{"id":1326,"date":"2024-03-07T05:23:09","date_gmt":"2024-03-07T05:23:09","guid":{"rendered":"https:\/\/nexunom.com\/members-area\/?page_id=1326"},"modified":"2024-03-07T05:23:10","modified_gmt":"2024-03-07T05:23:10","slug":"dental-practice-registration-form","status":"publish","type":"page","link":"https:\/\/nexunom.com\/members-area\/dental-practice-registration-form\/","title":{"rendered":"Dental Practice Registration Form"},"content":{"rendered":"<style type=\"text\/css\">#ipt_fsqm_form_wrap_63 .ipt_fsqm_form_logo img,\n\t#ipt_fsqm_form_wrap_63 .ipt-eform-width-restrain,\n\t#ipt_fsqm_form_wrap_63 .ipt_fsqm_form_message_restore,\n\t#ipt_fsqm_form_wrap_63 .ipt_fsqm_form_message_success,\n\t#ipt_fsqm_form_wrap_63 .ipt_fsqm_form_message_error,\n\t#ipt_fsqm_form_wrap_63 .ipt_fsqm_form_message_process,\n\t#ipt_fsqm_form_wrap_63 .ipt_fsqm_form_validation_error,\n\t#ipt_fsqm_form_wrap_63 .eform-ui-estimator {\n\t\tmax-width: 980px;\n\t\tmin-width: 240px;\n\t}\n\n\t\/**\/<\/style><div\nid=\"ipt_fsqm_form_wrap_63\"\nclass=\"ipt_uif_front ipt_uif_common ipt_fsqm_form type_1 ui-front eform-ltr eform-override-element-boxy eform-override-alignment-inherit\"\ndata-fsqmsayt=\"{&quot;auto_save&quot;:false,&quot;show_restore&quot;:true,&quot;restore&quot;:false,&quot;admin_override&quot;:false,&quot;user_update&quot;:false,&quot;interval_save&quot;:false,&quot;interval&quot;:&quot;30&quot;}\"\ndata-ui-type=\"1\"\ndata-ui-theme=\"[&quot;https:\\\/\\\/nexunom.com\\\/members-area\\\/wp-content\\\/plugins\\\/wp-fsqm-pro\\\/static\\\/front\\\/css\\\/material-themes\\\/light-themes\\\/blue.css?ver=4.20.1&quot;]\"\ndata-ui-theme-id=\"material-blue\"\ndata-eformanim=\"1\"\ndata-fsqmga=\"{&quot;enabled&quot;:false,&quot;manual_load&quot;:false,&quot;tracking_id&quot;:&quot;&quot;,&quot;cookie&quot;:&quot;auto&quot;,&quot;user_update&quot;:false,&quot;name&quot;:&quot;Practice Information Form&quot;,&quot;form_id&quot;:&quot;63&quot;}\"\ndata-fsqmreset=\"{&quot;reset&quot;:false,&quot;delay&quot;:10}\"\ndata-eformreg=\"{&quot;enabled&quot;:false,&quot;username_id&quot;:&quot;ipt_fsqm_form_63_pinfo_&quot;,&quot;password_id&quot;:&quot;ipt_fsqm_form_63_pinfo_&quot;,&quot;hide_pinfo&quot;:true,&quot;hide_meta&quot;:false,&quot;meta&quot;:[]}\"\ndata-eformscroll=\"{&quot;progress&quot;:true,&quot;message&quot;:true,&quot;offset&quot;:&quot;0&quot;,&quot;scrollOnError&quot;:true}\"\ndata-eform-cookie=\"0\"\ndata-subscription-form=\"false\"\ndata-instant-subscription=\"{&quot;doable&quot;:true,&quot;config&quot;:{&quot;enabled&quot;:false,&quot;min_tab&quot;:&quot;&quot;,&quot;debounce&quot;:&quot;3000&quot;},&quot;nonce&quot;:&quot;339534eb3c&quot;}\"\n>\n<noscript><div\nclass=\"ipt_fsqm_form_message_noscript ui-widget ui-widget-content ui-corner-all\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div>Javascript is disabled<\/div><\/div><div\nclass=\"ui-widget-content ui-corner-bottom\"><p>Javascript is disabled on your browser. Please enable it in order to use this form.<\/p><\/div><\/div>\n<\/noscript><style type=\"text\/css\">.ipt_uif_ajax_loader,\n\t\t\t.ipt_uif_ajax_loader *,\n\t\t\tipt_uif_ajax_loader *::before,\n\t\t\tipt_uif_ajax_loader *::after {\n\t\t\t\tbox-sizing: border-box;\n\t\t\t}<\/style><div\nclass=\"ipt_uif_init_loader ipt-eform-preloader-inline ipt_uif_ajax_loader\"><div\nclass=\"ipt-eform-preloader-inner\"><div\nclass=\"ipt-eform-preloader-circle\"><div\nclass=\"preloader-wrapper active\"><div\nclass=\"spinner-layer spinner-blue\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-red\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper 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\/>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_fsqm_timer_data\" id=\"ipt_fsqm_timer_data_63\" value=\"{&quot;type&quot;:&quot;none&quot;}\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_fsqm_epoc_data\" id=\"ipt_fsqm_epoc_data_63\" value=\"{&quot;CURRENTYEAR&quot;:2026,&quot;CURRENTDATE&quot;:1776053524000,&quot;CURRENTDAY&quot;:13,&quot;CURRENTMONTH&quot;:4,&quot;CURRENTHOUR&quot;:4,&quot;CURRENTMINUTE&quot;:12,&quot;CURRENTSECOND&quot;:4,&quot;CURRENTWEEK&quot;:16,&quot;CURRENTEPOC&quot;:20556}\" \/><div\nstyle=\"display: none;\" class=\"ipt_uif_hidden_init\"><form\nmethod=\"post\" action=\"\" class=\"ipt_uif_validate_form ipt_fsqm_main_form\" id=\"ipt_fsqm_form_63\" autocomplete=\"on\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"action\" id=\"action\" value=\"ipt_fsqm_save_form\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_epoc\" class=\"eform-epoc-value\" value=\"1776053524\" \/>\n<input\ntype=\"hidden\" class=\"ipt_fsqm_form_tab_pos\" name=\"fsqm_form63_tab_pos\" value=\"0\" id=\"fsqm_form63_tab_pos\" \/>\n<input\ntype=\"hidden\" id=\"ipt_fsqm_form_data_save\" name=\"ipt_fsqm_form_data_save\" value=\"a6b13c9a8f\" data-sayt-exclude \/>\t\t\t<input\ntype=\"hidden\" name=\"_wp_http_referer\" value=\"\/members-area\/wp-json\/wp\/v2\/pages\/1326\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"form_id\" value=\"63\" \/><div\nclass=\"ipt-eform-width-restrain\"><div\nclass=\"ipt-eform-content \"><div\ndata-settings=\"{&quot;can_previous&quot;:true,&quot;show_progress_bar&quot;:true,&quot;progress_bar_bottom&quot;:false,&quot;block_previous&quot;:false,&quot;any_tab&quot;:false,&quot;type&quot;:&quot;1&quot;,&quot;scroll&quot;:true,&quot;decimal_point&quot;:2,&quot;auto_progress&quot;:false,&quot;auto_progress_delay&quot;:&quot;1500&quot;,&quot;auto_submit&quot;:false,&quot;hidden_buttons&quot;:false,&quot;scroll_on_error&quot;:true}\" class=\"ipt_fsqm_main_tab ipt_uif_tabs horizontal\"><div\nclass=\"ipt-eform-tab-nav-wrap\"><ul><li\nid=\"ipt_fsqm_form_63_tab_0_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_63_tab_0\"><span\nclass=\"eform-tab-labels\">Practice Info <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_63_tab_1_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_63_tab_1\"><span\nclass=\"eform-tab-labels\">Contact Details <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_63_tab_2_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_63_tab_2\"><span\nclass=\"eform-tab-labels\">Hours <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_63_tab_3_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_63_tab_3\"><span\nclass=\"eform-tab-labels\">Insurances <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_63_tab_4_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_63_tab_4\"><span\nclass=\"eform-tab-labels\">Payments <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_63_tab_5_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_63_tab_5\"><span\nclass=\"eform-tab-labels\">Languages <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_63_tab_6_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_63_tab_6\"><span\nclass=\"eform-tab-labels\">Treatments <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_63_tab_7_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_63_tab_7\"><span\nclass=\"eform-tab-labels\">Canned responses <\/span><\/a><\/li><\/ul>\n<i\nclass=\"eform-tab-nav eform-tab-nav-right ipt-icomoon-angle-right disabled eform-ripple\"><\/i>\n<i\nclass=\"eform-tab-nav eform-tab-nav-left ipt-icomoon-angle-left disabled eform-ripple\"><\/i>\n<span\nclass=\"eform-tab-passive-notifier\"><\/span>\n<span\nclass=\"eform-tab-active-notifier\"><\/span><\/div><div\nid=\"ipt_fsqm_form_63_tab_0\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_63_layout_0_inner\" class=\"ipt-eform-layout-wrapper\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[pinfo][5][m_type]\" id=\"ipt_fsqm_form_63_pinfo_5_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[pinfo][5][type]\" id=\"ipt_fsqm_form_63_pinfo_5_type\" value=\"f_name\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_f_name\" id=\"ipt_fsqm_form_63_pinfo_5\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_pinfo_5_value\">Full Name<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[required,custom[personName]] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[pinfo][5][value]\"\nid=\"ipt_fsqm_form_63_pinfo_5_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf007;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_pinfo_5_value\">Your Full Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][0][m_type]\" id=\"ipt_fsqm_form_63_freetype_0_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][0][type]\" id=\"ipt_fsqm_form_63_freetype_0_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_63_freetype_0\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_0_value\">Practice Name<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[freetype][0][value]\"\nid=\"ipt_fsqm_form_63_freetype_0_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe000;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_0_value\">Practice Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][1][m_type]\" id=\"ipt_fsqm_form_63_freetype_1_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][1][type]\" id=\"ipt_fsqm_form_63_freetype_1_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_63_freetype_1\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_1_value\">Website