{"id":3201,"date":"2025-04-14T11:38:20","date_gmt":"2025-04-14T11:38:20","guid":{"rendered":"https:\/\/wecodepros.com\/dev\/progress\/?page_id=3201"},"modified":"2025-04-15T04:49:38","modified_gmt":"2025-04-15T04:49:38","slug":"patient-intake","status":"publish","type":"page","link":"https:\/\/wecodepros.com\/dev\/progress\/patient-intake\/","title":{"rendered":"Patient Intake"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3201\" class=\"elementor elementor-3201\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-798e0297 e-flex e-con-boxed e-con e-parent\" data-id=\"798e0297\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-20c0ae3 elementor-widget elementor-widget-heading\" data-id=\"20c0ae3\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Patient Intake Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4f1f8de7 elementor-widget__width-initial patient-form elementor-widget elementor-widget-text-editor\" data-id=\"4f1f8de7\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"forminator-ui forminator-custom-form forminator-custom-form-3150 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-3150\" data-uid=\"69e8f240b431e\"><\/div>\n<form\n\t\t\t\tid=\"forminator-module-3150\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-3150 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"3150\"\n\t\t\t\t\n\t\t\t\tdata-design=\"default\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\tenctype=\"multipart\/form-data\"\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"69e8f240b431e\"\n\t\t\t><\/p>\n<div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div>\n<div class=\"forminator-row\">\n<div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \">\n<div class=\"forminator-field\"><label for=\"forminator-field-email-1_69e8f240b431e\" id=\"forminator-field-email-1_69e8f240b431e-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"Your email\" id=\"forminator-field-email-1_69e8f240b431e\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" \/><\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \">\n<div class=\"forminator-field\"><label for=\"forminator-field-name-1_69e8f240b431e\" id=\"forminator-field-name-1_69e8f240b431e-label\" class=\"forminator-label\">Patient&#039;s First Legal Name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"Your answer\" id=\"forminator-field-name-1_69e8f240b431e\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-12 \">\n<div class=\"forminator-field\"><label for=\"forminator-field-name-2_69e8f240b431e\" id=\"forminator-field-name-2_69e8f240b431e-label\" class=\"forminator-label\">Patient&#039;s Last Legal Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"Your answer\" id=\"forminator-field-name-2_69e8f240b431e\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \">\n<div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69e8f240b431e\" id=\"forminator-field-date-1-picker_69e8f240b431e-label\" class=\"forminator-label\">Patient&#039;s Date of Birth<\/label><\/p>\n<div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_69e8f240b431e\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \">\n<div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e8f240b431e-label\"><span id=\"forminator-radiogroup-69e8f240b431e-label\" class=\"forminator-label\">Who is filling out this form?<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69e8f240b431e\" class=\"forminator-radio\" title=\"Patient\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-69e8f240b431e\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Patient<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69e8f240b431e\" class=\"forminator-radio\" title=\"Parent\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69e8f240b431e\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Parent<\/span><\/label><label id=\"forminator-field-radio-1-label-3\" for=\"forminator-field-radio-1-3-69e8f240b431e\" class=\"forminator-radio\" title=\"Child\"><input type=\"radio\" name=\"radio-1\" value=\"Option-2\" id=\"forminator-field-radio-1-3-69e8f240b431e\" aria-labelledby=\"forminator-field-radio-1-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Child<\/span><\/label><label id=\"forminator-field-radio-1-label-4\" for=\"forminator-field-radio-1-4-69e8f240b431e\" class=\"forminator-radio\" title=\"Partner\"><input type=\"radio\" name=\"radio-1\" value=\"Option-2\" id=\"forminator-field-radio-1-4-69e8f240b431e\" aria-labelledby=\"forminator-field-radio-1-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Partner<\/span><\/label><label id=\"forminator-field-radio-1-label-5\" for=\"forminator-field-radio-1-5-69e8f240b431e\" class=\"forminator-radio\" title=\"Friend\"><input type=\"radio\" name=\"radio-1\" value=\"Option-2\" id=\"forminator-field-radio-1-5-69e8f240b431e\" aria-labelledby=\"forminator-field-radio-1-label-5\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Friend<\/span><\/label><label