{"id":11053,"date":"2020-12-07T17:30:56","date_gmt":"2020-12-07T22:30:56","guid":{"rendered":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/?page_id=11053"},"modified":"2020-12-07T18:21:51","modified_gmt":"2020-12-07T23:21:51","slug":"ellenor-print-ems","status":"publish","type":"page","link":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/customer\/ellenor-print-ems\/","title":{"rendered":"Ellenor Print EMS"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-no-medium-visibility fusion-no-large-visibility\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;margin-bottom: 10px;margin-top: 15px;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 30px;\">\n<div>\n<table border=\"0\" cellspacing=\"0px\">\n<tbody>\n<tr>\n<th style=\"text-align: left; padding-left: 0px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/pl\/pl-dashboard\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-mobile-nav-logo.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/pl\/search-customers\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-customers-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/pl\/search-team-members\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-team-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/pl\/pl-reporting\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-reporting-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/pl\/my-account\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2019\/10\/robert-brown-icon.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:15px;width:100%;\"><div class=\"fusion-separator-border sep-single sep-solid\" style=\"border-color:#d3d3d3;border-top-width:1px;\"><\/div><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-equal-height-columns\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;margin-bottom: 0px;margin-top: 0px;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 30px 0px 30px;\"><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-0 fusion_builder_column_inner_5_6 5_6 fusion-five-sixth fusion-column-first fusion-column-no-min-height fusion-no-small-visibility\" style=\"width:83.333333333333%;width:calc(83.333333333333% - ( ( 0px ) * 0.83333333333333 ) );margin-right: 0px;margin-top:20px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-1\"><div>\n<table border=\"0\" cellspacing=\"0px\">\n<tbody>\n<tr>\n<th style=\"text-align: left; padding-left: 0px; padding-right: 15px; padding-top: 12px; vertical-align: top;\" align=\"top\"><img class=\"aligncenter size-full wp-image-5566\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/04\/ellenor-johnson-circle-white-36.png\" alt=\"\" width=\"36\" height=\"36\" \/><\/th>\n<th align=\"left\">\n<h1 style=\"margin-bottom: 0px; margin-top: 8px; margin-left: 0px; table-layout: auto;\"><a title=\"\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/customer\/ellenor-health\/\">Ellenor Johnson<\/a><\/h1>\n<p class=\"new-view\">Unit 117 \u00a0 | \u00a0 Assisted Living<\/p>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-1 fusion_builder_column_inner_1_6 1_6 fusion-one-sixth fusion-column-last fusion-column-no-min-height\" style=\"width:16.666666666667%;width:calc(16.666666666667% - ( ( 0px ) * 0.16666666666667 ) );margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><span class=\" fusion-imageframe imageframe-none imageframe-1 hover-type-none\" style=\"margin-left:25px;float:right;margin-right:0px;\"><img width=\"216\" height=\"216\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2019\/10\/legacy-website-logo.jpg\" class=\"img-responsive wp-image-1018\" srcset=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2019\/10\/legacy-website-logo-200x200.jpg 200w, https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2019\/10\/legacy-website-logo.jpg 