Address<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[freetype][1][value]\"\nid=\"ipt_fsqm_form_63_freetype_1_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe0dd;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_1_value\">https:\/\/yourptractice.com<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][1][m_type]\" id=\"ipt_fsqm_form_63_mcq_1_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][1][type]\" id=\"ipt_fsqm_form_63_mcq_1_type\" value=\"checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox\" id=\"ipt_fsqm_form_63_mcq_1\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_1\">Practice Specialities<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_1\"> Select all that apply<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][1][options][]\" id=\"ipt_fsqm_form_63_mcq_1_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_1_options__0\" data-labelcon=\"&#xe18e;\">\nGeneral Dentistry\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][1][options][]\" id=\"ipt_fsqm_form_63_mcq_1_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_1_options__1\" data-labelcon=\"&#xe18e;\">\nPediatric Dentistry\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][1][options][]\" id=\"ipt_fsqm_form_63_mcq_1_options__2\"\nvalue=\"2\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_1_options__2\" data-labelcon=\"&#xe18e;\">\nOrthodontics\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][1][options][]\" id=\"ipt_fsqm_form_63_mcq_1_options__3\"\nvalue=\"3\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_1_options__3\" data-labelcon=\"&#xe18e;\">\nCosmetic Dentistry\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][1][options][]\" id=\"ipt_fsqm_form_63_mcq_1_options__4\"\nvalue=\"4\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_1_options__4\" data-labelcon=\"&#xe18e;\">\nPeriodontics\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][1][options][]\" id=\"ipt_fsqm_form_63_mcq_1_options__5\"\nvalue=\"5\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_1_options__5\" data-labelcon=\"&#xe18e;\">\nEndodontics\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][1][options][]\" id=\"ipt_fsqm_form_63_mcq_1_options__6\"\nvalue=\"6\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_1_options__6\" data-labelcon=\"&#xe18e;\">\nOral and Maxillofacial Surgery\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][1][options][]\" id=\"ipt_fsqm_form_63_mcq_1_options__7\"\nvalue=\"7\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_1_options__7\" data-labelcon=\"&#xe18e;\">\nSedation Dentistry\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][1][options][]\" id=\"ipt_fsqm_form_63_mcq_1_options__8\"\nvalue=\"8\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_1_options__8\" data-labelcon=\"&#xe18e;\">\nRestorative Dentistry\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][1][options][]\" id=\"ipt_fsqm_form_63_mcq_1_options__9\"\nvalue=\"9\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_1_options__9\" data-labelcon=\"&#xe18e;\">\nImplantology\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][2][m_type]\" id=\"ipt_fsqm_form_63_mcq_2_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][2][type]\" id=\"ipt_fsqm_form_63_mcq_2_type\" value=\"checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox\" id=\"ipt_fsqm_form_63_mcq_2\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_2\">Practice Qualifications<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][2][options][]\" id=\"ipt_fsqm_form_63_mcq_2_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_2_options__0\" data-labelcon=\"&#xe18e;\">\nBoard Certified Practitioner(s)\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][3][m_type]\" id=\"ipt_fsqm_form_63_mcq_3_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][3][type]\" id=\"ipt_fsqm_form_63_mcq_3_type\" value=\"checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox\" id=\"ipt_fsqm_form_63_mcq_3\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_3\">Accessibility<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][3][options][]\" id=\"ipt_fsqm_form_63_mcq_3_options__7\"\nvalue=\"7\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_3_options__7\" data-labelcon=\"&#xe18e;\">\nCan accommodate special care patients\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][3][options][]\" id=\"ipt_fsqm_form_63_mcq_3_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_3_options__0\" data-labelcon=\"&#xe18e;\">\nWheelchair accessible entrance\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][3][options][]\" id=\"ipt_fsqm_form_63_mcq_3_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_3_options__1\" data-labelcon=\"&#xe18e;\">\nWheelchair accessible restroom\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][3][options][]\" id=\"ipt_fsqm_form_63_mcq_3_options__2\"\nvalue=\"2\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_3_options__2\" data-labelcon=\"&#xe18e;\">\nWheelchair accessible elevator\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][3][options][]\" id=\"ipt_fsqm_form_63_mcq_3_options__3\"\nvalue=\"3\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_3_options__3\" data-labelcon=\"&#xe18e;\">\nFree Wi-Fi\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][3][options][]\" id=\"ipt_fsqm_form_63_mcq_3_options__4\"\nvalue=\"4\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_3_options__4\" data-labelcon=\"&#xe18e;\">\nParking\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][3][options][]\" id=\"ipt_fsqm_form_63_mcq_3_options__5\"\nvalue=\"5\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_3_options__5\" data-labelcon=\"&#xe18e;\">\nAccessible parking\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][3][options][]\" id=\"ipt_fsqm_form_63_mcq_3_options__6\"\nvalue=\"6\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_3_options__6\" data-labelcon=\"&#xe18e;\">\nSign language interpreter available\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_63_tab_1\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_63_layout_1_inner\" class=\"ipt-eform-layout-wrapper\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][14][m_type]\" id=\"ipt_fsqm_form_63_freetype_14_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][14][type]\" id=\"ipt_fsqm_form_63_freetype_14_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_63_freetype_14\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_14_value\">Practice Email Address<\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_14_value\">Enter the practice's email address for receiving patient documents, such as transfer records.<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[freetype][14][value]\"\nid=\"ipt_fsqm_form_63_freetype_14_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe01f;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_14_value\">Email Address<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[pinfo][4][m_type]\" id=\"ipt_fsqm_form_63_pinfo_4_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[pinfo][4][type]\" id=\"ipt_fsqm_form_63_pinfo_4_type\" value=\"p_phone\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_phone\" id=\"ipt_fsqm_form_63_pinfo_4\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_pinfo_4_value\">Emergency Number<\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_pinfo_4_value\">Provide an emergency contact number for patients to reach the practice after hours.<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[phone]] ipt_uif_text\"\ntype=\"tel\"\nname=\"ipt_fsqm_form_63[pinfo][4][value]\"\nid=\"ipt_fsqm_form_63_pinfo_4_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe08c;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_pinfo_4_value\">Emergency Phone Number<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_63_tab_2\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_63_layout_2_inner\" class=\"ipt-eform-layout-wrapper\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][4][m_type]\" id=\"ipt_fsqm_form_63_mcq_4_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][4][type]\" id=\"ipt_fsqm_form_63_mcq_4_type\" value=\"radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio\" id=\"ipt_fsqm_form_63_mcq_4\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_4\">Practice Hours<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_4\">Where can we find your practice's most current working hours?