{"id":1528,"date":"2020-06-10T14:01:59","date_gmt":"2020-06-10T14:01:59","guid":{"rendered":"http:\/\/secure.thinkdesignsllc.com\/~ppcn\/?page_id=1528"},"modified":"2020-07-10T22:23:46","modified_gmt":"2020-07-10T22:23:46","slug":"for-participants","status":"publish","type":"page","link":"https:\/\/ppcn.org\/new\/for-participants\/","title":{"rendered":"For Participants"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column width=&#8221;2\/3&#8243;]<h1 class=\"sc_title sc_title_regular\">Enrollment Form<\/h1>[vc_column_text]Please select your Employer or Health Insurance Coverage Sponsor.[\/vc_column_text]<div class=\"sc_line sc_line_style_solid\" style=\"border-top-style:solid;\"><\/div>[\/vc_column][vc_column width=&#8221;1\/3&#8243;][vc_video link=&#8221;https:\/\/youtu.be\/7FtUPR2hess&#8221; el_width=&#8221;90&#8243;][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_9_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_h8hxs\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_hidden\">Enrollment Form<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"9\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_9\" id=\"frm_hide_fields_9\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"h8hxs\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_9\" name=\"frm_submit_entry_9\" value=\"cdb05b2160\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/new\/wp-json\/wp\/v2\/pages\/1528\" \/><div id=\"frm_field_117_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_ujjte\" class=\"frm_primary_label\">Employer \/ Health Insurance Coverage Sponsor\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[117]\" id=\"field_ujjte\"  data-frmval=\"Please Select Your Sponsor\/Employer\" data-reqmsg=\"Employer \/ Health Insurance Coverage Sponsor cannot be blank.\" aria-required=\"true\" data-invmsg=\"Employer \/ Health Insurance Coverage Sponsor is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Please Select Your Sponsor\/Employer\" selected='selected'>Please Select Your Sponsor\/Employer<\/option><option  value=\"Asheboro\">Asheboro<\/option><option  value=\"Asheville\">Asheville<\/option><option  value=\"Buncombe County\">Buncombe County<\/option><option  value=\"Cleveland County\">Cleveland County<\/option><option  value=\"Duplin County\">Duplin County<\/option><option  value=\"East Orange\">East Orange<\/option><option  value=\"Edgecombe County\">Edgecombe County<\/option><option  value=\"Gastonia\">Gastonia<\/option><option  value=\"Halifax\">Halifax<\/option><option  value=\"Haywood County\">Haywood County<\/option><option  value=\"Hendersonville\">Hendersonville<\/option><option  value=\"Lincoln County\">Lincoln County<\/option><option  value=\"Nags Head\">Nags Head<\/option><option  value=\"NC League of Municipalities\">NC League of Municipalities<\/option><option  value=\"Person County\">Person County<\/option><option  value=\"Prince George\">Prince George<\/option><option  value=\"Randolph County\">Randolph County<\/option><option  value=\"Robeson County\">Robeson County<\/option><option  value=\"Rocky Mount\">Rocky Mount<\/option><option  value=\"Rowan County\">Rowan County<\/option><option  value=\"Salisbury\">Salisbury<\/option><option  value=\"Sanford\">Sanford<\/option><option  value=\"Shelby\">Shelby<\/option><option  value=\"Union County\">Union County<\/option><option  value=\"Vance County\">Vance County<\/option><option  value=\"Vaya Health\">Vaya Health<\/option><option  value=\"Wayne County\">Wayne County<\/option><option  value=\"Western North Carolina Conference\">Western North Carolina Conference<\/option><option  value=\"Woodbridge\">Woodbridge<\/option><option  value=\"New Option\">New Option<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_88_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_oikve\" class=\"frm_primary_label\">First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_oikve\" name=\"item_meta[88]\" value=\"\"  data-reqmsg=\"First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"First Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_89_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_3dpxh\" class=\"frm_primary_label\">Middle Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_3dpxh\" name=\"item_meta[89]\" value=\"\"  data-invmsg=\"Middle Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_90_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_8x2an\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_8x2an\" name=\"item_meta[90]\" value=\"\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Last Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_91_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_xh17a\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xh17a\" name=\"item_meta[91]\" value=\"\"  maxlength=\"10\" data-reqmsg=\"Date of Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_92_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_kzw6g\" class=\"frm_primary_label\">Sex\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[92]\" id=\"field_kzw6g\"  data-frmval=\"Male\" data-reqmsg=\"Sex cannot be blank.\" aria-required=\"true\" data-invmsg=\"Sex is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Male\" selected='selected'>Male<\/option><option  value=\"Female\">Female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_93_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_hoia3\" class=\"frm_primary_label\">Ethnicity\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[93]\" id=\"field_hoia3\"  data-frmval=\"American Indian or Alaskan Native\" data-reqmsg=\"Ethnicity cannot be blank.