216w\" sizes=\"(max-width: 800px) 100vw, 200px\" \/><\/span><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:30px;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-text fusion-text-2\"><div style=\"margin-bottom: 15px; border-bottom: 1px solid #bbbbbb;\">\n<table border=\"0\" width=\"100%\" cellspacing=\"0px\">\n<tbody>\n<tr>\n<th style=\"text-align: left; padding-left: 0px;\" align=\"left\" width=\"20%\">\n<h3 style=\"padding: 15px 0 6px 0; margin: 0 0 3px 0; font-size: 18px; line-height: 1; font-family: Roboto Slab,Tahoma,sans-serif; font-weight: 300; color: #005174; background-color: transparent;\">EMS Information<\/h3>\n<\/th>\n<th style=\"text-align: left; padding-left: 0px; margin-top: 20px; margin-bottom: 0px;\" align=\"right\" width=\"41%\"><\/th>\n<th style=\"text-align: left; padding-left: 0px; margin-top: 20px; margin-bottom: 0px;\" align=\"right\" width=\"30%\"><span style=\"margin-top: 10px; text-align: right;\"><\/span><\/th>\n<th style=\"text-align: right; padding-left: 0px;\" align=\"right\" width=\"3%\"><a title=\"Print\" href=\"#\" target=\"_self\" rel=\"noopener noreferrer\"><div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-1 fb-icon-element fontawesome-icon fa-print fas circle-no\" style=\"font-size:18px;margin-top:4px;margin-right:5px;margin-bottom:0px;\"><\/i><\/div><style>i.fb-icon-element.fontawesome-icon.fb-icon-element-1{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-1:hover { color: #005174;}<\/style><\/a><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div><div class=\"fusion-text fusion-text-3\"><div class=\"frm_forms  with_frm_style frm_style_ems-print\" id=\"frm_form_367_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_printems\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Print EMS<\/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=\"367\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_367\" id=\"frm_hide_fields_367\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"printems\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_367\" name=\"frm_submit_entry_367\" value=\"e05122cb8a\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/pages\/11053\" \/><input type=\"hidden\" name=\"item_meta[11143]\" id=\"field_ka9zs\" value=\"\"  data-invmsg=\"EMS Hidden is invalid\"   \/>\n<div id=\"frm_field_11154_container\" class=\"frm_form_field frm_section_heading form-field  frm_hide_section\">\r\n<h3 class=\"frm_pos_none frm_section_spacing\">General Information<\/h3>\r\n\r\n\r\n<div id=\"frm_field_11155_container\" class=\"frm_form_field form-field  frm_top_container frm_half frm_first\">\r\n    <label for=\"field_lmri8\" id=\"field_lmri8_label\" class=\"frm_primary_label\">First Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_lmri8\" name=\"item_meta[11155]\" value=\"Ellenor\"  data-sectionid=\"11154\" data-frmval=\"Ellenor\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11156_container\" class=\"frm_form_field form-field  frm_top_container frm_half\">\r\n    <label for=\"field_rcnym\" id=\"field_rcnym_label\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_rcnym\" name=\"item_meta[11156]\" value=\"Johnson\"  data-sectionid=\"11154\" data-frmval=\"Johnson\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11157_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth frm_first\">\r\n    <label for=\"field_vxqgp\" id=\"field_vxqgp_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[11157]\" id=\"field_vxqgp\"  data-sectionid=\"11154\" data-frmval=\"Female\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  >\n\t\t\t\t<option value=\"\"  class=\"\">\n\t\t\t \t\t<\/option>\n\t\t\t<option value=\"Female\"  