<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_63[mcq][4][options][]\"\nid=\"ipt_fsqm_form_63_mcq_4_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_4_options__0\" data-labelcon=\"&#xe18e;\">\nWebsite\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_63[mcq][4][options][]\"\nid=\"ipt_fsqm_form_63_mcq_4_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_4_options__1\" data-labelcon=\"&#xe18e;\">\nGoogle Listing\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_63[mcq][4][options][]\"\nid=\"ipt_fsqm_form_63_mcq_4_options__2\"\nvalue=\"2\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_4_options__2\" data-labelcon=\"&#xe18e;\">\nFacebook Page\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_63[mcq][4][options][]\"\nid=\"ipt_fsqm_form_63_mcq_4_options__3\"\nvalue=\"3\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_4_options__3\" data-labelcon=\"&#xe18e;\">\nYelp Listing\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][2][m_type]\" id=\"ipt_fsqm_form_63_freetype_2_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][2][type]\" id=\"ipt_fsqm_form_63_freetype_2_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_2\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_2_value\">Office Hours Extra Info<\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_2_value\">If hours are different for each doctor\/location, please explain here:<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][2][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_2_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf274;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_2_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][5][m_type]\" id=\"ipt_fsqm_form_63_mcq_5_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][5][type]\" id=\"ipt_fsqm_form_63_mcq_5_type\" value=\"checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox\" id=\"ipt_fsqm_form_63_mcq_5\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_5\">Scheduling Preferences<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_5\">Check all that apply<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][5][options][]\" id=\"ipt_fsqm_form_63_mcq_5_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_5_options__0\" data-labelcon=\"&#xe18e;\">\nBy Appointments\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][5][options][]\" id=\"ipt_fsqm_form_63_mcq_5_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_5_options__1\" data-labelcon=\"&#xe18e;\">\nWalk ins Accepted\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_63_tab_3\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_63_layout_3_inner\" class=\"ipt-eform-layout-wrapper\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][3][m_type]\" id=\"ipt_fsqm_form_63_freetype_3_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][3][type]\" id=\"ipt_fsqm_form_63_freetype_3_type\" value=\"upload\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_uif_qtooltip ipt_fsqm_container_upload\" id=\"ipt_fsqm_form_63_freetype_3\" title=\"Please upload a list of accepted insurance plans, alternatively you can use the text field below to name the insurances you take.\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_container ipt_uif_iconbox\" data-opened=\"1\"><div\nclass=\"ipt_uif_container_head\"><h3>\t\t\t\t\t\t<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe172;\"><\/i>\n<span\nclass=\"ipt_uif_container_label\">Insurance Plans<\/span><\/h3><\/div><div\nclass=\"ipt_uif_container_inner\"><div\nclass=\"ipt_uif_uploader\" id=\"ipt_fsqm_file_upload_63_3__uploader_wrap\" data-settings=\"{&quot;accept_file_types&quot;:&quot;gif,jpeg,png,jpg,pdf&quot;,&quot;max_number_of_files&quot;:&quot;&quot;,&quot;min_number_of_files&quot;:&quot;&quot;,&quot;max_file_size&quot;:1000000,&quot;min_file_size&quot;:&quot;1&quot;,&quot;show_drop_zone&quot;:true,&quot;wp_media_integration&quot;:false,&quot;auto_upload&quot;:true,&quot;single_upload&quot;:false,&quot;drag_n_drop&quot;:true,&quot;progress_bar&quot;:true,&quot;preview_media&quot;:true,&quot;can_delete&quot;:true,&quot;required&quot;:false,&quot;minimal_ui&quot;:false,&quot;accept&quot;:&quot;all&quot;,&quot;capture&quot;:&quot;none&quot;,&quot;icon&quot;:&quot;57714&quot;,&quot;centered&quot;:false,&quot;dragdrop&quot;:&quot;Drag &#039;n Drop files here&quot;,&quot;upload_label&quot;:&quot;Select Files&quot;,&quot;recaptcha&quot;:false,&quot;site_key&quot;:&quot;&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;type&quot;:&quot;image&quot;,&quot;size&quot;:&quot;normal&quot;,&quot;hl&quot;:&quot;en&quot;}\" data-configuration=\"{&quot;id&quot;:&quot;ipt_fsqm_file_upload_63_3_&quot;,&quot;upload_url&quot;:&quot;?action=ipt_fsqm_fu_upload&quot;,&quot;download_url&quot;:&quot;?action=ipt_fsqm_fu_download&quot;,&quot;do_download&quot;:false,&quot;show_ui&quot;:true,&quot;captcha_url&quot;:&quot;?action=ipt_fsqm_fu_captcha&quot;}\" data-formData=\"{&quot;data_id&quot;:null,&quot;form_id&quot;:&quot;63&quot;,&quot;nonce&quot;:&quot;1423a3deed&quot;,&quot;element_key&quot;:&quot;3&quot;,&quot;files_key&quot;:&quot;ipt_fsqm_file_upload_63_3&quot;}\"><div\nclass=\"fileinput-dragdrop ui-state-active\">\n<span>Drag 'n Drop files here<\/span><\/div><div\nclass=\"fileupload-meta\"><p>Max file size: 976.56 KB. | Allowed file types: gif,jpeg,png,jpg,pdf<\/p><\/div><div\nclass=\"ipt_fsqm_fileuploader_list_wrap\"><table\nrole=\"presentation\" class=\"ipt_fsqm_fileuploader_list\"><thead><tr><td\ncolspan=\"4\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\">\n<span\nrole=\"button\" class=\"fileinput-button secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-plusthick\"><\/span>\n<span\nclass=\"ui-button-text\">\n<span\nclass=\"select secondary-button\">Select Files<\/span>\n<\/span>\n<input\nclass=\"ipt_uif_uploader_handle\" type=\"file\" multiple=\"multiple\" name=\"ipt_fsqm_file_upload_63_3[]\" id=\"ipt_fsqm_file_upload_63_3_\" \/>\n<\/span>\n<button\ntype=\"reset\" class=\"cancel secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-cancel\"><\/span>\n<span\nclass=\"ui-button-text\">\nCancel All Uploads\t\t\t\t\t\t\t\t\t\t<\/span>\n<\/button>\n<span\nclass=\"fileupload-process\"><\/span><\/div><div\nclass=\"fileupload-progress fade wp-eform-fileupload-globalprogress\" style=\"display: none;\"><div\nclass=\"progress ui-progressbar ui-widget ui-widget-content ui-corner-all\" role=\"progressbar\" aria-valuemin=\"0\" aria-valuemax=\"100\"><div\nclass=\"progress-bar ui-progressbar-value ui-widget-header ui-corner-left\" style=\"width: 0%;\"><\/div><\/div><div\nclass=\"progress-extended\">&nbsp;<\/div><\/div><\/div><\/td><td\nclass=\"delete_button\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\">\n<button\ntype=\"button\" class=\"delete secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-trash\"><\/span>\n<span\nclass=\"ui-button-text\">\nDelete Selected\t\t\t\t\t\t\t\t\t\t<\/span>\n<\/button><\/div><\/div><\/td><td\nclass=\"delete_toggle\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\"><div\nclass=\"ipt_uif_label_column\">\n<input\ntype=\"checkbox\" class=\"toggle ipt_uif_checkbox\" id=\"ipt_fsqm_file_upload_63_3__toggler\" \/>\n<label\ndata-labelcon=\"&#xe18e;\" for=\"ipt_fsqm_file_upload_63_3__toggler\"><\/label><\/div><\/div><\/div><\/td><\/tr><\/thead><tbody\nclass=\"files\"><\/tbody><\/table><\/div> <script class=\"template-upload\" id=\"ipt_fsqm_file_upload_63_3__tmpl_upload\" type=\"text\/x-tmpl\">{% for (var i=0, file; file=o.files[i]; i++) { %}\n\t<tr class=\"template-upload\">\n\t\t<td>\n\t\t\t<span class=\"preview\"><\/span>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p class=\"name\">{%=file.name%}<\/p>\n\t\t\t<strong class=\"error\"><\/strong>\n\t\t<\/td>\n\t\t<td class=\"fileupload_list_pb\">\n\t\t\t<p class=\"size\">Processing&hellip;<\/p>\n\t\t\t<div class=\"progress ui-progressbar ui-widget ui-widget-content ui-corner-all\" role=\"progressbar\" aria-valuemin=\"0\" aria-valuemax=\"100\">\n\t\t\t\t<div class=\"progress-bar ui-progressbar-value ui-widget-header ui-corner-left\" style=\"width: 0%;\"><\/div>\n\t\t\t<\/div>\n\t\t<\/td>\n\t\t<td colspan=\"3\">\n\t\t\t{% if (!i && !o.options.autoUpload) { %}\n\t\t\t\t<button class=\"start secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\" disabled>\n\t\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-circle-arrow-e\"><\/span>\n\t\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\t\tStart\t\t\t\t\t<\/span>\n\t\t\t\t<\/button>\n\t\t\t{% } %}\n\t\t\t{% if (!i) { %}\n\t\t\t\t<button class=\"cancel secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n\t\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-cancel\"><\/span>\n\t\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\t\tCancel\t\t\t\t\t<\/span>\n\t\t\t\t<\/button>\n\t\t\t{% } %}\n\t\t<\/td>\n\t<\/tr>\n{% } %}<\/script>  <script class=\"template-download\" id=\"ipt_fsqm_file_upload_63_3__tmpl_download\" type=\"text\/x-tmpl\">{%\n\twindow.ipt_fsqm_upload_count_global;\n\tif ( window.ipt_fsqm_upload_count_global == undefined ) {\n\t\twindow.ipt_fsqm_upload_count_global = 0;\n\t}\n%}\n{% for (var i=0, file; file=o.files[i]; i++) { %}\n{% var toggler_check_id = window.ipt_fsqm_upload_count_global++; %}\n\t<tr class=\"template-download\">\n\t\t<td class=\"preview_td\" colspan=\"2\">\n\t\t\t<span class=\"preview\">\n\t\t\t\t{% if (file.thumbnailUrl) { %}\n\t\t\t\t\t<a href=\"{%=file.url%}\" title=\"{%=file.name%}\" download=\"{%=file.name%}\" data-gallery><img decoding=\"async\" src=\"{%=file.thumbnailUrl%}\" \/><\/a>\n\t\t\t\t{% } else if ( file.validAudio ) { %}\n\t\t\t\t\t\t\t\t\t\t<audio controls=\"controls\">\n\t\t\t\t\t\t<source src=\"{%=file.url%}\" type=\"{%=file.type%}\" \/>\n\t\t\t\t\t\tYour browser does not support audio element.\t\t\t\t\t<\/audio>\n\t\t\t\t\t\t\t\t\t{% } else if ( file.validVideo ) { %}\n\t\t\t\t\t\t\t\t\t\t<video controls=\"controls\" height=\"100\" width=\"200\">\n\t\t\t\t\t\t<source src=\"{%=file.url%}\" type=\"{%=file.type%}\" \/>\n\t\t\t\t\t\tYour browser does not support video element.