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578 lines
58 KiB
578 lines
58 KiB
<?xml version="1.0" encoding="utf-8"?>
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<odoo>
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<template id="assessment_request_form">
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<t t-call="website.layout">
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<div id="wrap" class="oe_structure oe_empty">
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<section class="s_title parallax s_parallax_is_fixed bg-black-50 pt24 pb24" data-vcss="001" data-snippet="s_title" data-scroll-background-ratio="1">
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<span class="s_parallax_bg oe_img_bg" style="background-image: url('/web/image/website.s_banner_default_image'); background-position: 50% 0;"/>
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<div class="o_we_bg_filter bg-black-50"/>
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<div class="container">
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<h1>Assessment Request Form</h1>
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</div>
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</section>
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<p></p>
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<section class="s_website_form" data-vcss="001" data-snippet="s_website_form">
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<div class="container s_allow_columns">
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<div class="row">
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<div class="col-lg-8 mt-4 mt-lg-0">
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<section class="s_website_form" data-vcss="001" data-snippet="s_website_form">
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<div class="container">
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<form id="contactus_form" action="/assessment_request/submit" method="post" enctype="multipart/form-data" class="o_mark_required" data-mark="*" data-model_name="mail.mail" data-success-mode="redirect" data-success-page="/contactus-thank-you" data-pre-fill="true">
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<div class="s_website_form_rows row s_col_no_bgcolor">
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="applicant_name">
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<span class="s_website_form_label_content">Applicant's Full Name: </span>
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</label>
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<div class="col-sm">
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<input id="applicant_name" type="text" class="form-control s_website_form_input" name="applicant_name" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="date" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="birth_date">
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<span class="s_website_form_label_content">Birth Date: </span>
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</label>
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<div class="col-sm">
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<input id="birth_date" type="date" class="form-control s_website_form_input" name="birth_date" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="date" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="male">
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<span class="s_website_form_label_content">Gender: </span>
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</label>
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<div class="col-sm">
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<input type="radio" id="male" name="gender" value="male" required=""/>
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<label for="male">Male</label>
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<input type="radio" id="female" name="gender" value="female"/>
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<label for="female">Female</label>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="street">
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<span class="s_website_form_label_content">Applicant Address: </span>
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</label>
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<div class="col-sm">
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<input id="street" type="text" class="form-control s_website_form_input o_address_street" name="street" placeholder="Street" required=""/>
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<input id="city" type="text" class="form-control s_website_form_input o_address_city" name="city" placeholder="City" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="subject">
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<span class="s_website_form_label_content">Subject: </span>
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</label>
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<div class="col-sm">
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<input id="subject" type="text" class="form-control s_website_form_input" name="subject" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="marital_status">
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<span class="s_website_form_label_content">Marital Status: </span>
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</label>
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<div class="col-sm">
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<select id="marital_status" class="form-control s_website_form_input" name="marital_status">
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<option value="married">Married</option>
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<option value="single">Single</option>
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<option value="separated">Separated</option>
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<option value="widowed">Widowed</option>
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<option value="divorced">Divorced</option>
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</select>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="living_arrangement">
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<span class="s_website_form_label_content">Present Living Arrangements: </span>
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</label>
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<div class="col-sm">
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<select id="living_arrangement" class="form-control s_website_form_input" name="living_arrangement">
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<option value="with_relative">With Relative</option>
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<option value="non_relative">With Non-Relative</option>
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<option value="home_alone">Alone(Home/Apartment)</option>
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<option value="alone_single">Alone(Single Room)</option>
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</select>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="medicaid">
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<span class="s_website_form_label_content">Medicaid#: </span>
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</label>
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<div class="col-sm">
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<input id="medicaid" type="number" class="form-control s_website_form_input" name="medicaid"/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="medicare">
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<span class="s_website_form_label_content">Medicare#: </span>
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</label>
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<div class="col-sm">
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<input id="medicare" type="number" class="form-control s_website_form_input" name="medicare"/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="sup_sec_income">
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<span class="s_website_form_label_content">Supplemental Security Income: </span>
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</label>
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<div class="col-sm">
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<input id="sup_sec_income" type="number" class="form-control s_website_form_input" name="sup_sec_income"/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="why_interest">
