{"id":5458,"date":"2024-03-29T14:01:56","date_gmt":"2024-03-29T19:01:56","guid":{"rendered":"https:\/\/cgm.tailfish1.com\/?page_id=5458"},"modified":"2024-04-16T20:44:59","modified_gmt":"2024-04-17T01:44:59","slug":"inscripcion-en-linea","status":"publish","type":"page","link":"https:\/\/commongoodmedical.org\/es\/online-enrollment\/","title":{"rendered":"Inscripci\u00f3n en l\u00ednea"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5458\" class=\"elementor elementor-5458\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5a76b45 e-flex e-con-boxed e-con e-parent\" data-id=\"5a76b45\" data-element_type=\"container\" data-e-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-890a9e5 elementor-widget elementor-widget-heading\" data-id=\"890a9e5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Online Enrollment<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-e7382b8 e-flex e-con-boxed e-con e-parent\" data-id=\"e7382b8\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-39b17e1 elementor-widget elementor-widget-text-editor\" data-id=\"39b17e1\" data-element_type=\"widget\" data-e-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<h4 style=\"font-weight: 400; text-align: left !important;\">The electronic application will take approximately 15 minutes and you are given the option to Save and Return to the form if you need more time to complete.<\/h4><div style=\"text-align: left !important;\"><script>\n\/\/----------------------------------------------------------\n\/\/------ JAVASCRIPT HOOK FUNCTIONS FOR GRAVITY FORMS -------\n\/\/----------------------------------------------------------\n\nif ( ! gform ) {\n\tdocument.addEventListener( 'gform_main_scripts_loaded', function() { gform.scriptsLoaded = true; } );\n\tdocument.addEventListener( 'gform\/theme\/scripts_loaded', function() { gform.themeScriptsLoaded = true; } );\n\twindow.addEventListener( 'DOMContentLoaded', function() { gform.domLoaded = true; } );\n\n\tvar gform = {\n\t\tdomLoaded: false,\n\t\tscriptsLoaded: false,\n\t\tthemeScriptsLoaded: false,\n\t\tisFormEditor: () => typeof InitializeEditor === 'function',\n\n\t\t\/**\n\t\t * @deprecated 2.9 the use of initializeOnLoaded in the form editor context is deprecated.\n\t\t * @remove-in 4.0 this function will not check for gform.isFormEditor().\n\t\t *\/\n\t\tcallIfLoaded: function ( fn ) {\n\t\t\tif ( gform.domLoaded && gform.scriptsLoaded && ( gform.themeScriptsLoaded || gform.isFormEditor() ) ) {\n\t\t\t\tif ( gform.isFormEditor() ) {\n\t\t\t\t\tconsole.warn( 'The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.' );\n\t\t\t\t}\n\t\t\t\tfn();\n\t\t\t\treturn true;\n\t\t\t}\n\t\t\treturn false;\n\t\t},\n\n\t\t\/**\n\t\t * Call a function when all scripts are loaded\n\t\t *\n\t\t * @param function fn the callback function to call when all scripts are loaded\n\t\t *\n\t\t * @returns void\n\t\t *\/\n\t\tinitializeOnLoaded: function( fn ) {\n\t\t\tif ( ! gform.callIfLoaded( fn ) ) {\n\t\t\t\tdocument.addEventListener( 'gform_main_scripts_loaded', () => { gform.scriptsLoaded = true; gform.callIfLoaded( fn ); } );\n\t\t\t\tdocument.addEventListener( 'gform\/theme\/scripts_loaded', () => { gform.themeScriptsLoaded = true; gform.callIfLoaded( fn ); } );\n\t\t\t\twindow.addEventListener( 'DOMContentLoaded', () => { gform.domLoaded = true; gform.callIfLoaded( fn ); } );\n\t\t\t}\n\t\t},\n\n\t\thooks: { action: {}, filter: {} },\n\t\taddAction: function( action, callable, priority, tag ) {\n\t\t\tgform.addHook( 'action', action, callable, priority, tag );\n\t\t},\n\t\taddFilter: function( action, callable, priority, tag ) {\n\t\t\tgform.addHook( 'filter', action, callable, priority, tag );\n\t\t},\n\t\tdoAction: function( action ) {\n\t\t\tgform.doHook( 'action', action, arguments );\n\t\t},\n\t\tapplyFilters: function( action ) {\n\t\t\treturn gform.doHook( 'filter', action, arguments );\n\t\t},\n\t\tremoveAction: function( action, tag ) {\n\t\t\tgform.removeHook( 'action', action, tag );\n\t\t},\n\t\tremoveFilter: function( action, priority, tag ) {\n\t\t\tgform.removeHook( 'filter', action, priority, tag );\n\t\t},\n\t\taddHook: function( hookType, action, callable, priority, tag ) {\n\t\t\tif ( undefined == gform.hooks[hookType][action] ) {\n\t\t\t\tgform.hooks[hookType][action] = [];\n\t\t\t}\n\t\t\tvar hooks = gform.hooks[hookType][action];\n\t\t\tif ( undefined == tag ) {\n\t\t\t\ttag = action + '_' + hooks.length;\n\t\t\t}\n\t\t\tif( priority == undefined ){\n\t\t\t\tpriority = 10;\n\t\t\t}\n\n\t\t\tgform.hooks[hookType][action].push( { tag:tag, callable:callable, priority:priority } );\n\t\t},\n\t\tdoHook: function( hookType, action, args ) {\n\n\t\t\t\/\/ splice args from object into array and remove first index which is the hook name\n\t\t\targs = Array.prototype.slice.call(args, 1);\n\n\t\t\tif ( undefined != gform.hooks[hookType][action] ) {\n\t\t\t\tvar hooks = gform.hooks[hookType][action], hook;\n\t\t\t\t\/\/sort by priority\n\t\t\t\thooks.sort(function(a,b){return a[\"priority\"]-b[\"priority\"]});\n\n\t\t\t\thooks.forEach( function( hookItem ) {\n\t\t\t\t\thook = hookItem.callable;\n\n\t\t\t\t\tif(typeof hook != 'function')\n\t\t\t\t\t\thook = window[hook];\n\t\t\t\t\tif ( 'action' == hookType ) {\n\t\t\t\t\t\thook.apply(null, args);\n\t\t\t\t\t} else {\n\t\t\t\t\t\targs[0] = hook.apply(null, args);\n\t\t\t\t\t}\n\t\t\t\t} );\n\t\t\t}\n\t\t\tif ( 'filter'==hookType ) {\n\t\t\t\treturn args[0];\n\t\t\t}\n\t\t},\n\t\tremoveHook: function( hookType, action, priority, tag ) {\n\t\t\tif ( undefined != gform.hooks[hookType][action] ) {\n\t\t\t\tvar hooks = gform.hooks[hookType][action];\n\t\t\t\thooks = hooks.filter( function(hook, index, arr) {\n\t\t\t\t\tvar removeHook = (undefined==tag||tag==hook.tag) && (undefined==priority||priority==hook.priority);\n\t\t\t\t\treturn !removeHook;\n\t\t\t\t} );\n\t\t\t\tgform.hooks[hookType][action] = hooks;\n\t\t\t}\n\t\t}\n\t};\n}\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_7' style='display:none'><style>#gform_wrapper_7[data-form-index=\"0\"].gform-theme,[data-parent-form=\"7_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 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xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' 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0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_7' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Enrollment Application<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_7'  action='\/es\/wp-json\/wp\/v2\/pages\/5458#gf_7' data-formid='7' novalidate>\n        <div id='gf_progressbar_wrapper_7' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>8<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_12' style='width:12%;'><span>12%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_7_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_7' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_7_3\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Tell Us About You<\/h3><\/div><fieldset id=\"field_7_5\" class=\"gfield gfield--type-name gfield--input-type-name copy-5-to-75 gwcopy gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_7_5'>\n                            \n                            <span id='input_7_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_7_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_7_5_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.4' id='input_7_5_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_7_5_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_7_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_7_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_7_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_6'>Preferred First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_7_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_8\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_8'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_7_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_7_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_8_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_8' class='gform_hidden' value='https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_7_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_10'>\n\t\t\t<div class='gchoice gchoice_7_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Male'  id='choice_7_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_10_0' id='label_7_10_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Female'  id='choice_7_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_10_1' id='label_7_10_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_11'>Social Security Number<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_7_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_13\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Social Security Number<\/legend><div class='ginput_container ginput_container_consent'><input name='input_13.1' id='input_7_13_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_13_1' >I have no SSN.