\t\t\t\t\t<\/video>\n\t\t\t\t\t\t\t\t\t{% } %}\n\t\t\t<\/span>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p class=\"name\">\n\t\t\t\t<a href=\"{%=file.url%}\" title=\"{%=file.name%}\" download=\"{%=file.name%}\" {%=file.thumbnailUrl?'data-gallery':''%}>{%=file.name%}<\/a>\n\t\t\t<\/p>\n\t\t\t{% if (file.error) { %}\n\t\t\t\t<div><span class=\"error\">Error<\/span> {%=file.error%}<\/div>\n\t\t\t{% } %}\n\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][3][id][]\" value=\"{%=file.id%}\" \/>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<span class=\"size\">{%=o.formatFileSize(file.size)%}<\/span>\n\t\t<\/td>\n\t\t\t\t<td class=\"delete_button\">\n\t\t\t<button class=\"delete secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\" data-type=\"{%=file.deleteType%}\" data-url=\"{%=file.deleteUrl%}\"{% if (file.deleteWithCredentials) { %} data-xhr-fields='{\"withCredentials\":true}'{% } %}>\n\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-trash\"><\/span>\n\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\tDelete\t\t\t\t<\/span>\n\t\t\t<\/button>\n\t\t<\/td>\n\t\t\t\t\t<td class=\"delete_toggle\">\n\t\t\t\t<div class=\"ipt_uif_label_column\">\n\t\t\t\t\t<input type=\"checkbox\" name=\"delete\" value=\"1\" class=\"toggle ipt_uif_checkbox\" id=\"ipt_fsqm_file_upload_63_3__toggler_files_{%=toggler_check_id%}\" \/>\n\t\t\t\t\t<label data-labelcon=\"&#xe18e;\" for=\"ipt_fsqm_file_upload_63_3__toggler_files_{%=toggler_check_id%}\"><\/label>\n\t\t\t\t<\/div>\n\t\t\t<\/td>\n\t\t\t\t\t<\/tr>\n{% } %}<\/script> <\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][4][m_type]\" id=\"ipt_fsqm_form_63_freetype_4_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][4][type]\" id=\"ipt_fsqm_form_63_freetype_4_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_4\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_4_value\">Insurance Plans You Take<\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_4_value\">Please list the insurance plans you accept. If you have already uploaded the insurance plans using the feature above, there is no need to list them here again.<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][4][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_4_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf0cb;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_4_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][5][m_type]\" id=\"ipt_fsqm_form_63_freetype_5_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][5][type]\" id=\"ipt_fsqm_form_63_freetype_5_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_5\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_5_value\">Insurance Plans You Don't Take<\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_5_value\">List the insurance plans you do not accept. If you're using this for ad targeting, specify any plans you want to exclude as negative keywords.<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][5][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_5_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe92a;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_5_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][13][m_type]\" id=\"ipt_fsqm_form_63_mcq_13_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][13][type]\" id=\"ipt_fsqm_form_63_mcq_13_type\" value=\"checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox\" id=\"ipt_fsqm_form_63_mcq_13\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_13\">Do You Take Medicaid?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][13][options][]\" id=\"ipt_fsqm_form_63_mcq_13_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_13_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][13][options][]\" id=\"ipt_fsqm_form_63_mcq_13_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_13_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][13][m_type]\" id=\"ipt_fsqm_form_63_freetype_13_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][13][type]\" id=\"ipt_fsqm_form_63_freetype_13_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_13\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_13_value\">Conditions for Medicaid Acceptance<\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_13_value\">Please specify any criteria or limitations your practice has for Medicaid coverage. Include details such as age limits, types of eligible conditions, severity requirements, or any other relevant restrictions.<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][13][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_13_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf03a;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_13_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_63_tab_4\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_63_layout_4_inner\" class=\"ipt-eform-layout-wrapper\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][6][m_type]\" id=\"ipt_fsqm_form_63_mcq_6_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][6][type]\" id=\"ipt_fsqm_form_63_mcq_6_type\" value=\"checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox\" id=\"ipt_fsqm_form_63_mcq_6\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_6\">Payment Methods<\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_6\">Select all that apply<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][6][options][]\" id=\"ipt_fsqm_form_63_mcq_6_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_6_options__1\" data-labelcon=\"&#xe18e;\">\nDebit Card\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][6][options][]\" id=\"ipt_fsqm_form_63_mcq_6_options__2\"\nvalue=\"2\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_6_options__2\" data-labelcon=\"&#xe18e;\">\nFinancing\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][6][options][]\" id=\"ipt_fsqm_form_63_mcq_6_options__3\"\nvalue=\"3\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_6_options__3\" data-labelcon=\"&#xe18e;\">\nInvoice\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][6][options][]\" id=\"ipt_fsqm_form_63_mcq_6_options__4\"\nvalue=\"4\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_6_options__4\" data-labelcon=\"&#xe18e;\">\nPersonal Checks\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][6][options][]\" id=\"ipt_fsqm_form_63_mcq_6_options__5\"\nvalue=\"5\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_6_options__5\" data-labelcon=\"&#xe18e;\">\nVisa\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][6][options][]\" id=\"ipt_fsqm_form_63_mcq_6_options__6\"\nvalue=\"6\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_6_options__6\" data-labelcon=\"&#xe18e;\">\nCash\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][6][options][]\" id=\"ipt_fsqm_form_63_mcq_6_options__7\"\nvalue=\"7\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_6_options__7\" data-labelcon=\"&#xe18e;\">\nDiscover\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][6][options][]\" id=\"ipt_fsqm_form_63_mcq_6_options__8\"\nvalue=\"8\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_6_options__8\" data-labelcon=\"&#xe18e;\">\nDiner's Club\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][6][options][]\" id=\"ipt_fsqm_form_63_mcq_6_options__9\"\nvalue=\"9\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_6_options__9\" data-labelcon=\"&#xe18e;\">\nMastercard\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][6][options][]\" id=\"ipt_fsqm_form_63_mcq_6_options__10\"\nvalue=\"10\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_6_options__10\" data-labelcon=\"&#xe18e;\">\nTraveler's Check\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][6][options][]\" id=\"ipt_fsqm_form_63_mcq_6_options__11\"\nvalue=\"11\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_6_options__11\" data-labelcon=\"&#xe18e;\">\nAmerican Express\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][7][m_type]\" id=\"ipt_fsqm_form_63_mcq_7_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][7][type]\" id=\"ipt_fsqm_form_63_mcq_7_type\" value=\"checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox\" id=\"ipt_fsqm_form_63_mcq_7\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_7\">Financial Accommodations<\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_7\">Select all that apply<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][7][options][]\" id=\"ipt_fsqm_form_63_mcq_7_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_7_options__0\" data-labelcon=\"&#xe18e;\">\n0% Financing\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][7][options][]\" id=\"ipt_fsqm_form_63_mcq_7_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_7_options__1\" data-labelcon=\"&#xe18e;\">\nNo Down Payment\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][7][options][]\" id=\"ipt_fsqm_form_63_mcq_7_options__3\"\nvalue=\"3\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_7_options__3\" data-labelcon=\"&#xe18e;\">\nFree Consultation\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][7][options][]\" id=\"ipt_fsqm_form_63_mcq_7_options__4\"\nvalue=\"4\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_7_options__4\" data-labelcon=\"&#xe18e;\">\nX-Rays included in Free Consultation\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][7][options][]\" id=\"ipt_fsqm_form_63_mcq_7_options__5\"\nvalue=\"5\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_7_options__5\" data-labelcon=\"&#xe18e;\">\nIn-house Financing\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][6][m_type]\" id=\"ipt_fsqm_form_63_freetype_6_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][6][type]\" id=\"ipt_fsqm_form_63_freetype_6_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_6\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_6_value\">Free Consultation Restrictions<\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_6_value\">If the free consultation is only available for certain treatments, please mention those treatments here.