selected=\"selected\" class=\"\">\n\t\t\tFemale\t\t<\/option>\n\t\t\t<option value=\"Male\"  class=\"\">\n\t\t\tMale\t\t<\/option>\n\t\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11158_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_cw3lx\" id=\"field_cw3lx_label\" class=\"frm_primary_label\">SSN\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_cw3lx\" name=\"item_meta[11158]\" value=\"123-45-6789\"  data-sectionid=\"11154\" data-frmmask=\"999-99-9999\" data-frmval=\"123-45-6789\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\d-\\d\\d-\\d\\d\\d\\d$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11159_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_g90o4\" id=\"field_g90o4_label\" class=\"frm_primary_label\">DOB\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_g90o4\" name=\"item_meta[11159]\" value=\"08\/19\/1944\"  data-sectionid=\"11154\" data-frmval=\"08\/19\/1944\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11149_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_dy6nw\" id=\"field_dy6nw_label\" class=\"frm_primary_label\">Suite #\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_dy6nw\" name=\"item_meta[11149]\" value=\"315\"  data-sectionid=\"11154\" data-frmval=\"315\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11160_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_nenq\" id=\"field_nenq_label\" class=\"frm_primary_label\">Diagnosis\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_nenq\" name=\"item_meta[11160]\" value=\"Chest pains\"  data-sectionid=\"11154\" data-frmval=\"Chest pains\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11161_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_9oflr\" id=\"field_9oflr_label\" class=\"frm_primary_label\">Allergies\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_9oflr\" name=\"item_meta[11161]\" value=\"Tree Nuts\"  data-sectionid=\"11154\" data-frmval=\"Tree Nuts\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_11152_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Insurance<\/h3>\r\n\r\n\r\n<div id=\"frm_field_11144_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth frm_first\">\r\n    <label for=\"field_qh4jc\" id=\"field_qh4jc_label\" class=\"frm_primary_label\">Primary Insurance\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_qh4jc\" name=\"item_meta[11144]\" value=\"Medicare\"  data-sectionid=\"11152\" data-frmval=\"Medicare\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11145_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_ksizr\" id=\"field_ksizr_label\" class=\"frm_primary_label\">Primary Policy #\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ksizr\" name=\"item_meta[11145]\" value=\"10-987654321\"  data-sectionid=\"11152\" data-frmval=\"10-987654321\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11202_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_8fdjz\" id=\"field_8fdjz_label\" class=\"frm_primary_label\">Secondary Insurance\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_8fdjz\" name=\"item_meta[11202]\" value=\"Pinnacle Health\"  data-sectionid=\"11152\" data-frmval=\"Pinnacle Health\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11203_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_b2v6w\" id=\"field_b2v6w_label\" class=\"frm_primary_label\">Secondary Policy #\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_b2v6w\" name=\"item_meta[11203]\" value=\"12345678900\"  data-sectionid=\"11152\" data-frmval=\"12345678900\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11201_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_imrrf\" id=\"field_imrrf_label\" class=\"frm_primary_label\">Rx Drug Insurance\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_imrrf\" name=\"item_meta[11201]\" value=\"Pinnacle