{"id":5744,"date":"2020-04-25T15:41:20","date_gmt":"2020-04-25T19:41:20","guid":{"rendered":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/?page_id=5744"},"modified":"2020-10-06T17:03:53","modified_gmt":"2020-10-06T21:03:53","slug":"lsq-ellenor-johnson-medical-edit","status":"publish","type":"page","link":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/customer\/lsq-ellenor-johnson-medical-edit\/","title":{"rendered":"LSQ &#8211; Ellenor Johnson Medical Edit"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fixed-bottom-nav hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-no-medium-visibility fusion-no-large-visibility\" style=\"background-color: #eef0f4;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-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;border-width: 1px 0 0 0;border-color:#dddddd;border-style:solid;padding: 0px 30px 0px 30px;\">\n<div>\n<table border=\"0\" cellspacing=\"0px\">\n<tbody>\n<tr><!-- yiayia COMM Dashboard --><\/p>\n<th style=\"text-align: left; padding-left: 0px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/community-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<p><!-- yiayia COMM Admin --><\/p>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/customer\/admin-legacy-at-savannah-quarters\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-admin-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<p><!-- yiayia COMM Residents --><\/p>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-residents\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-residents-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<p><!-- yiayia COMM Health --><\/p>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-health\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-health-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<p><!-- yiayia COMM Documents --><\/p>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-documents\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-documents-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<p><!-- yiayia COMM Reporting --><\/p>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-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<p><!-- yiayia COMM Associates --><\/p>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-associates\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-associates-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<p><!-- yiayia COMM Corporate --><\/p>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-corporate\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-corporate-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<p><!-- yiayia COMM Learning --><\/p>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-learning\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-learning-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<p><!-- yiayia COMM Me JDL --><\/p>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-my-account\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/jdl-icon-clear-bg.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 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;background-color:#292A2B;padding: 12px 0px 0px 0px;\"><div class=\"fusion-column-content-centered\"><div class=\"fusion-column-content\"><div class=\"fusion-text fusion-text-1\"><p style=\"color: #ffffff; text-align: center; margin-bottom: 0px; padding-bottom: 15px;\">Copyright 2020 yiayia Technologies, LLC \u00a0\u00a0 | \u00a0\u00a0 <a style=\"color: #ffffff;\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/pl\/logout\/\">LOGOUT<\/a><\/p>\n<\/div><\/div><\/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-3 fusion_builder_column_1_6 1_6 fusion-one-sixth fusion-column-first narrow-nav fusion-no-small-visibility\" style=\"width:16.666666666667%;width:calc(16.666666666667% - ( ( 0px + 0px ) * 0.16666666666667 ) );margin-right: 0px;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;border-width: 0 1px 0 0;border-color:#cccccc;border-style:solid;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:25px;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"imageframe-align-center\"><span class=\" fusion-imageframe imageframe-none imageframe-1 hover-type-none\" style=\"width:100%;max-width:34px;\"><a class=\"fusion-no-lightbox\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/community-dashboard\/\" target=\"_self\"><img width=\"38\" height=\"47\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-Icon-Color.png\" class=\"img-responsive wp-image-4378\"\/><\/a><\/span><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:90px;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-text fusion-text-2\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Admin\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/customer\/admin-legacy-at-savannah-quarters\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-account-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-3\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Residents\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-residents\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-residents-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-4\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Health\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-health\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-health-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-5\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Documents\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-documents\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-documents-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-6\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Reporting\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-reporting\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-reporting-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-7\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Social\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-social\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/10\/social-calendar-icon.svg\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-8\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Building