<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][6][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_6_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe896;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_6_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][8][m_type]\" id=\"ipt_fsqm_form_63_freetype_8_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][8][type]\" id=\"ipt_fsqm_form_63_freetype_8_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_8\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_8_value\">Paid Consultation\/Exam<\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_8_value\">If the consultation is not free, please provide the approximate cost, the services included in the consultation\/exam, and any other relevant details.<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][8][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_8_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe896;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_8_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_63_tab_5\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_63_layout_5_inner\" class=\"ipt-eform-layout-wrapper\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][8][m_type]\" id=\"ipt_fsqm_form_63_mcq_8_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][8][type]\" id=\"ipt_fsqm_form_63_mcq_8_type\" value=\"checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox\" id=\"ipt_fsqm_form_63_mcq_8\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_8\">Spoken Languages<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_8\">Select all that apply<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][8][options][]\" id=\"ipt_fsqm_form_63_mcq_8_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_8_options__0\" data-labelcon=\"&#xe18e;\">\nEnglish\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][8][options][]\" id=\"ipt_fsqm_form_63_mcq_8_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_8_options__1\" data-labelcon=\"&#xe18e;\">\nSpanish\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][8][options][]\" id=\"ipt_fsqm_form_63_mcq_8_options__2\"\nvalue=\"2\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_8_options__2\" data-labelcon=\"&#xe18e;\">\nChinese\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][8][options][]\" id=\"ipt_fsqm_form_63_mcq_8_options__3\"\nvalue=\"3\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_8_options__3\" data-labelcon=\"&#xe18e;\">\nArabic\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][8][options][]\" id=\"ipt_fsqm_form_63_mcq_8_options__4\"\nvalue=\"4\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_8_options__4\" data-labelcon=\"&#xe18e;\">\nPersian\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][8][options][]\" id=\"ipt_fsqm_form_63_mcq_8_options__5\"\nvalue=\"5\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_8_options__5\" data-labelcon=\"&#xe18e;\">\nFrench\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][8][options][]\" id=\"ipt_fsqm_form_63_mcq_8_options__6\"\nvalue=\"6\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_8_options__6\" data-labelcon=\"&#xe18e;\">\nKorean\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][8][options][]\" id=\"ipt_fsqm_form_63_mcq_8_options__7\"\nvalue=\"7\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_8_options__7\" data-labelcon=\"&#xe18e;\">\nRussian\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][9][m_type]\" id=\"ipt_fsqm_form_63_freetype_9_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][9][type]\" id=\"ipt_fsqm_form_63_freetype_9_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_9\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_9_value\">Other Languages<\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_9_value\">List any additional languages spoken at your practice.<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][9][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_9_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf1ab;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_9_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_63_tab_6\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_63_layout_6_inner\" class=\"ipt-eform-layout-wrapper\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][10][m_type]\" id=\"ipt_fsqm_form_63_mcq_10_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][10][type]\" id=\"ipt_fsqm_form_63_mcq_10_type\" value=\"checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox\" id=\"ipt_fsqm_form_63_mcq_10\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_10\">Dental Treatments<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_10\">Select all that apply<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__0\" data-labelcon=\"&#xe18e;\">\nDental Implants\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__1\" data-labelcon=\"&#xe18e;\">\nDentures Adjustment\/Fixing\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__2\"\nvalue=\"2\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__2\" data-labelcon=\"&#xe18e;\">\nEmergency Care\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__3\"\nvalue=\"3\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__3\" data-labelcon=\"&#xe18e;\">\nPorcelain Veneers\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__4\"\nvalue=\"4\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__4\" data-labelcon=\"&#xe18e;\">\nDental Bridges\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__5\"\nvalue=\"5\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__5\" data-labelcon=\"&#xe18e;\">\nWhite Fillings\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__6\"\nvalue=\"6\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__6\" data-labelcon=\"&#xe18e;\">\nTooth Extractions\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__7\"\nvalue=\"7\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__7\" data-labelcon=\"&#xe18e;\">\nGum\/Bone Grafting\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__8\"\nvalue=\"8\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__8\" data-labelcon=\"&#xe18e;\">\nInvisalign Only\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__9\"\nvalue=\"9\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__9\" data-labelcon=\"&#xe18e;\">\nNew Dentures\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__10\"\nvalue=\"10\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__10\" data-labelcon=\"&#xe18e;\">\nExam\/Cleaning\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__11\"\nvalue=\"11\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__11\" data-labelcon=\"&#xe18e;\">\nRoot Canal Treatments\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__12\"\nvalue=\"12\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__12\" data-labelcon=\"&#xe18e;\">\nDental Crowns\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__13\"\nvalue=\"13\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__13\" data-labelcon=\"&#xe18e;\">\nTeeth Whitening\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__14\"\nvalue=\"14\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__14\" data-labelcon=\"&#xe18e;\">\nGum Disease Treatment\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__15\"\nvalue=\"15\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__15\" data-labelcon=\"&#xe18e;\">\nWisdom Teeth Removal\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][10][options][]\" id=\"ipt_fsqm_form_63_mcq_10_options__16\"\nvalue=\"16\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_10_options__16\" data-labelcon=\"&#xe18e;\">\nBraces\/Aligners\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][11][m_type]\" id=\"ipt_fsqm_form_63_mcq_11_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][11][type]\" id=\"ipt_fsqm_form_63_mcq_11_type\" value=\"checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox\" id=\"ipt_fsqm_form_63_mcq_11\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_11\">Type of Braces<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_11\">Select all that apply<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__0\" data-labelcon=\"&#xe18e;\">\nMetal Braces\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__1\" data-labelcon=\"&#xe18e;\">\nClear Aligners\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__2\"\nvalue=\"2\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__2\" data-labelcon=\"&#xe18e;\">\nSpark Aligners\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__3\"\nvalue=\"3\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__3\" data-labelcon=\"&#xe18e;\">\nLingual Braces (InBrace or other brands)\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__4\"\nvalue=\"4\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__4\" data-labelcon=\"&#xe18e;\">\nSelf-ligating