<\/label><input type='hidden' name='input_13.2' value='I have no SSN.' class='gform_hidden' \/><input type='hidden' name='input_13.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_14\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_14' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_14_1_container' >\n                                        <input type='text' name='input_14.1' id='input_7_14_1' value=''    aria-required='false'    \/>\n                                        <label for='input_7_14_1' id='input_7_14_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_14_3_container' >\n                                    <input type='text' name='input_14.3' id='input_7_14_3' value=''    aria-required='false'    \/>\n                                    <label for='input_7_14_3' id='input_7_14_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_14_4_container' >\n                                        <select name='input_14.4' id='input_7_14_4'     aria-required='false'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' selected='selected'>Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_14_4' id='input_7_14_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_14_5_container' >\n                                    <input type='text' name='input_14.5' id='input_7_14_5' value=''    aria-required='false'    \/>\n                                    <label for='input_7_14_5' id='input_7_14_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_14.6' id='input_7_14_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_7_119\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_119'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_119' id='input_7_119' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_7_15\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_15'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_7_15' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_16\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_16'>Mobile Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_7_16' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >May we text you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_18'>\n\t\t\t<div class='gchoice gchoice_7_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_7_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_18_0' id='label_7_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_7_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_18_1' id='label_7_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >May we call you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_17'>\n\t\t\t<div class='gchoice gchoice_7_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_7_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_17_0' id='label_7_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_7_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_17_1' id='label_7_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_22\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_22'>Contact Preference<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_7_22' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Home' >Home<\/option><option value='Work' >Work<\/option><option value='Mobile' >Mobile<\/option><\/select><\/div><\/div><div id=\"field_7_23\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_23'>Work Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_23' id='input_7_23' type='tel' value='' class='small'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_24\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_24'>Language<\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_7_24' class='large gfield_select'     aria-invalid=\"false\" ><option value='English' >English<\/option><option value='Spanish' >Spanish<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_7_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_25'>Other.  Please specify.<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_7_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Need Translator<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_29'>\n\t\t\t<div class='gchoice gchoice_7_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_7_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_29_0' id='label_7_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_7_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_29_1' id='label_7_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_26\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_26'>Race<\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_7_26' class='large gfield_select'     aria-invalid=\"false\" ><option value='American Indian' >American Indian<\/option><option value='Asian' >Asian<\/option><option value='Asian Indian' >Asian Indian<\/option><option value='Black or African American' >Black or African American<\/option><option value='European' >European<\/option><option value='Filipino' >Filipino<\/option><option value='Japanese' >Japanese<\/option><option value='Korean' >Korean<\/option><option value='Native Hawaiian' >Native Hawaiian<\/option><option value='Other Pacific Islander' >Other Pacific Islander<\/option><option value='White' >White<\/option><option value='Decline to Answer' >Decline to Answer<\/option><\/select><\/div><\/div><div id=\"field_7_27\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_27'>Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_7_27' class='large gfield_select'     aria-invalid=\"false\" ><option value='Not Hispanic or Latino' >Not Hispanic or Latino<\/option><option value='Central American' >Central American<\/option><option value='Cuban' >Cuban<\/option><option value='Dominican' >Dominican<\/option><option value='Hispanic' >Hispanic<\/option><option value='Latino \/ Spanish' >Latino \/ Spanish<\/option><option value='Mexican' >Mexican<\/option><option value='Puerto Rican' >Puerto Rican<\/option><option value='South American' >South American<\/option><option value='Spaniard' >Spaniard<\/option><option value='Decline to Answer' >Decline to Answer<\/option><\/select><\/div><\/div><div id=\"field_7_28\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_28'>Marital Status<\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_7_28' class='large gfield_select'     aria-invalid=\"false\" ><option value='Married' >Married<\/option><option value='Single' >Single<\/option><option value='Divorced' >Divorced<\/option><option value='Separated' >Separated<\/option><option value='Widowed Partner' >Widowed Partner<\/option><\/select><\/div><\/div><div id=\"field_7_30\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Emergency Contact<\/h3><\/div><div id=\"field_7_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_31'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_7_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_33\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_33'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_33' id='input_7_33' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_32'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_7_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_7_34' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_7_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save &#038; Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_2' class='gform_page' data-js='page-field-id-34' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><fieldset id=\"field_7_120\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Which clinic location  do you prefer?