Operations\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-building-ops\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/10\/building-ops-icon.svg\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-9\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Associates\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-associates\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-associates-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-10\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Corporate\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-corporate\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-corporate-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-11\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Learning\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-learning\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-learning-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-12\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Me\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/community-dashboard\/#\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/10\/jdl-icon-blue-border.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_2_3 2_3 fusion-two-third middle-width\" style=\"width:66.666666666667%;width:calc(66.666666666667% - ( ( 0px + 0px ) * 0.66666666666667 ) );margin-right: 0px;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_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last fusion-no-small-visibility\" style=\"width:100%;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-13\"><div>\n<table border=\"0\" cellspacing=\"0px\">\n<tbody>\n<tr>\n<th style=\"text-align: left; padding-left: 0px; padding-top: 3px; table-layout: auto;\" align=\"left\"><a  class=\"shiftnav-toggle shiftnav-toggle-create_resident shiftnav-toggle-button\" tabindex=\"0\" data-shiftnav-target=\"create_resident\" ><i class=\"fa fa-bars\"><\/i>  <\/a>\t<\/th>\n<th style=\"text-align: left; padding-left: 0px; padding-right: 15px; padding-top: 8px;\" align=\"center\"><a title=\"Dashboard\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/customer\/lsq-ellenor-johnson-dashboard\/\"><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\" \/><\/a><\/th>\n<th align=\"left\">\n<h1 style=\"margin-bottom: 0px; margin-top: 8px; margin-left: 0px; table-layout: auto;\"><a title=\"Dashboard\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/customer\/lsq-ellenor-johnson-dashboard\/\">Ellenor Johnson<\/a><\/h1>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div><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-14\"><div style=\"margin-top: 0px; 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\">\n<h3 style=\"padding: 15px 0 3px 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;\">Medical Providers<\/h3>\n<\/th>\n<th style=\"text-align: right; padding-left: 0px;\" align=\"right\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/customer\/lsq-ellenor-johnson-medical-view\/\"><div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-1 fb-icon-element fontawesome-icon fa-check fas circle-no\" style=\"font-size:18px;margin-top:10px;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-15\"><div class=\"frm_forms  with_frm_style frm_style_create-resident-style\" id=\"frm_form_188_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_medicalellenoredit67054c5928\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Ellenor Medical Edit<\/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=\"188\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_188\" id=\"frm_hide_fields_188\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"medicalellenoredit67054c5928\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_188\" name=\"frm_submit_entry_188\" value=\"dcb349c5ad\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/pages\/5744\" \/><input type=\"hidden\" name=\"item_meta[4232]\" id=\"field_s58vob740cbe1b8\" value=\"\"  data-invmsg=\"Medical Care is invalid\"   \/>\n<div id=\"frm_field_4233_container\" class=\"frm_form_field frm_section_heading form-field  frm_hide_section\">\r\n<h3 class=\"frm_pos_none frm_section_spacing\">Primary Care Providers<\/h3>\r\n\r\n\r\n<div id=\"frm_field_4234_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth frm_first\">\r\n    <label for=\"field_fcrko1b0503a7d8\" id=\"field_fcrko1b0503a7d8_label\" class=\"frm_primary_label\">Primary Physician\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_fcrko1b0503a7d8\" name=\"item_meta[4234]\" value=\"Jameson Mills\"  data-sectionid=\"4233\" data-frmval=\"Jameson Mills\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4235_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_95joa2c297bc279\" id=\"field_95joa2c297bc279_label\" class=\"frm_primary_label\">Primary Physician Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_95joa2c297bc279\" name=\"item_meta[4235]\" value=\"678.555.4567\"  data-sectionid=\"4233\" data-frmmask=\"999.999.9999\" data-frmval=\"678.555.4567\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\d\\.\\d\\d\\d\\.