Braces\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__18\"\nvalue=\"18\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__18\" data-labelcon=\"&#xe18e;\">\nInBrace\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__5\"\nvalue=\"5\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__5\" data-labelcon=\"&#xe18e;\">\nCeramic Braces\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__6\"\nvalue=\"6\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__6\" data-labelcon=\"&#xe18e;\">\nTwo-Phase Treatment\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__7\"\nvalue=\"7\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__7\" data-labelcon=\"&#xe18e;\">\nInvisalign\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__8\"\nvalue=\"8\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__8\" data-labelcon=\"&#xe18e;\">\nInvisalign Teen\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__9\"\nvalue=\"9\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__9\" data-labelcon=\"&#xe18e;\">\nRetainers\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__11\"\nvalue=\"11\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__11\" data-labelcon=\"&#xe18e;\">\nDamon Smiles\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__12\"\nvalue=\"12\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__12\" data-labelcon=\"&#xe18e;\">\nGlow-in-the-Dark\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__13\"\nvalue=\"13\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__13\" data-labelcon=\"&#xe18e;\">\nGold\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__16\"\nvalue=\"16\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__16\" data-labelcon=\"&#xe18e;\">\nAngel Aligners\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__17\"\nvalue=\"17\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__17\" data-labelcon=\"&#xe18e;\">\nLight Force Braces\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][11][options][]\" id=\"ipt_fsqm_form_63_mcq_11_options__15\"\nvalue=\"15\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_11_options__15\" data-labelcon=\"&#xe18e;\">\nOther\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][14][m_type]\" id=\"ipt_fsqm_form_63_mcq_14_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][14][type]\" id=\"ipt_fsqm_form_63_mcq_14_type\" value=\"checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox\" id=\"ipt_fsqm_form_63_mcq_14\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_14\">Type of Retainers<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_14\">Select all that apply<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][14][options][]\" id=\"ipt_fsqm_form_63_mcq_14_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_14_options__0\" data-labelcon=\"&#xe18e;\">\nRemovable Retainers\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][14][options][]\" id=\"ipt_fsqm_form_63_mcq_14_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_14_options__1\" data-labelcon=\"&#xe18e;\">\nHawley Retainers\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][14][options][]\" id=\"ipt_fsqm_form_63_mcq_14_options__2\"\nvalue=\"2\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_14_options__2\" data-labelcon=\"&#xe18e;\">\nEssix Retainers\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][14][options][]\" id=\"ipt_fsqm_form_63_mcq_14_options__3\"\nvalue=\"3\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_14_options__3\" data-labelcon=\"&#xe18e;\">\nVivera Retainers\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][14][options][]\" id=\"ipt_fsqm_form_63_mcq_14_options__4\"\nvalue=\"4\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_14_options__4\" data-labelcon=\"&#xe18e;\">\nLingual Retainers\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][14][options][]\" id=\"ipt_fsqm_form_63_mcq_14_options__18\"\nvalue=\"18\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_14_options__18\" data-labelcon=\"&#xe18e;\">\nBonded Retainers\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][14][options][]\" id=\"ipt_fsqm_form_63_mcq_14_options__5\"\nvalue=\"5\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_14_options__5\" data-labelcon=\"&#xe18e;\">\nPositioners\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][14][options][]\" id=\"ipt_fsqm_form_63_mcq_14_options__6\"\nvalue=\"6\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_14_options__6\" data-labelcon=\"&#xe18e;\">\nWraparound Retainers\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][14][options][]\" id=\"ipt_fsqm_form_63_mcq_14_options__7\"\nvalue=\"7\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_14_options__7\" data-labelcon=\"&#xe18e;\">\nSports Mouthguards\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][14][options][]\" id=\"ipt_fsqm_form_63_mcq_14_options__19\"\nvalue=\"19\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_14_options__19\" data-labelcon=\"&#xe18e;\">\nOther\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][11][m_type]\" id=\"ipt_fsqm_form_63_freetype_11_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][11][type]\" id=\"ipt_fsqm_form_63_freetype_11_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_11\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_11_value\">Other Braces Types\/Brands<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_11_value\">If your practice provides braces types or brands not listed above, please list them here.<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me validate[required]\"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][11][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_11_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf00b;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_11_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][12][m_type]\" id=\"ipt_fsqm_form_63_mcq_12_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[mcq][12][type]\" id=\"ipt_fsqm_form_63_mcq_12_type\" value=\"checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox\" id=\"ipt_fsqm_form_63_mcq_12\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_12\">Conditions Treated<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div>\t\t\t\t\t\t<label\nclass=\"ipt_uif_question_subtitle ipt_uif_label\" for=\"ipt_fsqm_form_63_mcq_12\">Select all that apply<\/label><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__0\" data-labelcon=\"&#xe18e;\">\nBite Problems\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__1\" data-labelcon=\"&#xe18e;\">\nChipped Teeth\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__2\"\nvalue=\"2\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__2\" data-labelcon=\"&#xe18e;\">\nFacial Traumas\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__3\"\nvalue=\"3\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__3\" data-labelcon=\"&#xe18e;\">\nGum Disease\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__4\"\nvalue=\"4\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__4\" data-labelcon=\"&#xe18e;\">\nHeadaches\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__5\"\nvalue=\"5\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__5\" data-labelcon=\"&#xe18e;\">\nJaw Pain & TMD\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__6\"\nvalue=\"6\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__6\" data-labelcon=\"&#xe18e;\">\nNeck Pain\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__7\"\nvalue=\"7\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__7\" data-labelcon=\"&#xe18e;\">\nPlaque\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__8\"\nvalue=\"8\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__8\" data-labelcon=\"&#xe18e;\">\nStained Teeth\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__9\"\nvalue=\"9\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__9\" data-labelcon=\"&#xe18e;\">\nThumb Sucking\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__10\"\nvalue=\"10\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__10\" data-labelcon=\"&#xe18e;\">\nTraumatic Injuries\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__11\"\nvalue=\"11\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__11\" data-labelcon=\"&#xe18e;\">\nCavities\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__12\"\nvalue=\"12\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__12\" data-labelcon=\"&#xe18e;\">\nCrowded Teeth\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__13\"\nvalue=\"13\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__13\" data-labelcon=\"&#xe18e;\">\nGaps & Spaces\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__14\"\nvalue=\"14\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__14\" data-labelcon=\"&#xe18e;\">\nHalitosis\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__15\"\nvalue=\"15\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__15\" data-labelcon=\"&#xe18e;\">\nHeat & Cold Sensitivity\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__16\"\nvalue=\"16\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__16\" data-labelcon=\"&#xe18e;\">\nMissing Teeth\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__17\"\nvalue=\"17\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__17\" data-labelcon=\"&#xe18e;\">\nOral Cancer\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__18\"\nvalue=\"18\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__18\" data-labelcon=\"&#xe18e;\">\nSleep