Health\"  data-sectionid=\"11152\" data-frmval=\"Pinnacle Health\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11204_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_p63l1\" id=\"field_p63l1_label\" class=\"frm_primary_label\">Rx Policy #\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_p63l1\" name=\"item_meta[11204]\" value=\"432156789\"  data-sectionid=\"11152\" data-frmval=\"432156789\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11148_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth frm_first\">\r\n    <label for=\"field_5qi3j\" id=\"field_5qi3j_label\" class=\"frm_primary_label\">Primary Care Physician\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_5qi3j\" name=\"item_meta[11148]\" value=\"Dr. George Smith\"  data-sectionid=\"11152\" data-frmval=\"Dr. George Smith\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11150_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_ilpux\" id=\"field_ilpux_label\" class=\"frm_primary_label\">Physician Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ilpux\" name=\"item_meta[11150]\" value=\"555.555.1234\"  data-sectionid=\"11152\" data-frmval=\"555.555.1234\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11151_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_i3wdq\" id=\"field_i3wdq_label\" class=\"frm_primary_label\">Hospital Preference\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_i3wdq\" name=\"item_meta[11151]\" value=\"Memorial Hospital\"  data-sectionid=\"11152\" data-frmval=\"Memorial Hospital\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11163_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_sg0jk\" id=\"field_sg0jk_label\" class=\"frm_primary_label\">Hospital Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_sg0jk\" name=\"item_meta[11163]\" value=\"888.555.5678\"  data-sectionid=\"11152\" data-frmval=\"888.555.5678\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11164_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_hwu49\" id=\"field_hwu49_label\" class=\"frm_primary_label\">Pharmacy Preference\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_hwu49\" name=\"item_meta[11164]\" value=\"CVS\"  data-sectionid=\"11152\" data-frmval=\"CVS\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11165_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_pbtiv\" id=\"field_pbtiv_label\" class=\"frm_primary_label\">Pharmacy Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_pbtiv\" name=\"item_meta[11165]\" value=\"777.555.9012\"  data-sectionid=\"11152\" data-frmval=\"777.555.9012\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_11166_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Emergency Contact<\/h3>\r\n\r\n\r\n<div id=\"frm_field_11167_container\" class=\"frm_form_field form-field  frm_top_container frm_half frm_first\">\r\n    <label for=\"field_7yy7d\" id=\"field_7yy7d_label\" class=\"frm_primary_label\">Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_7yy7d\" name=\"item_meta[11167]\" value=\"Dan Johnson\"  data-sectionid=\"11166\" data-frmval=\"Dan Johnson\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11168_container\" class=\"frm_form_field form-field  frm_top_container frm_half\">\r\n    <label for=\"field_5f339\" id=\"field_5f339_label\" class=\"frm_primary_label\">Relationship\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_5f339\" name=\"item_meta[11168]\" value=\"Spouse\"  data-sectionid=\"11166\" data-frmval=\"Spouse\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11169_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth frm_first\">\r\n    <label for=\"field_6x32a\" id=\"field_6x32a_label\" class=\"frm_primary_label\">Primary Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_6x32a\" name=\"item_meta[11169]\" value=\"222.555.1234\"  