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_120'><div class='gchoice gchoice_7_120_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.1' type='checkbox'  value='McKinney'  id='choice_7_120_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_120_1' id='label_7_120_1' class='gform-field-label gform-field-label--type-inline'>McKinney<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_120_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.2' type='checkbox'  value='Farmersville'  id='choice_7_120_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_120_2' id='label_7_120_2' class='gform-field-label gform-field-label--type-inline'>Farmersville<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_41\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Medical Records and Insurance<\/h3><\/div><div id=\"field_7_36\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_36'>How did you hear about CommonGood Medical<\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_7_36' class='large gfield_select'     aria-invalid=\"false\" ><option value='Advertising' >Advertising<\/option><option value='Other Physician' >Other Physician<\/option><option value='Word of Mouth' >Word of Mouth<\/option><option value='Commongood Medical Patient' >Commongood Medical Patient<\/option><option value='Hospital' >Hospital<\/option><option value='Church' >Church<\/option><\/select><\/div><\/div><div id=\"field_7_37\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_37'>If you had not come to CommonGood Medical today, where would you have gone to receive medical care?<\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_7_37' class='large gfield_select'     aria-invalid=\"false\" ><option value='Emergency Room' >Emergency Room<\/option><option value='Urgent Care' >Urgent Care<\/option><option value='Doctor&#039;s Office' >Doctor&#039;s Office<\/option><option value='Other Free Clinic' >Other Free Clinic<\/option><option value='Would not have received care' >Would not have received care<\/option><\/select><\/div><\/div><div id=\"field_7_40\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_40'>Other. Please Explain.<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_7_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_42' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_7_42' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_7_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save &#038; Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_3' class='gform_page' data-js='page-field-id-42' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_3' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_7_43\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_43'>What is\/are the reason(s) for your visit?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_7_43' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_7_121\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_121'>Please indicate your preferred pharmacy and city<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_7_121' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_44\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Patient Agreement and Permission to Treat<\/h3><\/div><div id=\"field_7_46\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >CommonGood Medical is a non-profit agency. To better serve you, we ask for your cooperation in following the policies listed below. These policies apply to both in-office and telehealth visits. If you are unable to follow these guidelines, or find them unacceptable, another care provider may be better able to meet your needs.<\/div><fieldset id=\"field_7_45\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please read and agree with each statement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_45' tabindex='0'>I understand that the examination and medical care given to me (or my minor child) will be provided by a licensed physician, physician assistant, or nurse practitioner.<\/div><div class='ginput_container ginput_container_consent'><input name='input_45.1' id='input_7_45_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_45\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_45_1' >I agree.<\/label><input type='hidden' name='input_45.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_45.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_48\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I understand that CommonGood Medical does not prescribe narcotics.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_48' tabindex='0'>I understand that CommonGood Medical does not prescribe narcotics.<\/div><div class='ginput_container ginput_container_consent'><input name='input_48.1' id='input_7_48_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_48\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_48_1' >I agree.<\/label><input type='hidden' name='input_48.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_48.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_52\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I understand that my medical records are available upon request by signing a medical records release form during clinic hours or through the Patient Portal.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_52' tabindex='0'>I understand that my medical records are available upon request by signing a medical records release form during clinic hours or through the Patient Portal.   <\/div><div class='ginput_container ginput_container_consent'><input name='input_52.1' id='input_7_52_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_52\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_52_1' >I agree.<\/label><input type='hidden' name='input_52.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_52.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_51\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I agree to complete the required annual re-enrollment process and provide my most current financial documents.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_51' tabindex='0'>I agree to complete the required annual re-enrollment process and provide my most current financial documents.   <\/div><div class='ginput_container ginput_container_consent'><input name='input_51.1' id='input_7_51_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_51\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_51_1' >I agree.<\/label><input type='hidden' name='input_51.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_51.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_50\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I understand that while CommonGood Medical will provide primary care needs, including necessary labs, at no cost. CommonGood Medical does not guarantee access to any care performed through outside services including imaging and specialty care. Furthermore, CommonGood Medical is not responsible for any costs incurred by my use of outside services.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_50' tabindex='0'>I understand that while CommonGood Medical will provide primary care needs, including necessary labs, at no cost. CommonGood Medical does not guarantee access to any care performed through outside services including imaging and specialty care. Furthermore, CommonGood Medical is not responsible for any costs incurred by my use of outside services.  <\/div><div class='ginput_container ginput_container_consent'><input name='input_50.1' id='input_7_50_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_50\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_50_1' >I agree.<\/label><input type='hidden' name='input_50.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_50.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_49\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I understand that I am solely responsible for the follow-through on testing and\/or treatment ordered by medical providers at CommonGood Medical, and that if I fail to do so my treatment may be unsuccessful. I understand that I am expected to obtain any labs or imaging ordered by my physician prior to my next appointment.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_49' tabindex='0'>I understand that I am solely responsible for the follow-through on testing and\/or treatment ordered by medical providers at CommonGood Medical, and that if I fail to do so my treatment may be unsuccessful. I understand that I am expected to obtain any labs or imaging ordered by my physician prior to my next appointment.  <\/div><div class='ginput_container ginput_container_consent'><input name='input_49.1' id='input_7_49_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_49\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_49_1' >I agree.<\/label><input type='hidden' name='input_49.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_49.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_62\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >All information is treated as confidential and will be held in strict confidence, except as required by the law or the following circumstances: (1) when there is a reasonable suspicion of child abuse, whether the patient is the victim or the abuser, or when there is a threat of harm to a third party; (2) when there is a threat of self-inflicted harm; (3) when there is a reasonable suspicion of intimate partner violence; (4) when there is a threat against the clinic itself.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_62' tabindex='0'>All information is treated as confidential and will be held in strict confidence, except as required by the law or the following circumstances: (1) when there is a reasonable suspicion of child abuse, whether the patient is the victim or the abuser, or when there is a threat of harm to a third party; (2) when there is a threat of self-inflicted harm; (3) when there is a reasonable suspicion of intimate partner violence; (4) when there is a threat against the clinic itself.  <\/div><div class='ginput_container ginput_container_consent'><input name='input_62.1' id='input_7_62_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_62\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_62_1' >I agree.<\/label><input type='hidden' name='input_62.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_62.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_61\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I understand that if I miss three (3) appointments in one year, without calling or texting to cancel more than 24 hours in advance, I may not remain a CommonGood Medical patient. I understand that I may leave a voicemail or reply in the confirmation text to cancel. I understand that if I am more than five (5) minutes late for my appointment, I am not guaranteed to be seen and may have to be rescheduled and that it will be considered a no-show.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_61' tabindex='0'>I understand that if I miss three (3) appointments in one year, without calling or texting to cancel more than 24 hours in advance, I may not remain a CommonGood Medical patient. I understand that I may leave a voicemail or reply in the confirmation text to cancel. I understand that if I am more than five (5) minutes late for my appointment, I am not guaranteed to be seen and may have to be rescheduled and that it will be considered a no-show.  <\/div><div class='ginput_container ginput_container_consent'><input name='input_61.1' id='input_7_61_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_61\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_61_1' >I agree.<\/label><input type='hidden' name='input_61.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_61.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_60\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I agree to inform CommonGood Medical within 30 days of any change in my name, address, telephone number, household income, or if I have qualified for insurance of any kind by calling (469) 712-4246.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_60' tabindex='0'>I agree to inform CommonGood Medical within 30 days of any change in my name, address, telephone number, household income, or if I have qualified for insurance of any kind by calling (469) 712-4246.  <\/div><div class='ginput_container ginput_container_consent'><input name='input_60.1' id='input_7_60_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_60\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_60_1' >I agree.<\/label><input type='hidden' name='input_60.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_60.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_59\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I authorize any health care professional associated with CommonGood Medical to disclose any personal, evaluation, and\/or treatment information to other health care professionals for continuation of care or for purposes of obtaining health care information from other facilities when medically necessary.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_59' tabindex='0'>I authorize any health care professional associated with CommonGood Medical to disclose any personal, evaluation, and\/or treatment information to other health care professionals for continuation of care or for purposes of obtaining health care information from other facilities when medically necessary.  <\/div><div class='ginput_container ginput_container_consent'><input name='input_59.1' id='input_7_59_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_59\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_59_1' >I agree.<\/label><input type='hidden' name='input_59.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_59.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_58\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I understand that if I no-show an in-clinic specialty appointment (any non-primary care), I will not be eligible to reschedule within the calendar year.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_58' tabindex='0'>I understand that if I no-show an in-clinic specialty appointment (any non-primary care), I will not be eligible to reschedule within the calendar year.  <\/div><div class='ginput_container ginput_container_consent'><input name='input_58.1' id='input_7_58_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_58\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_58_1' >I agree.<\/label><input type='hidden' name='input_58.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_58.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_57\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I understand that if I am uncooperative, verbally or physically abusive, intoxicated, or behave in an inappropriate manner, I may not be eligible for services at CommonGood Medical.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_57' tabindex='0'>I understand that if I am uncooperative, verbally or physically abusive, intoxicated, or behave in an inappropriate manner, I may not be eligible for services at CommonGood Medical.  <\/div><div class='ginput_container ginput_container_consent'><input name='input_57.1' id='input_7_57_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_57\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_57_1' >I agree.