Disorders\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__19\"\nvalue=\"19\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__19\" data-labelcon=\"&#xe18e;\">\nTeeth Grinding\t\t\t\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_random\">\n<input\ndata-num=\"\"\t\t\t\t\t\t\t\t\t\ttype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in \"\nname=\"ipt_fsqm_form_63[mcq][12][options][]\" id=\"ipt_fsqm_form_63_mcq_12_options__20\"\nvalue=\"20\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_63_mcq_12_options__20\" data-labelcon=\"&#xe18e;\">\nToothaches\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_63_tab_7\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_63_layout_7_inner\" class=\"ipt-eform-layout-wrapper\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[design][0][m_type]\" id=\"ipt_fsqm_form_63_design_0_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[design][0][type]\" id=\"ipt_fsqm_form_63_design_0_type\" value=\"richtext\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional\" id=\"ipt_fsqm_form_63_design_0\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_richtext\"><p\nstyle=\"caret-color: #000000; color: #000000;\" data-start=\"51\" data-end=\"96\"><strong\ndata-start=\"51\" data-end=\"94\">Live Chat Instructions\/Template Answers<\/strong><\/p><p\nstyle=\"caret-color: #000000; color: #000000;\" data-start=\"98\" data-end=\"342\" data-is-last-node=\"\" data-is-only-node=\"\">Use this page to include up to nine scenarios (chat inquiries) for which you want our live chat team to provide a specific (exact) answer or instructions on how to respond. Leave this page blank if you are not signing up for live chat services.<\/p><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][26][m_type]\" id=\"ipt_fsqm_form_63_freetype_26_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][26][type]\" id=\"ipt_fsqm_form_63_freetype_26_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_63_freetype_26\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_26_value\">Question 1<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[freetype][26][value]\"\nid=\"ipt_fsqm_form_63_freetype_26_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe110;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_26_value\">Write Question Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][27][m_type]\" id=\"ipt_fsqm_form_63_freetype_27_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][27][type]\" id=\"ipt_fsqm_form_63_freetype_27_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_27\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_27_value\">Answer\/Instruction For Question 1<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][27][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_27_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe8af;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_27_value\">Write Your Answer\/Instructions<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][28][m_type]\" id=\"ipt_fsqm_form_63_freetype_28_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][28][type]\" id=\"ipt_fsqm_form_63_freetype_28_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_63_freetype_28\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_28_value\">Question 2<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[freetype][28][value]\"\nid=\"ipt_fsqm_form_63_freetype_28_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe110;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_28_value\">Write Question Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][29][m_type]\" id=\"ipt_fsqm_form_63_freetype_29_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][29][type]\" id=\"ipt_fsqm_form_63_freetype_29_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_29\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_29_value\">Answer\/Instruction For Question 2<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][29][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_29_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe8af;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_29_value\">Write Your Answer\/Instructions<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][30][m_type]\" id=\"ipt_fsqm_form_63_freetype_30_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][30][type]\" id=\"ipt_fsqm_form_63_freetype_30_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_63_freetype_30\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_30_value\">Question 3<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[freetype][30][value]\"\nid=\"ipt_fsqm_form_63_freetype_30_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe110;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_30_value\">Write Question Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][31][m_type]\" id=\"ipt_fsqm_form_63_freetype_31_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][31][type]\" id=\"ipt_fsqm_form_63_freetype_31_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_31\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_31_value\">Answer\/Instruction For Question 3<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][31][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_31_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe8af;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_31_value\">Write Your Answer\/Instructions<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][32][m_type]\" id=\"ipt_fsqm_form_63_freetype_32_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][32][type]\" id=\"ipt_fsqm_form_63_freetype_32_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_63_freetype_32\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_32_value\">Question 4<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[freetype][32][value]\"\nid=\"ipt_fsqm_form_63_freetype_32_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe110;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_32_value\">Write Question Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][33][m_type]\" id=\"ipt_fsqm_form_63_freetype_33_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][33][type]\" id=\"ipt_fsqm_form_63_freetype_33_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_33\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_33_value\">Answer\/Instruction For Question 4<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][33][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_33_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe8af;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_33_value\">Write Your Answer\/Instructions<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][34][m_type]\" id=\"ipt_fsqm_form_63_freetype_34_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][34][type]\" id=\"ipt_fsqm_form_63_freetype_34_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_63_freetype_34\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_34_value\">Question 5<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[freetype][34][value]\"\nid=\"ipt_fsqm_form_63_freetype_34_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe110;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_34_value\">Write Question Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][35][m_type]\" id=\"ipt_fsqm_form_63_freetype_35_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][35][type]\" id=\"ipt_fsqm_form_63_freetype_35_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_35\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_35_value\">Answer\/Instruction For Question 5<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][35][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_35_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe8af;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_35_value\">Write Your Answer\/Instructions<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][36][m_type]\" id=\"ipt_fsqm_form_63_freetype_36_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][36][type]\" id=\"ipt_fsqm_form_63_freetype_36_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_63_freetype_36\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_36_value\">Question 6<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[freetype][36][value]\"\nid=\"ipt_fsqm_form_63_freetype_36_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe110;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_36_value\">Write Question Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][37][m_type]\" id=\"ipt_fsqm_form_63_freetype_37_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][37][type]\" id=\"ipt_fsqm_form_63_freetype_37_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_37\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_37_value\">Answer\/Instruction For Question 6<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][37][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_37_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe8af;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_37_value\">Write Your Answer\/Instructions<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][38][m_type]\" id=\"ipt_fsqm_form_63_freetype_38_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][38][type]\" id=\"ipt_fsqm_form_63_freetype_38_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_63_freetype_38\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_38_value\">Question 