data-sectionid=\"11166\" data-frmval=\"222.555.1234\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11170_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_5760i\" id=\"field_5760i_label\" class=\"frm_primary_label\">Secondary Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_5760i\" name=\"item_meta[11170]\" value=\"222.555.5678\"  data-sectionid=\"11166\" data-frmval=\"222.555.5678\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11171_container\" class=\"frm_form_field form-field  frm_top_container frm_half\">\r\n    <label for=\"field_602fn\" id=\"field_602fn_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_602fn\" name=\"item_meta[11171]\" value=\"danjohnson@gmail.com\"  data-sectionid=\"11166\" data-frmval=\"danjohnson@gmail.com\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11172_container\" class=\"frm_form_field form-field  frm_top_container frm_half frm_first\">\r\n    <label for=\"field_kmgrj\" id=\"field_kmgrj_label\" class=\"frm_primary_label\">Address\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_kmgrj\" name=\"item_meta[11172]\" value=\"4567 Greenridge Street\"  data-sectionid=\"11166\" data-frmval=\"4567 Greenridge Street\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11173_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_grzq6\" id=\"field_grzq6_label\" class=\"frm_primary_label\">City\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_grzq6\" name=\"item_meta[11173]\" value=\"Glendale\"  data-sectionid=\"11166\" data-frmval=\"Glendale\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11176_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_7r0bv\" id=\"field_7r0bv_label\" class=\"frm_primary_label\">State\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[11176]\" id=\"field_7r0bv\"  data-sectionid=\"11166\" data-frmval=\"Georgia\" data-invmsg=\"State is invalid\" aria-invalid=\"false\"  >\n\t\t\t\t<option value=\"Alabama\"  class=\"\">\n\t\t\tAlabama\t\t<\/option>\n\t\t\t<option value=\"Alaska\"  class=\"\">\n\t\t\tAlaska\t\t<\/option>\n\t\t\t<option value=\"Arizona\"  class=\"\">\n\t\t\tArizona\t\t<\/option>\n\t\t\t<option value=\"Arkansas\"  class=\"\">\n\t\t\tArkansas\t\t<\/option>\n\t\t\t<option value=\"California\"  class=\"\">\n\t\t\tCalifornia\t\t<\/option>\n\t\t\t<option value=\"Colorado\"  class=\"\">\n\t\t\tColorado\t\t<\/option>\n\t\t\t<option value=\"Connecticut\"  class=\"\">\n\t\t\tConnecticut\t\t<\/option>\n\t\t\t<option value=\"Delaware\"  class=\"\">\n\t\t\tDelaware\t\t<\/option>\n\t\t\t<option value=\"District of Columbia\"  class=\"\">\n\t\t\tDistrict of Columbia\t\t<\/option>\n\t\t\t<option value=\"Florida\"  class=\"\">\n\t\t\tFlorida\t\t<\/option>\n\t\t\t<option value=\"Georgia\"  selected=\"selected\" class=\"\">\n\t\t\tGeorgia\t\t<\/option>\n\t\t\t<option value=\"Hawaii\"  class=\"\">\n\t\t\tHawaii\t\t<\/option>\n\t\t\t<option value=\"Idaho\"  class=\"\">\n\t\t\tIdaho\t\t<\/option>\n\t\t\t<option value=\"Illinois\"  class=\"\">\n\t\t\tIllinois\t\t<\/option>\n\t\t\t<option value=\"Indiana\"  class=\"\">\n\t\t\tIndiana\t\t<\/option>\n\t\t\t<option value=\"Iowa\"  class=\"\">\n\t\t\tIowa\t\t<\/option>\n\t\t\t<option value=\"Kansas\"  class=\"\">\n\t\t\tKansas\t\t<\/option>\n\t\t\t<option value=\"Kentucky\"  class=\"\">\n\t\t\tKentucky\t\t<\/option>\n\t\t\t<option value=\"Louisiana\"  class=\"\">\n\t\t\tLouisiana\t\t<\/option>\n\t\t\t<option value=\"Maine\"  class=\"\">\n\t\t\tMaine\t\t<\/option>\n\t\t\t<option value=\"Maryland\"  class=\"\">\n\t\t\tMaryland\t\t<\/option>\n\t\t\t<option value=\"Massachusetts\"  class=\"\">\n\t\t\tMassachusetts\t\t<\/option>\n\t\t\t<option value=\"Michigan\"  