<\/label><input type='hidden' name='input_57.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_57.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_56\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I understand that if I no-show an outside specialty appointment two (2) times in one year, without providing the specialty office appropriate notice as determined by that office, I will not remain a CommonGood Medical patient.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_56' tabindex='0'>I understand that if I no-show an outside specialty appointment two (2) times in one year, without providing the specialty office appropriate notice as determined by that office, I will not remain a CommonGood Medical patient.<\/div><div class='ginput_container ginput_container_consent'><input name='input_56.1' id='input_7_56_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_56\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_56_1' >I agree.<\/label><input type='hidden' name='input_56.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_56.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_55\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I understand that video- or audio-taping of any portion of my visit, by any method or device, including cell phones, is strictly prohibited. I understand that CommonGood Medical and its representatives (paid or volunteer) do not consent to having any conversations recorded.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_55' tabindex='0'>I understand that video- or audio-taping of any portion of my visit, by any method or device, including cell phones, is strictly prohibited. I understand that CommonGood Medical and its representatives (paid or volunteer) do not consent to having any conversations recorded.  <\/div><div class='ginput_container ginput_container_consent'><input name='input_55.1' id='input_7_55_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_55\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_55_1' >I agree.<\/label><input type='hidden' name='input_55.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_55.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_54\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >If I am referred to another agency for assistance, I give my permission for pertinent information to be released to that agency. If CommonGood Medical provides me with referrals, I agree there is no legal responsibility for services provided by other agencies.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_54' tabindex='0'>If I am referred to another agency for assistance, I give my permission for pertinent information to be released to that agency. If CommonGood Medical provides me with referrals, I agree there is no legal responsibility for services provided by other agencies.  <\/div><div class='ginput_container ginput_container_consent'><input name='input_54.1' id='input_7_54_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_54\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_54_1' >I agree.<\/label><input type='hidden' name='input_54.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_54.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_53\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' >I understand that if I no longer meet the qualifications to be a CommonGood Medical patient, I may schedule a final \u201cgraduation appointment\u201d within 30 days of dismissal from practice in order to receive a one-time refill on any medications as determined by my provider. If I cancel or no-show the appointment, I may not reschedule.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_53' tabindex='0'>I understand that if I no longer meet the qualifications to be a CommonGood Medical patient, I may schedule a final \u201cgraduation appointment\u201d within 30 days of dismissal from practice in order to receive a one-time refill on any medications as determined by my provider. If I cancel or no-show the appointment, I may not reschedule.<\/div><div class='ginput_container ginput_container_consent'><input name='input_53.1' id='input_7_53_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_53\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_53_1' >I agree.<\/label><input type='hidden' name='input_53.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_53.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_7_63\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >I have read, understand, and agree to the guidelines set forth by CommonGood Medical. I understand that I can be denied further services provided CommonGood Medical if I have given false or misleading information.<\/div><div id=\"field_7_67\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_67'>Patient Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_67' id='input_7_67_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_7_67_Container' class='gfield_signature_container ginput_container' style='height:180px; width:500px; ' ><canvas id='input_7_67' width='500' height='180' style='border-style: solid; border-width: 1px; border-color: #aaaaaa; background-color:#fff; cursor: url(https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_7_67_toolbar' style='margin:5px 0;position:relative;height:20px;width:500px;max-width:100%;'><img id = 'input_7_67_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_7_67_data' name='input_7_67_data' value=''><\/div><\/div><div id=\"field_7_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_69'>Date<\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_69' id='input_7_69' type='text' value='04\/29\/2026' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is the patient under 18?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_64'>\n\t\t\t<div class='gchoice gchoice_7_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Yes'  id='choice_7_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_64_0' id='label_7_64_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='No'  id='choice_7_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_64_1' id='label_7_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_68\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_68'>Signature of Parent \/ Legal Guardian<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_68' id='input_7_68_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_7_68_Container' class='gfield_signature_container ginput_container' style='height:180px; width:500px; ' ><canvas id='input_7_68' width='500' height='180' style='border-style: solid; border-width: 1px; border-color: #aaaaaa; background-color:#fff; cursor: url(https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_7_68_toolbar' style='margin:5px 0;position:relative;height:20px;width:500px;max-width:100%;'><img id = 'input_7_68_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_7_68_data' name='input_7_68_data' value=''><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_70' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_7_70' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_7_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save &#038; Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_4' class='gform_page' data-js='page-field-id-70' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_4' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_7_71\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Privacy Statement<\/h3><\/div><fieldset id=\"field_7_74\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I have read and understand CommonGood Medical\u2019s Notice of Privacy Practices. I understand that if I have any questions I may contact CommonGood Medical\u2019s Director of Operations, who is acting as the Privacy Official at (469) 712-4246. I understand that I may receive a copy of these notices if I request one.