\" aria-required=\"true\" data-invmsg=\"Ethnicity is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"American Indian or Alaskan Native\" selected='selected'>American Indian or Alaskan Native<\/option><option  value=\"Asian or Pacific Islander\">Asian or Pacific Islander<\/option><option  value=\"Black or African American\">Black or African American<\/option><option  value=\"Hispanic or Latino\">Hispanic or Latino<\/option><option  value=\"Native Hawaiian or Other Pacific Islander\">Native Hawaiian or Other Pacific Islander<\/option><option  value=\"White not of Hispanic Origin\">White not of Hispanic Origin<\/option><option  value=\"White of Hispanic Origin\">White of Hispanic Origin<\/option><option  value=\"Not Selected\">Not Selected<\/option><option  value=\"Race\/Ethnicity Unknown\">Race\/Ethnicity Unknown<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_94_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <label  class=\"frm_primary_label\">Retired\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_94-0\">\t\t\t<label  for=\"field_dwohu-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[94][]\" id=\"field_dwohu-0\" value=\"Yes\"  data-reqmsg=\"Retired cannot be blank.\" data-invmsg=\"Retired is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_94-1\">\t\t\t<label  for=\"field_dwohu-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[94][]\" id=\"field_dwohu-1\" value=\"No\"  data-reqmsg=\"Retired cannot be blank.\" data-invmsg=\"Retired is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_95_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_8avah\" class=\"frm_primary_label\">Relationship to Employee\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[95]\" id=\"field_8avah\"  data-frmval=\"Self\" data-reqmsg=\"Relationship to Employee cannot be blank.\" aria-required=\"true\" data-invmsg=\"Relationship to Employee is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Self\" selected='selected'>Self<\/option><option  value=\"Spouse\">Spouse<\/option><option  value=\"Child\">Child<\/option><option  value=\"Other\">Other<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_116_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_f17zi\" class=\"frm_primary_label\">Location\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_f17zi\" name=\"item_meta[116]\" value=\"\"  data-reqmsg=\"Location cannot be blank.\" aria-required=\"true\" data-invmsg=\"Location is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_97_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h5>Contact Information<\/h5>\n<\/div>\n<div id=\"frm_field_98_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_i0qjv\" class=\"frm_primary_label\">Preferred Contact\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[98]\" id=\"field_i0qjv\"  data-frmval=\"Cell Phone - Text\" data-invmsg=\"Preferred Contact is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Cell Phone - Text\" selected='selected'>Cell Phone - Text<\/option><option  value=\"Cell Phone - Leave Message\">Cell Phone - Leave Message<\/option><option  value=\"Email\">Email<\/option><option  value=\"Home Phone - Leave Message\">Home Phone - Leave Message<\/option><option  value=\"Home Phone - No Message\">Home Phone - No Message<\/option><option  value=\"Work Phone - Leave Message\">Work Phone - Leave Message<\/option><option  value=\"Work Phone - No Message\">Work Phone - No Message<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_99_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_e976k\" class=\"frm_primary_label\">Mobile Phone\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_e976k\" name=\"item_meta[99]\" value=\"\"  data-reqmsg=\"Mobile Phone cannot be blank.\" aria-required=\"true\" data-invmsg=\"Mobile Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_100_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_heeyo\" class=\"frm_primary_label\">Work Phone\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_heeyo\" name=\"item_meta[100]\" value=\"\"  data-reqmsg=\"Work Phone cannot be blank.\" aria-required=\"true\" data-invmsg=\"Work Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_101_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_janho\" class=\"frm_primary_label\">Home Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_janho\" name=\"item_meta[101]\" value=\"\"  data-invmsg=\"Home Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_102_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_iglv8\" class=\"frm_primary_label\">Email Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_iglv8\" name=\"item_meta[102]\" value=\"\"  data-reqmsg=\"Email Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email Address is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_134_container\" class=\"frm_form_field form-field \">\n\t<div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Submit<\/button>\r\n\r\n<\/div>\n<\/div>\n<div id=\"frm_field_103_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h5>Mailing Address<\/h5>\n<\/div>\n<div id=\"frm_field_104_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_y848j\" class=\"frm_primary_label\">Address\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <fieldset aria-labelledby=\"field_y848j_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tAddress<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_104-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_y848j_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_y848j_line1\" value=\"\" name=\"item_meta[104][line1]\"  data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_104-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_y848j_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_y848j_line2\" value=\"\" name=\"item_meta[104][line2]\"  data-invmsg=\"Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_104-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_y848j_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_y848j_city\" value=\"\" name=\"item_meta[104][city]\"  data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_104-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_y848j_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t\t<select name=\"item_meta[104][state]\" id=\"field_y848j_state\"  data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Alabama\">Alabama<\/option><option  