\\d\\d\\d\\d$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4236_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_co3yq4d2b54e0ac\" id=\"field_co3yq4d2b54e0ac_label\" class=\"frm_primary_label\">Primary Physician Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_co3yq4d2b54e0ac\" name=\"item_meta[4236]\" value=\"jmills@hendersoninternalmed.com\"  data-sectionid=\"4233\" data-frmval=\"jmills@hendersoninternalmed.com\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4237_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_rnm5v015da385d5\" id=\"field_rnm5v015da385d5_label\" class=\"frm_primary_label\">Primary Physician Website\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_rnm5v015da385d5\" name=\"item_meta[4237]\" value=\"hendersoninternalmed.com\"  data-sectionid=\"4233\" data-frmval=\"hendersoninternalmed.com\" data-invmsg=\"Website\/URL is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_8435_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-2 fb-icon-element fontawesome-icon fa-minus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:2px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-2{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-2:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-3 fb-icon-element fontawesome-icon fa-plus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:30px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-3{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-3:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<\/div>\n<div id=\"frm_field_4238_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth frm_first\">\r\n    <label for=\"field_einb1609357cdc\" id=\"field_einb1609357cdc_label\" class=\"frm_primary_label\">Dentist\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_einb1609357cdc\" name=\"item_meta[4238]\" value=\"Peter Crossland\"  data-sectionid=\"4233\" data-frmval=\"Peter Crossland\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4239_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_gq9at6718e990df\" id=\"field_gq9at6718e990df_label\" class=\"frm_primary_label\">Dentist Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_gq9at6718e990df\" name=\"item_meta[4239]\" value=\"678.555.6543\"  data-sectionid=\"4233\" data-frmmask=\"999.999.9999\" data-frmval=\"678.555.6543\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\d\\.\\d\\d\\d\\.\\d\\d\\d\\d$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4240_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_x29wt61c3ef4292\" id=\"field_x29wt61c3ef4292_label\" class=\"frm_primary_label\">Dentist Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_x29wt61c3ef4292\" name=\"item_meta[4240]\" value=\"peter@crosslanddental.com\"  data-sectionid=\"4233\" data-frmval=\"peter@crosslanddental.com\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4241_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_q0xffd6ff239d10\" id=\"field_q0xffd6ff239d10_label\" class=\"frm_primary_label\">Dentist Website \r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_q0xffd6ff239d10\" name=\"item_meta[4241]\" value=\"crosslanddental.com\"  data-sectionid=\"4233\" data-frmval=\"crosslanddental.com\" data-invmsg=\"Website\/URL is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_8436_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-4 fb-icon-element fontawesome-icon fa-minus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:2px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-4{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-4:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-5 fb-icon-element fontawesome-icon fa-plus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:30px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-5{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-5:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<\/div>\n<div id=\"frm_field_4242_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth frm_first\">\r\n    <label for=\"field_nn3pp5455c68ba6\" id=\"field_nn3pp5455c68ba6_label\" class=\"frm_primary_label\">Hospital Preference\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_nn3pp5455c68ba6\" name=\"item_meta[4242]\" value=\"St. Helena Hospital\"  data-sectionid=\"4233\" data-frmval=\"St. Helena Hospital\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4243_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_c637c1e0763bf12\" id=\"field_c637c1e0763bf12_label\" class=\"frm_primary_label\">Hospital Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_c637c1e0763bf12\" name=\"item_meta[4243]\" value=\"678.555.6543\"  data-frmmask=\"999.999.9999\" data-frmval=\"678.555.6543\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\d\\.\\d\\d\\d\\.\\d\\d\\d\\d$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4244_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_e2b586ade8289e8\" id=\"field_e2b586ade8289e8_label\" class=\"frm_primary_label\">Hospital Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_e2b586ade8289e8\" name=\"item_meta[4244]\" value=\"frontdesk@sthelenahospital.com\"  data-sectionid=\"4233\" data-frmval=\"frontdesk@sthelenahospital.com\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4245_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_pp4bn544e530115\" id=\"field_pp4bn544e530115_label\" class=\"frm_primary_label\">Hospital Website\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_pp4bn544e530115\" name=\"item_meta[4245]\" value=\"sthelenahospital.com\"  data-sectionid=\"4233\" data-frmval=\"sthelenahospital.com\" data-invmsg=\"Website\/URL is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_8438_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-6 fb-icon-element fontawesome-icon fa-minus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:2px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-6{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-6:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-7 fb-icon-element fontawesome-icon fa-plus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:30px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-7{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-7:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<\/div>\n<div