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_74.1' id='input_7_74_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_74_1' >I agree to the privacy policy.<\/label><input type='hidden' name='input_74.2' value='I agree to the privacy policy.' class='gform_hidden' \/><input type='hidden' name='input_74.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_75\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_7_75'>\n                            \n                            <span id='input_7_75_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input readonly='readonly' type='text' name='input_75.3' id='input_7_75_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_7_75_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_7_75_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input readonly='readonly' type='text' name='input_75.4' id='input_7_75_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_7_75_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_7_75_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input readonly='readonly' type='text' name='input_75.6' id='input_7_75_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_7_75_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <input type=\"hidden\" id=\"gwro_hidden_capture_7_75_2\" name=\"gwro_hidden_capture_7_75_2\" value=\"\" class=\"gf-default-disabled\" \/><input type=\"hidden\" id=\"gwro_hidden_capture_7_75_3\" name=\"gwro_hidden_capture_7_75_3\" value=\"\" class=\"gf-default-disabled\" \/><input type=\"hidden\" id=\"gwro_hidden_capture_7_75_4\" name=\"gwro_hidden_capture_7_75_4\" value=\"\" class=\"gf-default-disabled\" \/><input type=\"hidden\" id=\"gwro_hidden_capture_7_75_6\" name=\"gwro_hidden_capture_7_75_6\" value=\"\" class=\"gf-default-disabled\" \/><input type=\"hidden\" id=\"gwro_hidden_capture_7_75_8\" name=\"gwro_hidden_capture_7_75_8\" value=\"\" class=\"gf-default-disabled\" \/><\/div><\/fieldset><div id=\"field_7_76\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_76'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input readonly='readonly' name='input_76' id='input_7_76' type='text' value='04\/29\/2026' class='gpro-disabled-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_7_76_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_76_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <input type=\"hidden\" id=\"gwro_hidden_capture_7_76\" name=\"gwro_hidden_capture_7_76\" value=\"04\/29\/2026\" class=\"gf-default-disabled\" \/><\/div>\n                        <input readonly='readonly' type='hidden' id='gforms_calendar_icon_input_7_76' class='gform_hidden' value='https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_7_78\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_78'>Patient Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_78' id='input_7_78_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_7_78_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><canvas id='input_7_78' width='400' height='180' style='border-style: solid; border-width: 1px; border-color: #cccccc; background-color:#ffffff; cursor: url(https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_7_78_toolbar' style='margin:5px 0;position:relative;height:20px;width:400px;max-width:100%;'><img id = 'input_7_78_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_7_78_data' name='input_7_78_data' value=''><\/div><\/div><div id=\"field_7_79\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_79'>Signature of Parent \/ Legal Guardian<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_79' id='input_7_79_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_7_79_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><canvas id='input_7_79' width='400' height='180' style='border-style: solid; border-width: 1px; border-color: #cccccc; background-color:#ffffff; cursor: url(https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_7_79_toolbar' style='margin:5px 0;position:relative;height:20px;width:400px;max-width:100%;'><img id = 'input_7_79_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_7_79_data' name='input_7_79_data' value=''><\/div><\/div><fieldset id=\"field_7_129\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Records Sharing Permissions<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_129' tabindex='0'>By clicking here, I consent to and understand that CommonGood Medical&#8217;s EMR system will automatically exchange my medical recordsw with any providers who care for me as a patient. The duration of this consent is indefinite unless otherwise revoked in writing.<\/div><div class='ginput_container ginput_container_consent'><input name='input_129.1' id='input_7_129_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_129\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_129_1' >I agree to the privacy policy.<\/label><input type='hidden' name='input_129.2' value='I agree to the privacy policy.' class='gform_hidden' \/><input type='hidden' name='input_129.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_80' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_7_80' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_7_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save &#038; Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_5' class='gform_page' data-js='page-field-id-80' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_5' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_7_81\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Social Determinants of Health Screening<\/h3><\/div><div id=\"field_7_82\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3>Food<\/h3><\/div><fieldset id=\"field_7_83\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Within the past 12 months, did you worry that your food would run out before you got money to buy more?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_83'>\n\t\t\t<div class='gchoice gchoice_7_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Yes'  id='choice_7_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_83_0' id='label_7_83_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='No'  id='choice_7_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_83_1' id='label_7_83_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Within the past 12 months, did the food you bought just not last and you didn\u2019t have money to get more?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_84'>\n\t\t\t<div class='gchoice gchoice_7_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Yes'  id='choice_7_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_84_0' id='label_7_84_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='No'  id='choice_7_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_84_1' id='label_7_84_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_85\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3>Housing \/ Utilities<\/h3><\/div><fieldset id=\"field_7_86\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have housing?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_86'>\n\t\t\t<div class='gchoice gchoice_7_86_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Yes'  id='choice_7_86_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_86_0' id='label_7_86_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_86_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='No'  id='choice_7_86_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_86_1' id='label_7_86_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_96\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you worried about losing your housing?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_96'>\n\t\t\t<div class='gchoice gchoice_7_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Yes'  id='choice_7_96_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_96_0' id='label_7_96_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='No'  id='choice_7_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_96_1' id='label_7_96_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_95\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Within the past 12 months, have you or your family members you live with been unable to get utilities (heat, electricity) when it was really needed?