value=\"Alaska\">Alaska<\/option><option  value=\"Arkansas\">Arkansas<\/option><option  value=\"Arizona\">Arizona<\/option><option  value=\"California\">California<\/option><option  value=\"Colorado\">Colorado<\/option><option  value=\"Connecticut\">Connecticut<\/option><option  value=\"Delaware\">Delaware<\/option><option  value=\"District of Columbia\">District of Columbia<\/option><option  value=\"Florida\">Florida<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"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=\"Ohio\">Ohio<\/option><option  value=\"Oklahoma\">Oklahoma<\/option><option  value=\"Oregon\">Oregon<\/option><option  value=\"Pennsylvania\">Pennsylvania<\/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=\"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>\t\t<\/select>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_104-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_y848j_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_y848j_zip\" value=\"\" name=\"item_meta[104][zip]\"  data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_105_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h5>Insurance Information<\/h5>\n<\/div>\n<div id=\"frm_field_106_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_98fma\" class=\"frm_primary_label\">Primary Care Provider\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_98fma\" name=\"item_meta[106]\" value=\"\"  data-invmsg=\"Primary Care Provider is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_108_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_ne4qc\" class=\"frm_primary_label\">Practice Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_ne4qc\" name=\"item_meta[108]\" value=\"\"  data-invmsg=\"Practice Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_107_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_h1s9e\" class=\"frm_primary_label\">Practice Address\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <fieldset aria-labelledby=\"field_h1s9e_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tPractice Address<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_107-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_h1s9e_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tPractice Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_h1s9e_line1\" value=\"\" name=\"item_meta[107][line1]\"  data-invmsg=\"Practice Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_107-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_h1s9e_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tPractice Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_h1s9e_line2\" value=\"\" name=\"item_meta[107][line2]\"  data-invmsg=\"Practice Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_107-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_h1s9e_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_h1s9e_city\" value=\"\" name=\"item_meta[107][city]\"  data-invmsg=\"Practice Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_107-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_h1s9e_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t<input type=\"text\" id=\"field_h1s9e_state\" value=\"\" name=\"item_meta[107][state]\"  data-invmsg=\"Practice Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_107-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_h1s9e_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_h1s9e_zip\" value=\"\" name=\"item_meta[107][zip]\"  data-invmsg=\"Practice Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<div id=\"frm_field_107-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_h1s9e_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[107][country]\" id=\"field_h1s9e_country\"  data-invmsg=\"Practice Address is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Macedonia\" data-code=\"MK\">Macedonia<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\" data-code=\"WF\">Wallis and Futuna<\/option><option  value=\"Western Sahara\" data-code=\"EH\">Western Sahara<\/option><option  value=\"Yemen\" data-code=\"YE\">Yemen<\/option><option  value=\"Zambia\" data-code=\"ZM\">Zambia<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_109_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_3lolo\" class=\"frm_primary_label\">Practice Phone Number\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_3lolo\" name=\"item_meta[109]\" value=\"\"  data-invmsg=\"Practice Phone Number is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_110_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_et6wu\" class=\"frm_primary_label\">Practice Fax\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_et6wu\" name=\"item_meta[110]\" value=\"\"  data-invmsg=\"Practice Fax is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_111_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_phufx\" class=\"frm_primary_label\">Insurance ID Number\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_phufx\" name=\"item_meta[111]\" value=\"\"  data-invmsg=\"Insurance ID Number is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_112_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h5>Emergency Contact<\/h5>\n<\/div>\n<div id=\"frm_field_113_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_3s5f0\" class=\"frm_primary_label\">Emergency Contact Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_3s5f0\" name=\"item_meta[113]\" value=\"\"  data-invmsg=\"Emergency Contact Name is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_114_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_vy0f5\" class=\"frm_primary_label\">Relationship to Emergency Contact\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[114]\" id=\"field_vy0f5\"  data-frmval=\"Spouse\" data-invmsg=\"Relationship to Emergency Contact is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Spouse\" selected='selected'>Spouse<\/option><option  value=\"Child\">Child<\/option><option  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