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<span class="s_website_form_label_content">Tell us why you are interested in joining this program?: </span>
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</label>
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<div class="col-sm">
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<input id="why_interest" type="text" class="form-control s_website_form_input" name="why_interest"/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="date" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="yes">
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<span class="s_website_form_label_content">Have you had previous experience in an adult day care program?: </span>
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</label>
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<div class="col-sm">
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<input type="radio" id="yes" name="experience" value="yes" required=""/>
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<label for="yes">Yes</label>
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<input type="radio" id="no" name="experience" value="no"/>
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<label for="no">No</label>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="where_when">
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<span class="s_website_form_label_content">If yes, Where and when?: </span>
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</label>
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<div class="col-sm">
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<input id="where_when" type="text" class="form-control s_website_form_input" name="where_when"/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="living_with_whom">
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<span class="s_website_form_label_content">Living with whom: </span>
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</label>
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<div class="col-sm">
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<input id="living_with_whom" type="text" class="form-control s_website_form_input" name="living_with_whom" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="relation_with_living">
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<span class="s_website_form_label_content">Relationship with whom their living: </span>
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</label>
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<div class="col-sm">
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<input id="relation_with_living" type="text" class="form-control s_website_form_input" name="relation_with_living" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="nearest_relative">
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<span class="s_website_form_label_content">Nearest responsible relative: </span>
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</label>
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<div class="col-sm">
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<input id="nearest_relative" type="text" class="form-control s_website_form_input" name="nearest_relative" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="nearest_relative_relation">
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<span class="s_website_form_label_content">Relationship to nearest relative: </span>
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</label>
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<div class="col-sm">
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<input id="nearest_relative_relation" type="text" class="form-control s_website_form_input" name="nearest_relative_relation" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="employed_where">
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<span class="s_website_form_label_content">If employed, Where: </span>
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</label>
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<div class="col-sm">
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<input id="employed_where" type="text" class="form-control s_website_form_input" name="employed_where"/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="business_phone">
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<span class="s_website_form_label_content">Business Phone: </span>
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</label>
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<div class="col-sm">
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<input id="business_phone" type="text" class="form-control s_website_form_input" name="business_phone"/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="emergency_contact_1">
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<span class="s_website_form_label_content">Emergency Contact#1: </span>
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</label>
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<div class="col-sm">
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<input id="emergency_contact_1" type="text" class="form-control s_website_form_input" name="emergency_contact_1" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="applicant_relation_1">
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<span class="s_website_form_label_content">Applicant Relationship#1: </span>
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</label>
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<div class="col-sm">
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<input id="applicant_relation_1" type="text" class="form-control s_website_form_input" name="applicant_relation_1" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="emergency_address_1">
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<span class="s_website_form_label_content">Emergency Address#1: </span>
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</label>
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<div class="col-sm">
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<input id="emergency_address_1" type="text" class="form-control s_website_form_input" name="emergency_address_1" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="emergency_phone_1">
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<span class="s_website_form_label_content">Emergency Phone#1: </span>
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</label>
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<div class="col-sm">
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<input id="emergency_phone_1" type="text" class="form-control s_website_form_input" name="emergency_phone_1" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="emergency_contact_2">
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<span class="s_website_form_label_content">Emergency Contact#2: </span>
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</label>
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<div class="col-sm">
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<input id="emergency_contact_2" type="text" class="form-control s_website_form_input" name="emergency_contact_2" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="applicant_relation_2">
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<span class="s_website_form_label_content">Applicant Relationship#2: </span>
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</label>
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<div class="col-sm">
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<input id="applicant_relation_2" type="text" class="form-control s_website_form_input" name="applicant_relation_2" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="emergency_address_2">
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<span class="s_website_form_label_content">Emergency Address#2: </span>
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</label>
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<div class="col-sm">
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<input id="emergency_address_2" type="text" class="form-control s_website_form_input" name="emergency_address_2" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="emergency_phone_2">
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<span class="s_website_form_label_content">Emergency Phone#2: </span>
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</label>
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<div class="col-sm">
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<input id="emergency_phone_2" type="text" class="form-control s_website_form_input" name="emergency_phone_2" required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="physician_name">