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_95'>\n\t\t\t<div class='gchoice gchoice_7_95_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='Yes'  id='choice_7_95_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_95_0' id='label_7_95_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_95_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='No'  id='choice_7_95_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_95_1' id='label_7_95_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_97\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3>Transportation<\/h3><\/div><fieldset id=\"field_7_94\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Within the past 12 months, has lack of transportation kept you from medical appointments, getting your medicines, non-medical meetings or appointments, work, or from getting things that you need?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_94'>\n\t\t\t<div class='gchoice gchoice_7_94_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Yes'  id='choice_7_94_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_94_0' id='label_7_94_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_94_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='No'  id='choice_7_94_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_94_1' id='label_7_94_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_98\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3>Interpersonal Safety<\/h3><\/div><fieldset id=\"field_7_93\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you feel physically and emotionally safe where you currently live?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_93'>\n\t\t\t<div class='gchoice gchoice_7_93_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='Yes'  id='choice_7_93_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_93_0' id='label_7_93_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_93_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='No'  id='choice_7_93_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_93_1' id='label_7_93_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_92\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Within the past 12 months, have you been hit, slapped, kicked or otherwise physically hurt by someone?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_92'>\n\t\t\t<div class='gchoice gchoice_7_92_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Yes'  id='choice_7_92_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_92_0' id='label_7_92_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_92_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='No'  id='choice_7_92_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_92_1' id='label_7_92_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_91\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Within the past 12 months, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_91'>\n\t\t\t<div class='gchoice gchoice_7_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='Yes'  id='choice_7_91_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_91_0' id='label_7_91_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='No'  id='choice_7_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_91_1' id='label_7_91_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_99' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_7_99' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_7_6_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save &#038; Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_6' class='gform_page' data-js='page-field-id-99' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_6' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_7_100\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Free Clinic Federal Tort Claims Act (FTCA) Patient Notice of Limited Liability<\/h3><\/div><div id=\"field_7_101\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p style=\"font-style:italic; text-align:center;\">To be provided to the individual patient before health care services are provided, except in emergency cases when notice may be provided as soon after the emergency as is practical, or to a parent or guardian when the patient lacks legal responsibility for his\/her are under state law.<\/p>\n \n<p><u>Notice to Patients<\/u><\/p>\n<p><\/p>\n<p>This is to notify you that under Federal law relating to the operation of free clinics, the Federal Tort Claims Act (FTCA), (See 28 U.S.C. \u00a7\u00a7 1346(b), 2401(b), 2671-80) provides the exclusive remedy for damage from personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions by any free clinic volunteer health care practitioner who the department of Health and Human Services has deemed to be an employee of the Public Health Service. This FTCA medical malpractice coverage applies to deemed free clinic volunteer healthcare practitioners who have provided a regular or authorized service under Title XIX of Social Security Act. The legal liability of the deemed individual is limited pursuant to section 224(o) off the Public Health Service Act, 42 U.S.C. 233(o).<\/p>\n<p>(i.e.: Medicaid program) at a free clinic site or through offsite programs or events carried out by a free clinic (See 42 U.S.C. \u00a7 233(a), (o)). <\/p>\n<p>The above federal law may cover certain free clinic healthcare professionals providing health care services to patients at this free clinic.<\/p>\n<p><\/p>\n<h3>CONSENT FOR CHARITY CARE<\/h3>\n<\/div><fieldset id=\"field_7_102\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent for Charity Care<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_102' tabindex='0'>I acknowledge that the physicians of CommonGood Medical are volunteer health care providers and are not administrating care for or in expectation of compensation. I also understand that as volunteer health care providers, these physicians are immune from civil liability for any act or omission resulting in death, damage, or injury, as long as the volunteers act in good faith and in the scope of his or her duties within the organization in providing the health care services. Furthermore, I realize that the civil liabilities of both the charitable organization and an employee of the charitable organization are limited to money. These limits apply to the employee and the organization separately; they are not aggregate limits.<\/div><div class='ginput_container ginput_container_consent'><input name='input_102.1' id='input_7_102_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_102\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_102_1' >I understand.<\/label><input type='hidden' name='input_102.2' value='I understand.' class='gform_hidden' \/><input type='hidden' name='input_102.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_103' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_7_103' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_7_7_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save &#038; Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_7' class='gform_page' data-js='page-field-id-103' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_7' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_7_104\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Communication of Health Information<\/h3><\/div><div id=\"field_7_105\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >In regards to communicating medical details to the patient, please answer the following questions.<\/div><fieldset id=\"field_7_107\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >On my cell phone,<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_107'>\n\t\t\t<div class='gchoice gchoice_7_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='CommonGood Medical may leave detailed medical information.'  