class=\"\">\n\t\t\tMichigan\t\t<\/option>\n\t\t\t<option value=\"Minnesota\"  class=\"\">\n\t\t\tMinnesota\t\t<\/option>\n\t\t\t<option value=\"Mississippi\"  class=\"\">\n\t\t\tMississippi\t\t<\/option>\n\t\t\t<option value=\"Missouri\"  class=\"\">\n\t\t\tMissouri\t\t<\/option>\n\t\t\t<option value=\"Montana\"  class=\"\">\n\t\t\tMontana\t\t<\/option>\n\t\t\t<option value=\"Nebraska\"  class=\"\">\n\t\t\tNebraska\t\t<\/option>\n\t\t\t<option value=\"Nevada\"  class=\"\">\n\t\t\tNevada\t\t<\/option>\n\t\t\t<option value=\"New Hampshire\"  class=\"\">\n\t\t\tNew Hampshire\t\t<\/option>\n\t\t\t<option value=\"New Jersey\"  class=\"\">\n\t\t\tNew Jersey\t\t<\/option>\n\t\t\t<option value=\"New Mexico\"  class=\"\">\n\t\t\tNew Mexico\t\t<\/option>\n\t\t\t<option value=\"New York\"  class=\"\">\n\t\t\tNew York\t\t<\/option>\n\t\t\t<option value=\"North Carolina\"  class=\"\">\n\t\t\tNorth Carolina\t\t<\/option>\n\t\t\t<option value=\"North Dakota\"  class=\"\">\n\t\t\tNorth Dakota\t\t<\/option>\n\t\t\t<option value=\"Ohio\"  class=\"\">\n\t\t\tOhio\t\t<\/option>\n\t\t\t<option value=\"Oklahoma\"  class=\"\">\n\t\t\tOklahoma\t\t<\/option>\n\t\t\t<option value=\"Oregon\"  class=\"\">\n\t\t\tOregon\t\t<\/option>\n\t\t\t<option value=\"Pennsylvania\"  class=\"\">\n\t\t\tPennsylvania\t\t<\/option>\n\t\t\t<option value=\"Rhode Island\"  class=\"\">\n\t\t\tRhode Island\t\t<\/option>\n\t\t\t<option value=\"South Carolina\"  class=\"\">\n\t\t\tSouth Carolina\t\t<\/option>\n\t\t\t<option value=\"South Dakota\"  class=\"\">\n\t\t\tSouth Dakota\t\t<\/option>\n\t\t\t<option value=\"Tennessee\"  class=\"\">\n\t\t\tTennessee\t\t<\/option>\n\t\t\t<option value=\"Texas\"  class=\"\">\n\t\t\tTexas\t\t<\/option>\n\t\t\t<option value=\"Utah\"  class=\"\">\n\t\t\tUtah\t\t<\/option>\n\t\t\t<option value=\"Vermont\"  class=\"\">\n\t\t\tVermont\t\t<\/option>\n\t\t\t<option value=\"Virginia\"  class=\"\">\n\t\t\tVirginia\t\t<\/option>\n\t\t\t<option value=\"Washington\"  class=\"\">\n\t\t\tWashington\t\t<\/option>\n\t\t\t<option value=\"West Virginia\"  class=\"\">\n\t\t\tWest Virginia\t\t<\/option>\n\t\t\t<option value=\"Wisconsin\"  class=\"\">\n\t\t\tWisconsin\t\t<\/option>\n\t\t\t<option value=\"Wyoming\"  class=\"\">\n\t\t\tWyoming\t\t<\/option>\n\t\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11174_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_ndrr4\" id=\"field_ndrr4_label\" class=\"frm_primary_label\">ZIP\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ndrr4\" name=\"item_meta[11174]\" value=\"31000\"  data-sectionid=\"11166\" data-frmval=\"31000\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_11177_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Mortuary<\/h3>\r\n\r\n\r\n<div id=\"frm_field_11178_container\" class=\"frm_form_field form-field  frm_top_container frm_half frm_first\">\r\n    <label for=\"field_22ev6\" id=\"field_22ev6_label\" class=\"frm_primary_label\">Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_22ev6\" name=\"item_meta[11178]\" value=\"Three Rivers Funeral Home\"  data-sectionid=\"11177\" data-frmval=\"Three Rivers Funeral Home\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11179_container\" class=\"frm_form_field form-field  frm_top_container frm_half\">\r\n    <label for=\"field_a9ruj\" id=\"field_a9ruj_label\" class=\"frm_primary_label\">Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_a9ruj\" name=\"item_meta[11179]\" value=\"444.555.1234\"  data-sectionid=\"11177\" data-frmval=\"444.555.1234\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11183_container\" class=\"frm_form_field form-field  frm_top_container frm_half frm_first\">\r\n    <label for=\"field_llq5g\" id=\"field_llq5g_label\" class=\"frm_primary_label\">Address\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_llq5g\" name=\"item_meta[11183]\" value=\"1234 