id=\"frm_field_4246_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth frm_first\">\r\n    <label for=\"field_e0zj7bcdd84441e\" id=\"field_e0zj7bcdd84441e_label\" class=\"frm_primary_label\">Pharmacy Preference\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_e0zj7bcdd84441e\" name=\"item_meta[4246]\" value=\"Longview Pharmacy\"  data-sectionid=\"4233\" data-frmval=\"Longview Pharmacy\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4247_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_hzbsw9766161b69\" id=\"field_hzbsw9766161b69_label\" class=\"frm_primary_label\">Pharmacy Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_hzbsw9766161b69\" name=\"item_meta[4247]\" value=\"678.555.7654\"  data-frmmask=\"999.999.9999\" data-frmval=\"678.555.7654\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\d\\.\\d\\d\\d\\.\\d\\d\\d\\d$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4248_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_m03vl31a1036db9\" id=\"field_m03vl31a1036db9_label\" class=\"frm_primary_label\">Pharmacy Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_m03vl31a1036db9\" name=\"item_meta[4248]\" value=\"rx@longviewpharmacy.com\"  data-sectionid=\"4233\" data-frmval=\"rx@longviewpharmacy.com\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4249_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_diji6dd57c0f389\" id=\"field_diji6dd57c0f389_label\" class=\"frm_primary_label\">Pharmacy Website\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_diji6dd57c0f389\" name=\"item_meta[4249]\" value=\"longviewpharmacy.com\"  data-sectionid=\"4233\" data-frmval=\"longviewpharmacy.com\" data-invmsg=\"Website\/URL is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_8437_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-8 fb-icon-element fontawesome-icon fa-minus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:2px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-8{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-8:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-9 fb-icon-element fontawesome-icon fa-plus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:30px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-9{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-9:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<\/div>\n<\/div>\n<div id=\"frm_field_4281_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing frm_trigger\"><i class=\"frm_icon_font frm_arrow_icon\" aria-expanded=\"false\" aria-label=\"Toggle fields\"><\/i> Approved Service Providers<\/h3>\r\n\r\n<div class=\"frm_toggle_container frm_grid_container\" style=\"display:none;\">\r\n<div id=\"frm_field_4282_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth frm_first\">\r\n    <label for=\"field_3ds5i\" id=\"field_3ds5i_label\" class=\"frm_primary_label\">Service Provider\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_3ds5i\" name=\"item_meta[4282]\" value=\"Village Physical Therapy\"  data-sectionid=\"4281\" data-frmval=\"Village Physical Therapy\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4299_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_za691\" id=\"field_za691_label\" class=\"frm_primary_label\">Service Provider Type\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[4299]\" id=\"field_za691\"  data-sectionid=\"4281\" data-frmval=\"Physical Therapy\" data-invmsg=\"Service Provider Type 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=\"Physical Therapy\"  selected=\"selected\" class=\"\">\n\t\t\tPhysical Therapy\t\t<\/option>\n\t\t\t<option value=\"Stylist\"  class=\"\">\n\t\t\tStylist\t\t<\/option>\n\t\t\t<option value=\"Others from Confluence...\"  class=\"\">\n\t\t\tOthers from Confluence...\t\t<\/option>\n\t\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4283_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_83biw\" id=\"field_83biw_label\" class=\"frm_primary_label\">Service Provider Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_83biw\" name=\"item_meta[4283]\" value=\"456.555.4321\"  data-sectionid=\"4281\" data-frmmask=\"999.999.9999\" data-frmval=\"456.555.4321\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\d\\.\\d\\d\\d\\.\\d\\d\\d\\d$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4284_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_6e2d4\" id=\"field_6e2d4_label\" class=\"frm_primary_label\">Service Provider Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_6e2d4\" name=\"item_meta[4284]\" value=\"jmills@hendersoninternalmed.com\"  data-sectionid=\"4281\" data-frmval=\"jmills@hendersoninternalmed.com\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4302_container\" class=\"frm_form_field  frm_full frm_html_container form-field\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-10 fb-icon-element fontawesome-icon fa-minus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:2px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-10{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-10:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<div id=\"frm_field_4303_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth frm_first\">\r\n    <label for=\"field_jqmki\" id=\"field_jqmki_label\" class=\"frm_primary_label\">Service Provider\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_jqmki\" name=\"item_meta[4303]\" value=\"Cassia In-Home Salon\"  data-sectionid=\"4281\" data-frmval=\"Cassia In-Home Salon\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4304_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_jfygz\" id=\"field_jfygz_label\" class=\"frm_primary_label\">Service Provider Type\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[4304]\" id=\"field_jfygz\"  data-sectionid=\"4281\" data-frmval=\"Stylist\" data-invmsg=\"Service Provider Type 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=\"Physical Therapy\"  class=\"\">\n\t\t\tPhysical Therapy\t\t<\/option>\n\t\t\t<option value=\"Stylist\"  selected=\"selected\" class=\"\">\n\t\t\tStylist\t\t<\/option>\n\t\t\t<option value=\"Others from Confluence...