{"id":10195,"date":"2024-09-12T12:56:03","date_gmt":"2024-09-12T16:56:03","guid":{"rendered":"https:\/\/alliantplans.com\/?page_id=10195"},"modified":"2024-09-12T13:06:39","modified_gmt":"2024-09-12T17:06:39","slug":"appointment-access-survey","status":"publish","type":"page","link":"https:\/\/alliantplans.com\/es\/appointment-access-survey\/","title":{"rendered":"Appointment Access Survey"},"content":{"rendered":"<style>.kb-row-layout-id10195_3577bc-fc > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id10195_3577bc-fc > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id10195_3577bc-fc > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);max-width:var( --global-content-width, 1440px );padding-left:var(--global-content-edge-padding);padding-right:var(--global-content-edge-padding);padding-top:var(--global-kb-spacing-sm, 1.5rem);padding-bottom:var(--global-kb-spacing-sm, 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gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_23' style='display:none'><div id='gf_23' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Appointment Access Survey<\/h2>\n                            <p class='gform_description'>Como proveedor activo de Alliant Health Plans, le pedimos su ayuda para completar la encuesta de proveedores para el a\u00f1o del plan 2024.\nLe pedimos que responda a estas preguntas con la informaci\u00f3n m\u00e1s precisa. <\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_23'  action='\/es\/wp-json\/wp\/v2\/pages\/10195#gf_23' data-formid='23' novalidate>\n        <div id='gf_progressbar_wrapper_23' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>6<\/span><span class='gf_step_page_name'> &#8211; Welcome<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_16' style='width:16%;'><span>16%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_23_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_23' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_23_10\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Name \/ Tax Information<\/h3><\/div><fieldset id=\"field_23_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Select Your Specialty<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_46'>\n\t\t\t<div class='gchoice gchoice_23_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Behavioral Health'  id='choice_23_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_46_0' id='label_23_46_0' class='gform-field-label gform-field-label--type-inline'>Behavioral Health<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='OB-GYN'  id='choice_23_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_46_1' id='label_23_46_1' class='gform-field-label gform-field-label--type-inline'>OB-GYN<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Oncology'  id='choice_23_46_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_46_2' id='label_23_46_2' class='gform-field-label gform-field-label--type-inline'>Oncology<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_3\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_3'>Practice\/Group Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_23_3' type='text' value='' class='large' maxlength='100'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_8\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_8'>Tax ID<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_23_8' type='text' value='' class='large' maxlength='50'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_7\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Service Location<\/h3><\/div><fieldset id=\"field_23_5\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_23_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_23_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_23_5_1' value=''    aria-required='true'    \/>\n                                        <label for='input_23_5_1' id='input_23_5_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_23_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_23_5_2' value=''     aria-required='false'   \/>\n                                        <label for='input_23_5_2' id='input_23_5_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_23_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_23_5_3' value=''    aria-required='true'    \/>\n                                    <label for='input_23_5_3' id='input_23_5_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_23_5_4_container' >\n                                        <select name='input_5.4' id='input_23_5_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' selected='selected'>Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_23_5_4' id='input_23_5_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_23_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_23_5_5' value=''    aria-required='true'    \/>\n                                    <label for='input_23_5_5' id='input_23_5_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_23_5_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_23_49\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_49'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_49' id='input_23_49' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_23_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gw-none-of-the-above gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please check all the types of clinicians in practice at this location. Select all that apply.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_23_9'><div class='gchoice gchoice_23_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Practitioners with prescribing authority'  id='choice_23_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_9_1' id='label_23_9_1' class='gform-field-label gform-field-label--type-inline'>Practitioners with prescribing authority<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Practitioners without prescribing authority'  id='choice_23_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_9_2' id='label_23_9_2' class='gform-field-label gform-field-label--type-inline'>Practitioners without prescribing authority<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='None of the Above'  id='choice_23_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_9_3' id='label_23_9_3' class='gform-field-label gform-field-label--type-inline'>None of the Above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_23_15' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_23_2' class='gform_page' data-js='page-field-id-15' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_23_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_23_62\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Provide the number of clinicians in practice in each category<\/h3><\/div><div id=\"field_23_12\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_12'>Provide the number of psychiatrists and nurse practitioners with prescribing authority<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_12' id='input_23_12' type='text' step='any' min='0'  value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_23_63\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_63'>Provide the number of all other licensed clinicians without prescribing authority<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_63' id='input_23_63' type='text' step='any' min='0'  value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_23_56\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_56'>Provide the Number of Physicians<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_56' id='input_23_56' type='number' step='any' min='0'  