7<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[freetype][38][value]\"\nid=\"ipt_fsqm_form_63_freetype_38_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe110;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_38_value\">Write Question Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][39][m_type]\" id=\"ipt_fsqm_form_63_freetype_39_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][39][type]\" id=\"ipt_fsqm_form_63_freetype_39_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_39\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_39_value\">Answer\/Instruction For Question 7<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][39][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_39_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe8af;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_39_value\">Write Your Answer\/Instructions<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][40][m_type]\" id=\"ipt_fsqm_form_63_freetype_40_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][40][type]\" id=\"ipt_fsqm_form_63_freetype_40_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_63_freetype_40\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_40_value\">Question 8<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[freetype][40][value]\"\nid=\"ipt_fsqm_form_63_freetype_40_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe110;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_40_value\">Write Question Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][41][m_type]\" id=\"ipt_fsqm_form_63_freetype_41_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][41][type]\" id=\"ipt_fsqm_form_63_freetype_41_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_41\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_41_value\">Answer\/Instruction For Question 8<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][41][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_41_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe8af;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_41_value\">Write Your Answer\/Instructions<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][42][m_type]\" id=\"ipt_fsqm_form_63_freetype_42_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][42][type]\" id=\"ipt_fsqm_form_63_freetype_42_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_63_freetype_42\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_42_value\">Question 9<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_63[freetype][42][value]\"\nid=\"ipt_fsqm_form_63_freetype_42_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe110;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_42_value\">Write Question Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][43][m_type]\" id=\"ipt_fsqm_form_63_freetype_43_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_63[freetype][43][type]\" id=\"ipt_fsqm_form_63_freetype_43_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_63_freetype_43\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_vertical\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_63_freetype_43_value\">Answer\/Instruction For Question 9<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_63[freetype][43][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_63_freetype_43_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe8af;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_63_freetype_43_value\">Write Your Answer\/Instructions<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear\"><\/div><div\nid=\"ipt_fsqm_form_63_button_container\" class=\"ipt_fsqm_form_button_container ipt_fsqm_form_button_container--classic ipt-eform-material-button-container\"><div\nclass=\"eform-button-container-inner\">\n<button\ntype=\"button\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_prev medium primary-button\" name=\"ipt_fsqm_form_63_button_prev\" id=\"ipt_fsqm_form_63_button_prev\"> Previous<\/button>\n<button\ntype=\"submit\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_submit medium primary-button\" name=\"ipt_fsqm_form_63_button_submit\" id=\"ipt_fsqm_form_63_button_submit\"> Submit<\/button>\n<button\ntype=\"button\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_next medium primary-button\" name=\"ipt_fsqm_form_63_button_next\" id=\"ipt_fsqm_form_63_button_next\"> Next<\/button><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/form><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_success ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><h3><i\ntitle=\"\" class=\" ipt-icomoon-checkmark-circle ipticm prefix\"><\/i>\nYour form has been submitted<\/h3><\/div><div\nclass=\"ui-widget-content ui-corner-all ipt_fsqm_success_wrap\"><p>Thank you %NAME% for taking the time to fill out the practice information form.<br\n\/>\nWe have received your answers.<\/p><\/div><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_error ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div><i\ntitle=\"\" class=\" ipt-icomoon-laptop ipticm prefix\"><\/i>\nServer Side Error<\/div><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p>We faced problems while connecting to the server or receiving data from the server. Please wait for a few seconds and try again.<\/p><p>If the problem persists, then check your internet connectivity. If all other sites open fine, then please contact the administrator of this website with the following information.<\/p><p\nclass=\"jqXHR\">\n<strong>TextStatus: <\/strong><span\nclass=\"textStatus\">undefined<\/span><br\n\/>\n<strong>HTTP Error: <\/strong><span\nclass=\"errorThrown\">undefined<\/span><\/p><\/div><\/div><div\nstyle=\"display: none\" class=\"ipt_uif_widget_box ipt_fsqm_form_message_process\"><div\nclass=\"ui-widget ui-widget-header ui-corner-all\"><style type=\"text\/css\">.ipt_uif_ajax_loader,\n\t\t\t.ipt_uif_ajax_loader *,\n\t\t\tipt_uif_ajax_loader *::before,\n\t\t\tipt_uif_ajax_loader *::after {\n\t\t\t\tbox-sizing: border-box;\n\t\t\t}<\/style><div\nclass=\"ipt-eform-preloader-inline ipt_uif_ajax_loader\"><div\nclass=\"ipt-eform-preloader-inner\"><div\nclass=\"ipt-eform-preloader-circle\"><div\nclass=\"preloader-wrapper active\"><div\nclass=\"spinner-layer spinner-blue\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-red\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-yellow\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-green\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><\/div><\/div><div\nclass=\"ipt-eform-preloader-text\"><div\nclass=\"ipt-eform-preloader-text-inner ipt_uif_ajax_loader_text\">Processing your request<\/div><\/div><div\nclass=\"clear\"><\/div><\/div><\/div><\/div><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_validation_error ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div><i\ntitle=\"\" class=\" ipt-icomoon-warning2 ipticm prefix\"><\/i>\n<span\nclass=\"fsqm_ve_text\">Error<\/span><\/div><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p\nclass=\"fsqm_ve_msg\">Some error has occured.<\/p><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"Javascript is disabledJavascript is disabled on your browser. Please enable it in order to use this form. Loading Practice Info Contact Details Hours Insurances Payments Languages Treatments Canned responses Full Name* Your Full Name Practice Name* Practice Name Website Address* https:\/\/yourptractice.com Practice Specialities* Select all that apply General Dentistry Pediatric Dentistry Orthodontics Cosmetic Dentistry Periodontics Endodontics Oral and Maxillofacial Surgery Sedation Dentistry Restorative Dentistry Implantology Practice Qualifications Board Certified Practitioner(s) Accessibility Can accommodate special care patients Wheelchair accessible entrance Wheelchair accessible restroom Wheelchair accessible elevator Free Wi-Fi Parking Accessible parking Sign language interpreter available Practice Email Address Enter the practice's email address for receiving patient documents, such as transfer records. Email Address Emergency Number Provide an emergency contact number for patients to reach the practice after hours. Emergency Phone Number Practice Hours* Where can we find your practice's most current working hours? Website Google Listing Facebook Page Yelp Listing Office Hours Extra Info If hours are different for each doctor\/location, please explain here: Write Here Scheduling Preferences* Check all that apply By Appointments Walk ins Accepted Insurance Plans Drag 'n Drop files hereMax file size: 976.56 KB. | Allowed file types: gif,jpeg,png,jpg,pdf Select Files Cancel All Uploads &nbsp; Delete Selected [...]","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"pmpro_default_level":"","inline_featured_image":false,"footnotes":""},"class_list":["post-1326","page","type-page","status-publish","hentry","pmpro-has-access"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Dental Practice Registration Form - Nexunom<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/nexunom.com\/members-area\/dental-practice-registration-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Dental Practice Registration Form - 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