\"  class=\"\">\n\t\t\tOthers from Confluence...\t\t<\/option>\n\t\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4305_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_2ib4k\" id=\"field_2ib4k_label\" class=\"frm_primary_label\">Service Provider Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_2ib4k\" name=\"item_meta[4305]\" value=\"345.555.9876\"  data-sectionid=\"4281\" data-frmmask=\"999.999.9999\" data-frmval=\"345.555.9876\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\d\\.\\d\\d\\d\\.\\d\\d\\d\\d$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4306_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_xddza\" id=\"field_xddza_label\" class=\"frm_primary_label\">Service Provider Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_xddza\" name=\"item_meta[4306]\" value=\"style@cassiasalon.com\"  data-sectionid=\"4281\" data-frmval=\"style@cassiasalon.com\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_8422_container\" class=\"frm_form_field  frm_full frm_html_container form-field\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-11 fb-icon-element fontawesome-icon fa-minus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:2px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-11{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-11:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<div id=\"frm_field_8423_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth frm_first\">\r\n    <label for=\"field_3l2th\" id=\"field_3l2th_label\" class=\"frm_primary_label\">Service Provider\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_3l2th\" name=\"item_meta[8423]\" value=\"Ziggy Mobile Groomers\"  data-sectionid=\"4281\" data-frmval=\"Ziggy Mobile Groomers\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_8424_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_7oy1i\" id=\"field_7oy1i_label\" class=\"frm_primary_label\">Service Provider Type\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[8424]\" id=\"field_7oy1i\"  data-sectionid=\"4281\" data-frmval=\"Dog Groomer\" data-invmsg=\"Service Provider Type 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=\"Physical Therapy\"  class=\"\">\n\t\t\tPhysical Therapy\t\t<\/option>\n\t\t\t<option value=\"Stylist\"  class=\"\">\n\t\t\tStylist\t\t<\/option>\n\t\t\t<option value=\"Dog Groomer\"  selected=\"selected\" class=\"\">\n\t\t\tDog Groomer\t\t<\/option>\n\t\t\t<option value=\"Others from Confluence...\"  class=\"\">\n\t\t\tOthers from Confluence...\t\t<\/option>\n\t\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_8425_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_n8itg\" id=\"field_n8itg_label\" class=\"frm_primary_label\">Service Provider Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_n8itg\" name=\"item_meta[8425]\" value=\"708.555.4567\"  data-sectionid=\"4281\" data-frmmask=\"999.999.9999\" data-frmval=\"708.555.4567\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\d\\.\\d\\d\\d\\.\\d\\d\\d\\d$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_8426_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_6n1ej\" id=\"field_6n1ej_label\" class=\"frm_primary_label\">Service Provider Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_6n1ej\" name=\"item_meta[8426]\" value=\"ziggygroomers@gmail.com\"  data-sectionid=\"4281\" data-frmval=\"ziggygroomers@gmail.com\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4307_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-12 fb-icon-element fontawesome-icon fa-minus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:2px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-12{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-12:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-13 fb-icon-element fontawesome-icon fa-plus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:30px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-13{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-13:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"frm_field_8431_container\" class=\"frm_form_field frm_section_heading form-field \">\n<h3 class=\"frm_pos_top frm_section_spacing frm_trigger\"><i class=\"frm_icon_font frm_arrow_icon\" aria-expanded=\"false\" aria-label=\"Toggle fields\"><\/i> Insurance<\/h3>\n\n<div class=\"frm_toggle_container frm_grid_container\" style=\"display:none;\">\n<div id=\"frm_field_4252_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth frm_first\">\r\n    <label for=\"field_2p6u59b692def8b\" id=\"field_2p6u59b692def8b_label\" class=\"frm_primary_label\">Primary Insurance Provider\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_2p6u59b692def8b\" name=\"item_meta[4252]\" value=\"PrimeSouth Healthcare\"  data-sectionid=\"8431\" data-frmval=\"PrimeSouth Healthcare\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4253_container\" class=\"frm_form_field form-field  frm_top_container frm_eighth\">\r\n    <label for=\"field_xl1erfcdffb9a83\" id=\"field_xl1erfcdffb9a83_label\" class=\"frm_primary_label\">Policy Number\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xl1erfcdffb9a83\" name=\"item_meta[4253]\" value=\"123456789\"  data-sectionid=\"8431\" data-frmval=\"123456789\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4254_container\" class=\"frm_form_field form-field  frm_top_container frm_eighth\">\r\n    <label for=\"field_t7t8m69e3f868b1\" id=\"field_t7t8m69e3f868b1_label\" class=\"frm_primary_label\">Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_t7t8m69e3f868b1\" name=\"item_meta[4254]\" value=\"234.555.7890\"  