value='' class='small'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_23_56\" \/><div class='gfield_description instruction ' id='gfield_instruction_23_56'>Please enter a number greater than or equal to <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_23_57\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_57'>Provider the Number of Nurse Practitioners and Physician Assistants<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_57' id='input_23_57' type='number' step='any' min='0'  value='' class='small'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_23_57\" \/><div class='gfield_description instruction ' id='gfield_instruction_23_57'>Please enter a number greater than or equal to <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_23_58\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_58'>Provide the number of Nurse Midwives<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_58' id='input_23_58' type='number' step='any' min='0'  value='' class='small'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_23_58\" \/><div class='gfield_description instruction ' id='gfield_instruction_23_58'>Please enter a number greater than or equal to <strong>0<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_23_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have 3 available appointment times with the next 30 days for a new patient initial visit?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_60'>\n\t\t\t<div class='gchoice gchoice_23_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Yes'  id='choice_23_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_60_0' id='label_23_60_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='No'  id='choice_23_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_60_1' id='label_23_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have 3 available appointment times within the next 30  days for a routine follow-up for an established patient?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_61'>\n\t\t\t<div class='gchoice gchoice_23_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Yes'  id='choice_23_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_61_0' id='label_23_61_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='No'  id='choice_23_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_61_1' id='label_23_61_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_23_53' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_23_53' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_23_3' class='gform_page' data-js='page-field-id-53' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_23_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_23_11\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Prescriber Appointment Accessibility<\/h3><\/div><fieldset id=\"field_23_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have availability to offer non-life threatening emergency care within 6 hours or do you refer them to the emergency room?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_13'>\n\t\t\t<div class='gchoice gchoice_23_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes, we have availability to offer non-life threatening emergency care within 6 hours.'  id='choice_23_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_13_0' id='label_23_13_0' class='gform-field-label gform-field-label--type-inline'>Yes, we have availability to offer non-life threatening emergency care within 6 hours.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No, we refer patients to the emergency room.'  id='choice_23_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_13_1' id='label_23_13_1' class='gform-field-label gform-field-label--type-inline'>No, we refer patients to the emergency room.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you provide urgent care within 48 hours?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_17'>\n\t\t\t<div class='gchoice gchoice_23_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_23_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_17_0' id='label_23_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_23_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_17_1' id='label_23_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do  you have availability for an initial visit for routine care within 10 business days?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_14'>\n\t\t\t<div class='gchoice gchoice_23_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Yes'  id='choice_23_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_14_0' id='label_23_14_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='No'  id='choice_23_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_14_1' id='label_23_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you offer follow-up routine care?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_19'>\n\t\t\t<div class='gchoice gchoice_23_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_23_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_19_0' id='label_23_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_23_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_19_1' id='label_23_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_23_16' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_23_16' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_23_4' class='gform_page' data-js='page-field-id-16' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_23_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_23_23\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Non-Prescriber Appointment Accessibility<\/h3><\/div><fieldset id=\"field_23_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have availability to offer non-life threatening emergency care within 6 hours or do you refer them to the emergency room?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_18'>\n\t\t\t<div class='gchoice gchoice_23_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes, we have availability to offer non-life threatening emergency care within 6 hours.'  id='choice_23_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_18_0' id='label_23_18_0' class='gform-field-label gform-field-label--type-inline'>Yes, we have availability to offer non-life threatening emergency care within 6 hours.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No, we refer patients to the emergency room.'  id='choice_23_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_18_1' id='label_23_18_1' class='gform-field-label gform-field-label--type-inline'>No, we refer patients to the emergency room.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you provide urgent care within 48 hours?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_20'>\n\t\t\t<div class='gchoice gchoice_23_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes'  id='choice_23_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_20_0' id='label_23_20_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No'  id='choice_23_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_20_1' id='label_23_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do  you have availability for an initial visit for routine care within 10 business days?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_21'>\n\t\t\t<div class='gchoice gchoice_23_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_23_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_21_0' id='label_23_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_23_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_21_1' id='label_23_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you offer follow-up routine care?