id=\"forminator-field-radio-1-label-6\" for=\"forminator-field-radio-1-6-69e8f240b431e\" class=\"forminator-radio\" title=\"Other:\"><input type=\"radio\" name=\"radio-1\" value=\"Option-2\" id=\"forminator-field-radio-1-6-69e8f240b431e\" aria-labelledby=\"forminator-field-radio-1-label-6\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Other:<\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \">\n<div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69e8f240b431e\" id=\"forminator-field-phone-1_69e8f240b431e-label\" class=\"forminator-label\">Best Contact Number<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"Your answer\" id=\"forminator-field-phone-1_69e8f240b431e\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \">\n<div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_69e8f240b431e\" id=\"forminator-field-textarea-2_69e8f240b431e-label\" class=\"forminator-label\">Patient&#039;s Home Address<\/label><textarea name=\"textarea-2\" placeholder=\"Your answer\" id=\"forminator-field-textarea-2_69e8f240b431e\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:30px;\" ><\/textarea><\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \">\n<div class=\"forminator-field\"><label for=\"forminator-field-text-5_69e8f240b431e\" id=\"forminator-field-text-5_69e8f240b431e-label\" class=\"forminator-label\">Briefly: what made you\/the patient want to begin therapy?<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"Your answer\" id=\"forminator-field-text-5_69e8f240b431e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \">\n<div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69e8f240b431e-label\"><span id=\"forminator-checkbox-group-69e8f240b431e-label\" class=\"forminator-label\">Are you seeking a particular type of therapy?<\/span><label id=\"forminator-field-checkbox-1-1-69e8f240b431e-label\" for=\"forminator-field-checkbox-1-1-69e8f240b431e\" class=\"forminator-checkbox\" title=\"Talk Therapy\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69e8f240b431e\" aria-labelledby=\"forminator-field-checkbox-1-1-69e8f240b431e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Talk Therapy<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69e8f240b431e-label\" for=\"forminator-field-checkbox-1-2-69e8f240b431e\" class=\"forminator-checkbox\" title=\"CBT (Cognitive Behavioral Therapy)\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-69e8f240b431e\" aria-labelledby=\"forminator-field-checkbox-1-2-69e8f240b431e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">CBT (Cognitive Behavioral Therapy)<\/span><\/label><label id=\"forminator-field-checkbox-1-3-69e8f240b431e-label\" for=\"forminator-field-checkbox-1-3-69e8f240b431e\" class=\"forminator-checkbox\" title=\"DBT (Dialectical Behavior Therapy)\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"DBT-(Dialectical-Behavior-Therapy)\" id=\"forminator-field-checkbox-1-3-69e8f240b431e\" aria-labelledby=\"forminator-field-checkbox-1-3-69e8f240b431e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">DBT (Dialectical Behavior Therapy)<\/span><\/label><label id=\"forminator-field-checkbox-1-4-69e8f240b431e-label\" for=\"forminator-field-checkbox-1-4-69e8f240b431e\" class=\"forminator-checkbox\" title=\"Trauma Therapy\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Trauma-Therapy\" id=\"forminator-field-checkbox-1-4-69e8f240b431e\" aria-labelledby=\"forminator-field-checkbox-1-4-69e8f240b431e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Trauma Therapy<\/span><\/label><label id=\"forminator-field-checkbox-1-5-69e8f240b431e-label\" for=\"forminator-field-checkbox-1-5-69e8f240b431e\" class=\"forminator-checkbox\" title=\"EMDR (Eye Movement Desensitization and Reprocessing)\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"EMDR-(Eye-Movement-Desensitization-and-Reprocessing)\" id=\"forminator-field-checkbox-1-5-69e8f240b431e\" aria-labelledby=\"forminator-field-checkbox-1-5-69e8f240b431e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">EMDR (Eye Movement Desensitization and Reprocessing)<\/span><\/label><label id=\"forminator-field-checkbox-1-6-69e8f240b431e-label\" for=\"forminator-field-checkbox-1-6-69e8f240b431e\" class=\"forminator-checkbox\" title=\"Couples Therapy\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Couples-Therapy\" id=\"forminator-field-checkbox-1-6-69e8f240b431e\" aria-labelledby=\"forminator-field-checkbox-1-6-69e8f240b431e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Couples Therapy<\/span><\/label><label id=\"forminator-field-checkbox-1-7-69e8f240b431e-label\" for=\"forminator-field-checkbox-1-7-69e8f240b431e\" class=\"forminator-checkbox\" title=\"Family Therapy\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Family-Therapy\" id=\"forminator-field-checkbox-1-7-69e8f240b431e\" aria-labelledby=\"forminator-field-checkbox-1-7-69e8f240b431e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Family