id='choice_7_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_107_0' id='label_7_107_0' class='gform-field-label gform-field-label--type-inline'>CommonGood Medical may leave detailed medical information.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='CommonGood Medical may leave a message with a call back number &lt;u&gt;ONLY&lt;\/u&gt;'  id='choice_7_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_107_1' id='label_7_107_1' class='gform-field-label gform-field-label--type-inline'>CommonGood Medical may leave a message with a call back number <u>ONLY<\/u><\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_108\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >On my home phone,<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_108'>\n\t\t\t<div class='gchoice gchoice_7_108_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='CommonGood Medical may leave detailed medical information.'  id='choice_7_108_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_108_0' id='label_7_108_0' class='gform-field-label gform-field-label--type-inline'>CommonGood Medical may leave detailed medical information.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_108_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='CommonGood Medical may leave a message with a call back number &lt;u&gt;ONLY&lt;\/u&gt;'  id='choice_7_108_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_108_1' id='label_7_108_1' class='gform-field-label gform-field-label--type-inline'>CommonGood Medical may leave a message with a call back number <u>ONLY<\/u><\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_109\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3>Communication With Others<\/h3><\/div><fieldset id=\"field_7_110\" class=\"gfield gfield--type-list gfield--input-type-list gp-field-maxrows-0 field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I hereby give permission to the staff of CommonGood Medical to disclose and discuss any information related to my medical condition(s) with the following family member(s), other relative(s), and\/or close personal friends:<\/legend><div class='gfield_description' id='gfield_description_7_110'>Add and remove additional names by pressing the <img decoding=\"async\" src=\"\/wp-content\/plugins\/gravityforms\/images\/list-add.svg\" style=\"height:12px;width:12px;margin-bottom:0px;\"\/> and <img decoding=\"async\" src=\"\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg\" style=\"width:12px;height:12px;margin-bottom:0px;\"\/> on the end of each row.<\/div><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Relationship<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Phone Number<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_110_cell1 gform-grid-col' data-label='Name'><input aria-invalid='false'  aria-describedby=\"gfield_description_7_110\" aria-label='Name, Row 1' data-aria-label-template='Name, Row {0}' type='text' name='input_110[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_110_cell2 gform-grid-col' data-label='Relationship'><input aria-invalid='false'  aria-describedby=\"gfield_description_7_110\" aria-label='Relationship, Row 1' data-aria-label-template='Relationship, Row {0}' type='text' name='input_110[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_110_cell3 gform-grid-col' data-label='Phone Number'><input aria-invalid='false'  aria-describedby=\"gfield_description_7_110\" aria-label='Phone Number, Row 1' data-aria-label-template='Phone Number, Row {0}' type='text' name='input_110[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_111\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_111'><div class='gchoice gchoice_7_111_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_111.1' type='checkbox'  value='I do not wish to disclose any information with anyone.'  id='choice_7_111_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_111_1' id='label_7_111_1' class='gform-field-label gform-field-label--type-inline'>I do not wish to disclose any information with anyone.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_113\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent to Share Information<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_113' tabindex='0'>The duration of this authorization is indefinite unless otherwise revoked in writing. I<br \/>\nunderstand that requests for medical information from persons not listed above will require<br \/>\nmy specific authorization prior to the disclosure of medical information.<\/div><div class='ginput_container ginput_container_consent'><input name='input_113.1' id='input_7_113_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_113\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_113_1' >I understand<\/label><input type='hidden' name='input_113.2' value='I understand' class='gform_hidden' \/><input type='hidden' name='input_113.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_114' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_7_114' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_7_8_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save &#038; Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_8' class='gform_page' data-js='page-field-id-114' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_8' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_7_115\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Patient Rights and Responsibilities<\/h3><\/div><div id=\"field_7_116\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>At CommonGood Medical we believe in team-based health care. That means that we, as health care providers have an active role, and you, as a patient have an active role.<\/p>\n<p>CommonGood Medical is responsible for:<br>\n<ul class=\"bullets\"><li>Providing evidence-based primary care services.<\/li>\n  <li>Providing considerate and respectful care.<\/li>\n  <li>Explaining all procedures and test results at patient appointments. Providing reasonable answers to questions at appointments.<\/li>\n\t<li>Keeping all medical information private.<\/li>\n\t<\/ul>\n  You, as a patient, are responsible for:<br>\n  <ul class=\"bullets\"><li>Being on time for appointments. If you must cancel or reschedule, you must call us at (469) 712-4246 at least 24 hours prior to the appointment time. Leaving a voicemail will constitute contact.<\/li>\n  <li>If you miss three appointments in one year without calling to cancel or reschedule, CommonGood Medical may discontinue care.<\/li>\n  <li>As you are able, making a donation of any amount at each visit to help cover the costs associated with the care provided to the next patient.<\/li>\n  <li>Obtaining any lab testing or imaging that is ordered by your physician prior to your next appointment.<\/li>\n  Informing CommonGood Medical within 30 days of any change in your insurance status, income, or contact information. Failure to do so can result in delayed treatment.<\/li>\n  <li>Timely providing updated patient enrollment documents (proof of residency and income) each year.<\/li>\n  <li>Being an active partner in managing your health.<\/li>\n\t<\/ul>\n\n<style>\nul.bullets li\n\t{\n\t\tlist-style-type: disc;\n\t}\n<\/style><\/div><div id=\"field_7_117\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_117'>Patient Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_117' id='input_7_117_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_7_117_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><canvas id='input_7_117' width='400' height='180' style='border-style: solid; border-width: 1px; border-color: #aaaaaa; background-color:#ffffff; cursor: url(https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_7_117_toolbar' style='margin:5px 0;position:relative;height:20px;width:400px;max-width:100%;'><img id = 'input_7_117_resetbutton' 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