South Easy Street\"  data-sectionid=\"11177\" data-frmval=\"1234 South Easy Street\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11184_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_4j189\" id=\"field_4j189_label\" class=\"frm_primary_label\">City\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_4j189\" name=\"item_meta[11184]\" value=\"Glendale\"  data-sectionid=\"11177\" data-frmval=\"Glendale\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11185_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_y9bjn\" id=\"field_y9bjn_label\" class=\"frm_primary_label\">State\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[11185]\" id=\"field_y9bjn\"  data-sectionid=\"11177\" data-frmval=\"Georgia\" data-invmsg=\"State is invalid\" aria-invalid=\"false\"  >\n\t\t\t\t<option value=\"Alabama\"  class=\"\">\n\t\t\tAlabama\t\t<\/option>\n\t\t\t<option value=\"Alaska\"  class=\"\">\n\t\t\tAlaska\t\t<\/option>\n\t\t\t<option value=\"Arizona\"  class=\"\">\n\t\t\tArizona\t\t<\/option>\n\t\t\t<option value=\"Arkansas\"  class=\"\">\n\t\t\tArkansas\t\t<\/option>\n\t\t\t<option value=\"California\"  class=\"\">\n\t\t\tCalifornia\t\t<\/option>\n\t\t\t<option value=\"Colorado\"  class=\"\">\n\t\t\tColorado\t\t<\/option>\n\t\t\t<option value=\"Connecticut\"  class=\"\">\n\t\t\tConnecticut\t\t<\/option>\n\t\t\t<option value=\"Delaware\"  class=\"\">\n\t\t\tDelaware\t\t<\/option>\n\t\t\t<option value=\"District of Columbia\"  class=\"\">\n\t\t\tDistrict of Columbia\t\t<\/option>\n\t\t\t<option value=\"Florida\"  class=\"\">\n\t\t\tFlorida\t\t<\/option>\n\t\t\t<option value=\"Georgia\"  selected=\"selected\" class=\"\">\n\t\t\tGeorgia\t\t<\/option>\n\t\t\t<option value=\"Hawaii\"  class=\"\">\n\t\t\tHawaii\t\t<\/option>\n\t\t\t<option value=\"Idaho\"  class=\"\">\n\t\t\tIdaho\t\t<\/option>\n\t\t\t<option value=\"Illinois\"  class=\"\">\n\t\t\tIllinois\t\t<\/option>\n\t\t\t<option value=\"Indiana\"  class=\"\">\n\t\t\tIndiana\t\t<\/option>\n\t\t\t<option value=\"Iowa\"  class=\"\">\n\t\t\tIowa\t\t<\/option>\n\t\t\t<option value=\"Kansas\"  class=\"\">\n\t\t\tKansas\t\t<\/option>\n\t\t\t<option value=\"Kentucky\"  class=\"\">\n\t\t\tKentucky\t\t<\/option>\n\t\t\t<option value=\"Louisiana\"  class=\"\">\n\t\t\tLouisiana\t\t<\/option>\n\t\t\t<option value=\"Maine\"  class=\"\">\n\t\t\tMaine\t\t<\/option>\n\t\t\t<option value=\"Maryland\"  class=\"\">\n\t\t\tMaryland\t\t<\/option>\n\t\t\t<option value=\"Massachusetts\"  class=\"\">\n\t\t\tMassachusetts\t\t<\/option>\n\t\t\t<option value=\"Michigan\"  class=\"\">\n\t\t\tMichigan\t\t<\/option>\n\t\t\t<option value=\"Minnesota\"  class=\"\">\n\t\t\tMinnesota\t\t<\/option>\n\t\t\t<option value=\"Mississippi\"  class=\"\">\n\t\t\tMississippi\t\t<\/option>\n\t\t\t<option value=\"Missouri\"  class=\"\">\n\t\t\tMissouri\t\t<\/option>\n\t\t\t<option value=\"Montana\"  class=\"\">\n\t\t\tMontana\t\t<\/option>\n\t\t\t<option value=\"Nebraska\"  class=\"\">\n\t\t\tNebraska\t\t<\/option>\n\t\t\t<option value=\"Nevada\"  class=\"\">\n\t\t\tNevada\t\t<\/option>\n\t\t\t<option value=\"New Hampshire\"  class=\"\">\n\t\t\tNew Hampshire\t\t<\/option>\n\t\t\t<option value=\"New Jersey\"  class=\"\">\n\t\t\tNew Jersey\t\t<\/option>\n\t\t\t<option value=\"New Mexico\"  class=\"\">\n\t\t\tNew Mexico\t\t<\/option>\n\t\t\t<option value=\"New York\"  class=\"\">\n\t\t\tNew York\t\t<\/option>\n\t\t\t<option value=\"North Carolina\"  class=\"\">\n\t\t\tNorth Carolina\t\t<\/option>\n\t\t\t<option value=\"North Dakota\"  class=\"\">\n\t\t\tNorth Dakota\t\t<\/option>\n\t\t\t<option value=\"Ohio\"  class=\"\">\n\t\t\tOhio\t\t<\/option>\n\t\t\t<option value=\"Oklahoma\"  