Therapy<\/span><\/label><label id=\"forminator-field-checkbox-1-8-69e8f240b431e-label\" for=\"forminator-field-checkbox-1-8-69e8f240b431e\" class=\"forminator-checkbox\" title=\"Children&#039;s Therapy\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Children&#039;s-Therapy\" id=\"forminator-field-checkbox-1-8-69e8f240b431e\" aria-labelledby=\"forminator-field-checkbox-1-8-69e8f240b431e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Children&#8217;s Therapy<\/span><\/label><label id=\"forminator-field-checkbox-1-9-69e8f240b431e-label\" for=\"forminator-field-checkbox-1-9-69e8f240b431e\" class=\"forminator-checkbox\" title=\"Anger Management\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Anger-Management\" id=\"forminator-field-checkbox-1-9-69e8f240b431e\" aria-labelledby=\"forminator-field-checkbox-1-9-69e8f240b431e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Anger Management<\/span><\/label><label id=\"forminator-field-checkbox-1-10-69e8f240b431e-label\" for=\"forminator-field-checkbox-1-10-69e8f240b431e\" class=\"forminator-checkbox\" title=\"Addiction Counseling\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Addiction-Counseling\" id=\"forminator-field-checkbox-1-10-69e8f240b431e\" aria-labelledby=\"forminator-field-checkbox-1-10-69e8f240b431e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Addiction Counseling<\/span><\/label><label id=\"forminator-field-checkbox-1-11-69e8f240b431e-label\" for=\"forminator-field-checkbox-1-11-69e8f240b431e\" class=\"forminator-checkbox\" title=\"Grief Counseling\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Grief-Counseling\" id=\"forminator-field-checkbox-1-11-69e8f240b431e\" aria-labelledby=\"forminator-field-checkbox-1-11-69e8f240b431e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Grief Counseling<\/span><\/label><label id=\"forminator-field-checkbox-1-12-69e8f240b431e-label\" for=\"forminator-field-checkbox-1-12-69e8f240b431e\" class=\"forminator-checkbox\" title=\"Unsure\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Unsure\" id=\"forminator-field-checkbox-1-12-69e8f240b431e\" aria-labelledby=\"forminator-field-checkbox-1-12-69e8f240b431e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Unsure<\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12 \">\n<div class=\"forminator-field\"><label for=\"forminator-field-text-3_69e8f240b431e\" id=\"forminator-field-text-3_69e8f240b431e-label\" class=\"forminator-label\">Are you seeking a particular type of therapist (i.e., any personal or professional characteristics)?<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"Your answer\" id=\"forminator-field-text-3_69e8f240b431e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12 \">\n<div class=\"forminator-field\"><label for=\"forminator-field-upload-1_69e8f240b431e\" id=\"forminator-field-upload-1_69e8f240b431e-label\" class=\"forminator-label\">Please upload a photo of the front of your insurance card for insurance verification.<\/label><\/p>\n<div class=\"forminator-file-upload \" data-element=\"upload-1_69e8f240b431e\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1_69e8f240b431e\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\"><button id=\"forminator-field-upload-1_69e8f240b431e_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-1_69e8f240b431e\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"upload-2\" class=\"forminator-field-upload forminator-col forminator-col-12 \">\n<div class=\"forminator-field\"><label for=\"forminator-field-upload-2_69e8f240b431e\" id=\"forminator-field-upload-2_69e8f240b431e-label\" class=\"forminator-label\">Please upload a photo of the back of your insurance card for insurance verification.<\/label><\/p>\n<div class=\"forminator-file-upload \" data-element=\"upload-2_69e8f240b431e\"><input type=\"file\" name=\"upload-2\" id=\"forminator-field-upload-2_69e8f240b431e\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\"><button id=\"forminator-field-upload-2_69e8f240b431e_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-2_69e8f240b431e\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \">\n<div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><label class=\"forminator-label\">If the picture of your insurance card is not uploading please share the following information:<\/label><\/p>\n<ol>\n<li>Insurance company<\/li>\n<li>Insurance ID<\/li>\n<li>Group number<\/li>\n<\/ol>\n<p>    <label for=\"insurance-info\">Your answer:<\/label><br \/>\n    <textarea cols=\"50\" rows=\"4\" name=\"insurance-info\" id=\"insurance-info\"><\/textarea><\/div>\n<\/div>\n<\/div>\n<div class=\"forminator-row\">\n<div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \">\n<div role=\"group\" class=\"forminator-field\" 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