|
|
<span class="s_website_form_label_content">Physician Name: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="physician_name" type="text" class="form-control s_website_form_input" name="physician_name" required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="physician_address">
|
|
<span class="s_website_form_label_content">Physician Address: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="physician_address" type="text" class="form-control s_website_form_input" name="physician_address" required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="physician_phone">
|
|
<span class="s_website_form_label_content">Physician Phone: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="physician_phone" type="text" class="form-control s_website_form_input" name="physician_phone" required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="date" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="physician_last_visit">
|
|
<span class="s_website_form_label_content">Physician Last Visit: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="physician_last_visit" type="date" class="form-control s_website_form_input" name="physician_last_visit" required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="dentist_name">
|
|
<span class="s_website_form_label_content">Dentist Name: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="dentist_name" type="text" class="form-control s_website_form_input" name="dentist_name" required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="dentist_address">
|
|
<span class="s_website_form_label_content">Dentist Address: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="dentist_address" type="text" class="form-control s_website_form_input" name="dentist_address" required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="dentist_phone">
|
|
<span class="s_website_form_label_content">Dentist Phone: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="dentist_phone" type="text" class="form-control s_website_form_input" name="dentist_phone" required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="date" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="dentist_last_visit">
|
|
<span class="s_website_form_label_content">Dentist Last Visit: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="dentist_last_visit" type="date" class="form-control s_website_form_input" name="dentist_last_visit" required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="transport_provider">
|
|
<span class="s_website_form_label_content">Transportation will be provided by: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<select id="transport_provider" class="form-control s_website_form_input" name="transport_provider">
|
|
<option value="relative_friend">Relative or Friend</option>
|
|
<option value="public_transport">Public Transportation</option>
|
|
<option value="blessed_assurance">Blessed Assurance</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="int" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="arrive_time">
|
|
<span class="s_website_form_label_content">Arrive Time: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="arrive_time" type="number" class="form-control s_website_form_input" name="arrive_time"/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="int" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="departure_time">
|
|
<span class="s_website_form_label_content">Departure Time: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="departure_time" type="number" class="form-control s_website_form_input" name="departure_time"/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="date" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="yes">
|
|
<span class="s_website_form_label_content">Special Diet?: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input type="radio" id="yes" name="diet" value="yes" required=""/>
|
|
<label for="yes">Yes</label>
|
|
<input type="radio" id="no" name="diet" value="no"/>
|
|
<label for="no">No</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="diet_detail">
|
|
<span class="s_website_form_label_content">If yes, give details: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="diet_detail" type="text" class="form-control s_website_form_input" name="diet_detail"/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="allergies">
|
|
<span class="s_website_form_label_content">List all allergies: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="allergies" type="text" class="form-control s_website_form_input" name="allergies"/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="request_assurance">
|
|
<span class="s_website_form_label_content">Days and times requested to be at Blessed Assurance: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="request_assurance" type="text" class="form-control s_website_form_input" name="request_assurance"/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="paid_by">
|
|
<span class="s_website_form_label_content">I acknowledge that the participation in this program will be paid by : </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<select id="paid_by" class="form-control s_website_form_input" name="paid_by">
|
|
<option value="myself">Myself</option>
|
|
<option value="relative">Relative</option>
|
|
<option value="another_party">Another Party</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="paid_by_name">
|
|
<span class="s_website_form_label_content">Give name of person/party responsible that is mentioned above: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="paid_by_name" type="text" class="form-control s_website_form_input" name="paid_by_name" required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="paid_by_phone">
|
|
<span class="s_website_form_label_content">Phone number of person to pay bill: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="paid_by_phone" type="text" class="form-control s_website_form_input" name="paid_by_phone" required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="email">
|
|
<span class="s_website_form_label_content">Your Email: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="email" type="email" class="form-control s_website_form_input" name="email" required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="hospital_choice">
|
|
<span class="s_website_form_label_content">If emergency medical care becomes necessary, I give permission for any treatment the physician deems necessary. My hospital choice is: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="hospital_choice" type="text" class="form-control s_website_form_input" name="hospital_choice" placeholder="e.g.City Life Hospital"/>
|
|
<span>But I (the applicant) may be treated at the nearest facility if the emergency deems it necessary.</span>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required" data-type="char" data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label" style="width: 200px" for="digital_sign">
|
|
<span class="s_website_form_label_content">By entering your full name, you are digitally signing this form: </span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="digital_sign" type="text" class="form-control s_website_form_input" name="digital_sign" required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_submit" data-name="Submit Button">
|
|
<div style="width: 200px;" class="s_website_form_label"/>
|
|
<button type="submit" class="btn btn-primary">Submit</button>
|
|
</div>
|
|
</div>
|
|
</form>
|
|
</div>
|
|
</section>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</section>
|
|
</div>
|
|
</t>
|
|
</template>
|
|
|
|
<template id="assessment_request_submit_template" name="Assessment Request Submitted">
|
|
<t t-call="website.layout">
|
|
<div id="wrap" class="oe_structure oe_empty">
|
|
<section class="s_title parallax s_parallax_is_fixed bg-black-50 pt24 pb24" data-vcss="001" data-snippet="s_title" data-scroll-background-ratio="1">
|
|
<span class="s_parallax_bg oe_img_bg" style="background-image: url('/web/image/website.s_banner_default_image'); background-position: 50% 0;"/>
|
|
<div class="o_we_bg_filter bg-black-50"/>
|
|
<div class="container">
|
|
<h1>Assessment Request Form</h1>
|
|
</div>
|
|
</section>
|
|
<p></p>
|
|
<section class="s_website_form" data-vcss="001" data-snippet="s_website_form">
|
|
<div class="container s_allow_columns">
|
|
<div class="row">
|
|
<div class="col-lg-8 mt-4 mt-lg-0">
|
|
<div class="alert alert-success">
|
|
Your Day Care Assessment Request is "<t t-esc="lead['name']"/>".<br/>
|
|
Please Note it for further communication.<br/>
|
|
You Will Receive Email from our Team shortly.<br/>
|
|
Please reply to that mail for feature conversation.<br/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</section>
|
|
</div>
|
|
</t>
|
|
</template>
|
|
|
|
</odoo>
|