class=\"\">\n\t\t\tOklahoma\t\t<\/option>\n\t\t\t<option value=\"Oregon\"  class=\"\">\n\t\t\tOregon\t\t<\/option>\n\t\t\t<option value=\"Pennsylvania\"  class=\"\">\n\t\t\tPennsylvania\t\t<\/option>\n\t\t\t<option value=\"Rhode Island\"  class=\"\">\n\t\t\tRhode Island\t\t<\/option>\n\t\t\t<option value=\"South Carolina\"  class=\"\">\n\t\t\tSouth Carolina\t\t<\/option>\n\t\t\t<option value=\"South Dakota\"  class=\"\">\n\t\t\tSouth Dakota\t\t<\/option>\n\t\t\t<option value=\"Tennessee\"  class=\"\">\n\t\t\tTennessee\t\t<\/option>\n\t\t\t<option value=\"Texas\"  class=\"\">\n\t\t\tTexas\t\t<\/option>\n\t\t\t<option value=\"Utah\"  class=\"\">\n\t\t\tUtah\t\t<\/option>\n\t\t\t<option value=\"Vermont\"  class=\"\">\n\t\t\tVermont\t\t<\/option>\n\t\t\t<option value=\"Virginia\"  class=\"\">\n\t\t\tVirginia\t\t<\/option>\n\t\t\t<option value=\"Washington\"  class=\"\">\n\t\t\tWashington\t\t<\/option>\n\t\t\t<option value=\"West Virginia\"  class=\"\">\n\t\t\tWest Virginia\t\t<\/option>\n\t\t\t<option value=\"Wisconsin\"  class=\"\">\n\t\t\tWisconsin\t\t<\/option>\n\t\t\t<option value=\"Wyoming\"  class=\"\">\n\t\t\tWyoming\t\t<\/option>\n\t\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11186_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_f8t77\" id=\"field_f8t77_label\" class=\"frm_primary_label\">ZIP\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_f8t77\" name=\"item_meta[11186]\" value=\"31000\"  data-sectionid=\"11177\" data-frmval=\"31000\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_11188_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_hidden frm_section_spacing\">Summary<\/h3>\r\n\r\n\r\n<div id=\"frm_field_11190_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_dvdkr\" id=\"field_dvdkr_label\" class=\"frm_primary_label\">Medications Summary\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_dvdkr\" name=\"item_meta[11190]\" value=\"BP Med Name, etc.\"  data-sectionid=\"11188\" data-frmval=\"BP Med Name, etc.\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11191_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_22c2k\" id=\"field_22c2k_label\" class=\"frm_primary_label\">Code Status\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_22c2k\" name=\"item_meta[11191]\" value=\"Code status here...\"  data-sectionid=\"11188\" data-frmval=\"Code status here...\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11192_container\" class=\"frm_form_field form-field  frm_top_container frm_third frm_first\">\r\n    <label for=\"field_bmsrr\" id=\"field_bmsrr_label\" class=\"frm_primary_label\">POA\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_bmsrr\" name=\"item_meta[11192]\" value=\"Dan Johnson\"  data-sectionid=\"11188\" data-frmval=\"Dan Johnson\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11193_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_xqm2k\" id=\"field_xqm2k_label\" class=\"frm_primary_label\">DNR\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xqm2k\" name=\"item_meta[11193]\" value=\"Dan Johnson\"  data-sectionid=\"11188\" data-frmval=\"Dan Johnson\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11194_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_c11xw\" id=\"field_c11xw_label\" class=\"frm_primary_label\">Advanced Directives\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_c11xw\" name=\"item_meta[11194]\" value=\"Dan Johnson\"  data-sectionid=\"11188\" data-frmval=\"Dan Johnson\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t<div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<\/form>\n<\/div>\n\n<\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:20px;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div 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