-element-width-12\"><label for=\"field-f3BsQcYPga3uee6\" class=\"erf-checkbox-group-label\">I have read and understand the above policy<span class=\"erf-required\">*<\/span><\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-f3BsQcYPga3uee6-0\" name='field-f3BsQcYPga3uee6[]' required='required' class='form-control' multiple='1'  type=\"checkbox\" value=\"I HAVE READ AND UNDERSTAND THE ABOVE POLICY\" \/><label for=\"field-f3BsQcYPga3uee6-0\">Yes<\/label><\/div><\/div><\/div><div class=\"erf-separator erf-element-width-12\"><div data-non-input='1' custom-type='spacer' class='spacer' data-ref-label='ref-J8XE4NMq' data-ref-id='ref-JzCQ8l5y' >Separator<\/div><\/div><div class=\"erf-file form-group field-field-a0M3YuuqXSwFT3w erf-element-width-12\"><label for=\"field-a0M3YuuqXSwFT3w\" class=\"erf-file-label\">If you have any additional documentation, please upload here:<\/label><input type='file' class='form-control' name='field-a0M3YuuqXSwFT3w' id='field-a0M3YuuqXSwFT3w'  \/><\/div><div class=\"erf-separator erf-element-width-12\"><div data-non-input='1' custom-type='spacer' class='spacer' data-ref-label='ref-aD378uEO' data-ref-id='ref-RVlV0AJR' >Separator<\/div><\/div><div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-label='ref-BOZhonhS' data-ref-id='ref-zZi0l7bc' class='' >Patient's Rights and Privacy Policy<\/h1><\/div><div class=\"erf-richtext erf-element-width-12\"><div data-non-input='1' data-ref-label='ref-tkMqWTSc' data-ref-id='ref-xfpYC33r' class='erf-rich-text' ><p><a href=\"http:\/\/www.pacificneurosurgery.com\/?page_id=4110\">I have read and agree to the Patient's Rights and Privacy Policy<\/a><\/p><\/div><\/div><div class=\"erf-checkbox-group form-group field-field-Sr6Iu5J0EPNpAS0 erf-element-width-12\"><label for=\"field-Sr6Iu5J0EPNpAS0\" class=\"erf-checkbox-group-label\">I agree<span class=\"erf-required\">*<\/span><\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-Sr6Iu5J0EPNpAS0-0\" name='field-Sr6Iu5J0EPNpAS0[]' required='required' class='form-control' multiple='1'  type=\"checkbox\" value=\"I AGREE\" \/><label for=\"field-Sr6Iu5J0EPNpAS0-0\"><\/label><\/div><\/div><\/div><div class=\"erf-button form-group field-button-1623614466 erf-element-width-12\"><button type='submit'class='btn btn-default'name='button-1623614466'id='button-1623614466'>Send<\/button><\/div>                    <\/div> \n                <\/div>    \n\n                <div class=\"erf-external-form-elements\">\n                    \n                    \n                    \n\n                    \n                                        <div class=\"erf-errors\" style=\"display:none\">\n                        <span class=\"erf-errors-head erf-error-row\">Error occured. Please confirm your data and submit again:<\/span>\n                        <div class=\"erf-errors-body\">\n                                                    <\/div> \n                    <\/div>\n\n                <\/div>\n                <!-- Contains multipage Next,Previous buttons -->\n                <div class=\"erf-form-nav clearfix\"><\/div> \n\n                <!-- Single page form button -->\n                <div class=\"erf-submit-button clearfix\"><\/div>\n\n\n                <input type=\"hidden\" name=\"erform_id\" value=\"4074\" \/>\n                <input type=\"hidden\" id=\"erform_submission_nonce\" name=\"erform_submission_nonce\" value=\"c36f2abdf7\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F4066\" \/>                <input type=\"hidden\" name=\"action\" value=\"erf_submit_form\" \/>\n\n            <\/form>\n            \n<\/div>\n<\/p>\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":{"_et_pb_use_builder":"off","_et_pb_old_content":"","_et_gb_content_width":"1080","_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"class_list":["post-4066","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"http:\/\/www.pacificneurosurgery.com\/index.php?rest_route=\/wp\/v2\/pages\/4066","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/www.pacificneurosurgery.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/www.pacificneurosurgery.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/www.pacificneurosurgery.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/www.pacificneurosurgery.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=4066"}],"version-history":[{"count":4,"href":"http:\/\/www.pacificneurosurgery.com\/index.php?rest_route=\/wp\/v2\/pages\/4066\/revisions"}],"predecessor-version":[{"id":4076,"href":"http:\/\/www.pacificneurosurgery.com\/index.php?rest_route=\/wp\/v2\/pages\/4066\/revisions\/4076"}],"wp:attachment":[{"href":"http:\/\/www.pacificneurosurgery.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=4066"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}