data-sectionid=\"8431\" data-frmval=\"234.555.7890\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4255_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_yob3660280ee5da\" id=\"field_yob3660280ee5da_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_yob3660280ee5da\" name=\"item_meta[4255]\" value=\"agent@primesouth.com\"  data-sectionid=\"8431\" data-frmval=\"agent@primesouth.com\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4256_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_awenaffe4d42f15\" id=\"field_awenaffe4d42f15_label\" class=\"frm_primary_label\">Website\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_awenaffe4d42f15\" name=\"item_meta[4256]\" value=\"primesouth.com\"  data-sectionid=\"8431\" data-frmval=\"primesouth.com\" data-invmsg=\"Website\/URL is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_8439_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-14 fb-icon-element fontawesome-icon fa-minus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:2px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-14{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-14:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-15 fb-icon-element fontawesome-icon fa-plus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:30px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-15{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-15:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<\/div>\n<div id=\"frm_field_4257_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth frm_first\">\r\n    <label for=\"field_h4gc33a81b08e77\" id=\"field_h4gc33a81b08e77_label\" class=\"frm_primary_label\">Secondary Insurance Provider\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_h4gc33a81b08e77\" name=\"item_meta[4257]\" value=\"White Swan Insurance\"  data-sectionid=\"8431\" data-frmval=\"White Swan Insurance\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4258_container\" class=\"frm_form_field form-field  frm_top_container frm_eighth\">\r\n    <label for=\"field_e3cwn30768e3f1e\" id=\"field_e3cwn30768e3f1e_label\" class=\"frm_primary_label\">Policy Number\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_e3cwn30768e3f1e\" name=\"item_meta[4258]\" value=\"987654321-2345\"  data-sectionid=\"8431\" data-frmval=\"987654321-2345\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4259_container\" class=\"frm_form_field form-field  frm_top_container frm_eighth\">\r\n    <label for=\"field_qtvan1b640eedc0\" id=\"field_qtvan1b640eedc0_label\" class=\"frm_primary_label\">Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_qtvan1b640eedc0\" name=\"item_meta[4259]\" value=\"258.555.7896\"  data-sectionid=\"8431\" data-frmval=\"258.555.7896\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4260_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_tw3gpa7282a893d\" id=\"field_tw3gpa7282a893d_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_tw3gpa7282a893d\" name=\"item_meta[4260]\" value=\"info@whiteswaninsurance.com\"  data-sectionid=\"8431\" data-frmval=\"info@whiteswaninsurance.com\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4261_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_sb8n1c144a8cf7\" id=\"field_sb8n1c144a8cf7_label\" class=\"frm_primary_label\">Website\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_sb8n1c144a8cf7\" name=\"item_meta[4261]\" value=\"whiteswaninsurance.com\"  data-sectionid=\"8431\" data-frmval=\"whiteswaninsurance.com\" data-invmsg=\"Website\/URL is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_8440_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-16 fb-icon-element fontawesome-icon fa-minus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:2px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-16{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-16:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<div style=\"display: inline;\"><a href=\"#\"><\/p>\n<div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-17 fb-icon-element fontawesome-icon fa-plus fas circle-no\" style=\"font-size:18px;margin-top:-40px;margin-right:30px;margin-bottom:0px;\"><\/i><\/div>\n<style>i.fb-icon-element.fontawesome-icon.fb-icon-element-17{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-17:hover { color: #005174;}<\/style>\n<p><\/a><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"frm_field_4251_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing frm_trigger\"><i class=\"frm_icon_font frm_arrow_icon\" aria-expanded=\"false\" aria-label=\"Toggle fields\"><\/i> Medical Documents Log<\/h3>\r\n\r\n<div class=\"frm_toggle_container frm_grid_container\" style=\"display:none;\">\r\n<div id=\"frm_field_5868_container\" class=\"frm_form_field form-field  frm_none_container frm_sixth frm_first\">\n    <label for=\"field_zimye\" id=\"field_zimye_label\" class=\"frm_primary_label\">Category\n        <span class=\"frm_required\"><\/span>\n    <\/label>\n    \t\t<select name=\"item_meta[5868]\" id=\"field_zimye\"  data-sectionid=\"4251\" data-frmval=\"Insurance\" data-invmsg=\"Category is invalid\" aria-invalid=\"false\"  >\n\t\t\t\t<option value=\"Insurance\"  selected=\"selected\" class=\"\">\n\t\t\tInsurance\t\t<\/option>\n\t\t<\/select>\n\t\n    \n    \n<\/div>\n<div id=\"frm_field_5869_container\" class=\"frm_form_field form-field  frm_none_container frm_third\">\n    <label for=\"field_56t08\" id=\"field_56t08_label\" class=\"frm_primary_label\">Document Type\n        <span class=\"frm_required\"><\/span>\n    <\/label>\n    \t\t<select name=\"item_meta[5869]\" id=\"field_56t08\"  data-sectionid=\"4251\" data-frmval=\"Insurance Card Images\" data-invmsg=\"Document Type 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=\"Insurance