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_22'>\n\t\t\t<div class='gchoice gchoice_23_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_23_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_22_0' id='label_23_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_23_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_22_1' id='label_23_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_23_24' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_23_24' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_23_5' class='gform_page' data-js='page-field-id-24' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_23_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_23_25\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Contact Information<\/h3><\/div><fieldset id=\"field_23_31\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is the preferred Medical Record Request Method?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_23_31'><div class='gchoice gchoice_23_31_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.1' type='checkbox'  value='Email'  id='choice_23_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_31_1' id='label_23_31_1' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_31_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.2' type='checkbox'  value='Fax'  id='choice_23_31_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_31_2' id='label_23_31_2' class='gform-field-label gform-field-label--type-inline'>Fax<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_31_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.3' type='checkbox'  value='Mail'  id='choice_23_31_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_31_3' id='label_23_31_3' class='gform-field-label gform-field-label--type-inline'>Mail<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_27\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_27'>Provide the Medical Record Delivery Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_23_27' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_28\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_28'>Provide the Medical Record Delivery Contact Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_23_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_29\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_29'>Provide the Newsletter Recipient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_23_29' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_30\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_30'>Provide the Newsletter Recipient Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_30' id='input_23_30' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_23_51\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_51'>Provide the Newsletter Recipient Fax Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_51' id='input_23_51' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_23_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is the preferred Newsletter Delivery Method?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_23_26'><div class='gchoice gchoice_23_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Email'  id='choice_23_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_26_1' id='label_23_26_1' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Fax'  id='choice_23_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_26_2' id='label_23_26_2' class='gform-field-label gform-field-label--type-inline'>Fax<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Mail'  id='choice_23_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_26_3' id='label_23_26_3' class='gform-field-label gform-field-label--type-inline'>Mail<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_23_34' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_23_34' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_23_6' class='gform_page' data-js='page-field-id-34' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_23_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_23_33\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Confirmation<\/h3><\/div><div id=\"field_23_38\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_38'>Please provide your name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_23_38' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_40\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_40'>Please provide your email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_23_40' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_23_42\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_42'>Please provide your phone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_42' id='input_23_42' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_44\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_44'>By providing your first and last name below you are confirming that you answered to the best of your ability and hold the authority to complete these questions on behalf of your entire practice.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_23_44' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_36\" class=\"gfield gfield--type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_36'>CAPTCHA<\/label><div id='input_23_36' class='ginput_container ginput_recaptcha' data-sitekey='6LdOWFgdAAAAAAg-H_jqn0grTMFESeD76WUKb8sZ'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_23' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_23' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_23' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_23' id='gform_theme_23' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_23' id='gform_style_settings_23' value='{&quot;theme&quot;:&quot;gravity-theme&quot;,&quot;inputPrimaryColor&quot;:&quot;var(--global-palette1)&quot;,&quot;buttonPrimaryBackgroundColor&quot;:&quot;var(--global-palette1)&quot;}' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_23' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='23' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='jqFwzLbDJ385E\/WG5eIX8CtDLU7yRs62ASe\/\/\/42uGf0s2VP8LZg2efeUlAH7UyGMjj7mzazQz0395qE+A\/4eIo9uXp3GgpCr2BfRPaIXgVqfKE=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_23' value='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' 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#fff;\r\n}\r\n\r\n.gform_wrapper.gravity-theme .gf_step_active .gf_step_number {\r\n  background: #fff;\r\n  color: #185abc;\r\n}\r\n\r\n\/* Submit Button Styling *\/\r\n.gform_wrapper .gform_footer input[type=submit] {\r\n  background-color: #91ce6e;\r\n  border: 0;\r\n  color: #ffffff;\r\n  border-radius: 0px;\r\n  display: block;\r\n  font-size: 2em;\r\n  font-weight: 400;\r\n  margin: 0 auto;\r\n  text-transform: uppercase;\r\n  text-align: center;\r\n  width: 20%;\r\n}\r\n\r\n\/* Generic Button Styling *\/\r\n.gform_wrapper .button {\r\n  color: #fff;\r\n  border-radius: 0px;\r\n  border: 1px solid rgba(114, 114, 114, 0.4);\r\n  box-shadow: 0 1px 0px rgba(114, 114, 114, 0.3);\r\n \r\n}\r\n\r\n\/* Section Styling *\/\r\n.gform_wrapper.gravity-theme .gsection {\r\n  border-bottom: 3px solid #1e73be;\r\n}\r\n\r\n\/* Label Styling *\/\r\n.contact-form .gform_wrapper .top_label .gfield_label {\r\n  font-size: 16px;\r\n}\r\n\r\n\/* Section Title Styling *\/\r\n.gform_wrapper .gform_body 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