Card Images\"  selected=\"selected\" class=\"\">\n\t\t\tInsurance Card Images\t\t<\/option>\n\t\t\t<option value=\"Insurance Forms\"  class=\"\">\n\t\t\tInsurance Forms\t\t<\/option>\n\t\t\t<option value=\"Miscellaneous\"  class=\"\">\n\t\t\tMiscellaneous\t\t<\/option>\n\t\t<\/select>\n\t\n    \n    \n<\/div>\n<div id=\"frm_field_5870_container\" class=\"frm_form_field form-field  frm_none_container frm_half\">\n    <label for=\"field_nlpf5\" id=\"field_nlpf5_label\" class=\"frm_primary_label\">Placeholder\n        <span class=\"frm_required\"><\/span>\n    <\/label>\n    <input type=\"text\" id=\"field_nlpf5\" name=\"item_meta[5870]\" value=\"\"  data-sectionid=\"4251\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\n    \n    \n<\/div>\n<div id=\"frm_field_4279_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<div>\n<table style=\"padding: 0px;\" width=\"100%\" cellspacing=\"10px\">\n<thead style=\"border-bottom: 1px solid #cccccc; margin-bottom: 10px;\">\n<tr>\n<th style=\"font-weight: 400; color: #005174;\" align=\"left\">Upload Date<\/th>\n<th style=\"font-weight: 400; color: #005174;\" align=\"left\">Category<\/th>\n<th style=\"font-weight: 400; color: #005174;\" align=\"left\">Document Type<\/th>\n<th style=\"font-weight: 400; color: #005174;\" align=\"left\">Document Name<\/th>\n<th style=\"font-weight: 400; color: #005174;\" align=\"left\">Insurance Type<\/th>\n<th style=\"font-weight: 400; color: #005174;\" align=\"left\">Effective Date<\/th>\n<th style=\"font-weight: 400; color: #005174;\" align=\"left\">Expiration Date<\/th>\n<th style=\"font-weight: 400; color: #005174;\" align=\"left\">Side<\/th>\n<th style=\"font-weight: 400; color: #005174;\" align=\"left\"><\/th>\n<th style=\"font-weight: 400; color: #005174;\" align=\"left\"><\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr style=\"border-bottom: 1px solid #cccccc; margin-top: 10px;\">\n<td align=\"left\">04\/25\/2020<\/td>\n<td align=\"left\">Insurance<\/td>\n<td align=\"left\">Card Image<\/td>\n<td align=\"left\">Ellenor Johnson Primary<br \/>\nInsurance Card Front.jpg<\/td>\n<td align=\"left\">Primary<\/td>\n<td align=\"left\">02\/01\/2020<\/td>\n<td align=\"left\">01\/31\/2021<\/td>\n<td align=\"left\">Front<\/td>\n<td align=\"left\" width=\"20px\">\n<div class=\"fusion-fa-align-right\"><a class=\"fb-icon-element-18 fb-icon-element fontawesome-icon fa-search fas circle-no fusion-link\" style=\"font-size:18px;margin-left:9px;\" href=\"#\" aria-label=\"Link to #\" target=\"_self\"><\/a><\/div>\n<style>a.fb-icon-element.fontawesome-icon.fb-icon-element-18{ color: #005174;}a.fb-icon-element.fontawesome-icon.fb-icon-element-18:hover { color: #9e9e9e;}<\/style>\n<\/td>\n<td align=\"left\" width=\"20px\">\n<div class=\"fusion-fa-align-right\"><a class=\"fb-icon-element-19 fb-icon-element fontawesome-icon fa-minus fas circle-no fusion-link\" style=\"font-size:18px;margin-left:9px;\" href=\"#\" aria-label=\"Link to #\" target=\"_self\"><\/a><\/div>\n<style>a.fb-icon-element.fontawesome-icon.fb-icon-element-19{ color: #005174;}a.fb-icon-element.fontawesome-icon.fb-icon-element-19:hover { color: #9e9e9e;}<\/style>\n<\/td>\n<\/tr>\n<p><!--2nd line--><\/p>\n<tr style=\"border-bottom: 1px solid #cccccc; margin-top: 10px;\">\n<td align=\"left\">04\/25\/2020<\/td>\n<td align=\"left\">Insurance<\/td>\n<td align=\"left\">Card Image<\/td>\n<td align=\"left\">Ellenor Johnson Primary<br \/>\nInsurance Card Back.jpg<\/td>\n<td align=\"left\">Primary<\/td>\n<td align=\"left\">02\/01\/2020<\/td>\n<td align=\"left\">01\/31\/2021<\/td>\n<td align=\"left\">Back<\/td>\n<td align=\"left\" width=\"20px\">\n<div class=\"fusion-fa-align-right\"><a class=\"fb-icon-element-20 fb-icon-element fontawesome-icon fa-search fas circle-no fusion-link\" style=\"font-size:18px;margin-left:9px;\" href=\"#\" aria-label=\"Link to #\" target=\"_self\"><\/a><\/div>\n<style>a.fb-icon-element.fontawesome-icon.fb-icon-element-20{ color: #005174;}a.fb-icon-element.fontawesome-icon.fb-icon-element-20:hover { color: #9e9e9e;}<\/style>\n<\/td>\n<td align=\"left\" width=\"20px\">\n<div class=\"fusion-fa-align-right\"><a class=\"fb-icon-element-21 fb-icon-element fontawesome-icon fa-minus fas circle-no fusion-link\" style=\"font-size:18px;margin-left:9px;\" href=\"#\" aria-label=\"Link to #\" target=\"_self\"><\/a><\/div>\n<style>a.fb-icon-element.fontawesome-icon.fb-icon-element-21{ color: #005174;}a.fb-icon-element.fontawesome-icon.fb-icon-element-21:hover { color: #9e9e9e;}<\/style>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"frm_field_8433_container\" class=\"frm_form_field frm_section_heading form-field \">\n<h3 class=\"frm_pos_top frm_section_spacing frm_trigger\"><i class=\"frm_icon_font frm_arrow_icon\" aria-expanded=\"false\" aria-label=\"Toggle fields\"><\/i> Medical Document Uploads<\/h3>\n\n<div class=\"frm_toggle_container frm_grid_container\" style=\"display:none;\">\n<div id=\"frm_field_4264_container\" class=\"frm_form_field form-field  frm_none_container frm_third frm_first\">\r\n    <div  id=\"field_9j92caa5bf2d037_label\" class=\"frm_primary_label\">File Upload\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <input type=\"hidden\" name=\"item_meta[4264]\"  value=\"\" data-frmfile=\"4264\" \/>\n\n<div class=\"frm_dropzone frm_single_upload frm_clearfix\" id=\"file4264_dropzone\" role=\"group\" >\n\t<div class=\"fallback\">\n\t\t<input type=\"file\" name=\"file4264\" id=\"field_9j92caa5bf2d037\"  data-sectionid=\"8433\" data-invmsg=\"File Upload is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\n\t\t\t\t<div class=\"frm_clearfix \"><\/div>\n\t<\/div>\n\t<div class=\"dz-message needsclick\">\n\t\t<span class=\"frm_icon_font frm_upload_icon\"><\/span>\n\t\t<span class=\"frm_upload_text\"><button type=\"button\">Drop a file or click to upload<\/button><\/span>\n\t\t<span class=\"frm_compact_text\"><button type=\"button\">Choose File<\/button><\/span>\n\t\t<div class=\"frm_small_text\">\n\t\t\tMaximum upload size: 2.1MB\t\t<\/div>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4265_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_symn7d7a9d95d82\" id=\"field_symn7d7a9d95d82_label\" class=\"frm_primary_label\">Category\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[4265]\" id=\"field_symn7d7a9d95d82\"  data-sectionid=\"8433\" data-frmval=\"Insurance\" data-invmsg=\"Category is invalid\" aria-invalid=\"false\"  >\n\t\t\t\t<option value=\"Insurance\"  selected=\"selected\" class=\"\">\n\t\t\tInsurance\t\t<\/option>\n\t\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4272_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_digdw7227c4ab55\" id=\"field_digdw7227c4ab55_label\" class=\"frm_primary_label\">Document Type\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[4272]\" id=\"field_digdw7227c4ab55\"  data-sectionid=\"8433\" data-frmval=\"Insurance Card Images\" data-invmsg=\"Document Type 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=\"Insurance Card Images\"  selected=\"selected\" class=\"\">\n\t\t\tInsurance Card Images\t\t<\/option>\n\t\t\t<option value=\"Insurance Forms\"  class=\"\">\n\t\t\tInsurance Forms\t\t<\/option>\n\t\t\t<option value=\"Miscellaneous\"  class=\"\">\n\t\t\tMiscellaneous\t\t<\/option>\n\t\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4273_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_83i3sebfa6a10fe\" id=\"field_83i3sebfa6a10fe_label\" class=\"frm_primary_label\">Effective Date\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_83i3sebfa6a10fe\" name=\"item_meta[4273]\" value=\"\"  data-sectionid=\"8433\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4274_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_oyyh7962ffd488a\" id=\"field_oyyh7962ffd488a_label\" class=\"frm_primary_label\">Insurance Type\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[4274]\" id=\"field_oyyh7962ffd488a\"  data-sectionid=\"8433\" data-invmsg=\"Insurance Type is invalid\" aria-invalid=\"false\"  >\n\t\t\t\t<option value=\"\"  selected=\"selected\" class=\"\">\n\t\t\t \t\t<\/option>\n\t\t\t<option value=\"Primary\"  class=\"\">\n\t\t\tPrimary\t\t<\/option>\n\t\t\t<option value=\"Secondary\"  class=\"\">\n\t\t\tSecondary\t\t<\/option>\n\t\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4275_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_7cxq607946ba4c6\" id=\"field_7cxq607946ba4c6_label\" class=\"frm_primary_label\">Expiration Date\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_7cxq607946ba4c6\" name=\"item_meta[4275]\" value=\"\"  data-sectionid=\"8433\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4276_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_kto4kcb5df9c8a6\" id=\"field_kto4kcb5df9c8a6_label\" class=\"frm_primary_label\">Document Side\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[4276]\" id=\"field_kto4kcb5df9c8a6\"  data-sectionid=\"8433\" data-invmsg=\"Document Side is invalid\" aria-invalid=\"false\"  >\n\t\t\t\t<option value=\"\"  selected=\"selected\" class=\"\">\n\t\t\t \t\t<\/option>\n\t\t\t<option value=\"Front\"  class=\"\">\n\t\t\tFront\t\t<\/option>\n\t\t\t<option value=\"Back\"  class=\"\">\n\t\t\tBack\t\t<\/option>\n\t\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_4277_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<div style=\"border-bottom: 1px solid #cccccc;\">\n<div class=\"fusion-fa-align-right\"><a class=\"fb-icon-element-22 fb-icon-element fontawesome-icon fa-check fas circle-no fusion-link\" style=\"font-size:24px;margin-top:5px;margin-right:5px;margin-bottom:18px;\" href=\"#\" aria-label=\"Link to #\" target=\"_self\"><\/a><\/div>\n<style>a.fb-icon-element.fontawesome-icon.fb-icon-element-22{ color: #005174;}a.fb-icon-element.fontawesome-icon.fb-icon-element-22:hover { color: #005174;}<\/style>\n<\/div>\n<\/div>\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\"   formnovalidate=\"formnovalidate\">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-no-small-visibility fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:40px;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:40px;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_6 1_6 fusion-one-sixth fusion-column-last insights-display fusion-no-small-visibility\" style=\"width:16.666666666667%;width:calc(16.666666666667% - ( ( 0px + 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;border-width: 0 0 0 1px;border-color:#cccccc;border-style:solid;padding: 0px 0px 0px 20px;\"><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-no-small-visibility fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:130px;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-text fusion-text-16\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-no-small-visibility fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:70%;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":789,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"100-width.php","meta":[],"_links":{"self":[{"href":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/pages\/5744"}],"collection":[{"href":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/comments?post=5744"}],"version-history":[{"count":9,"href":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/pages\/5744\/revisions"}],"predecessor-version":[{"id":5749,"href":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/pages\/5744\/revisions\/5749"}],"up":[{"embeddable":true,"href":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/pages\/789"}],"wp:attachment":[{"href":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/media?parent=5744"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}