Domain Name: SENDGRID.NET
Registry Domain ID: 1552841547_DOMAIN_NET-VRSN
Registrar WHOIS Server: whois.godaddy.com
Registrar URL: https://www.godaddy.com
Updated Date: 2021-04-19T10:49:41Z
Creation Date: 2009-04-20T04:09:23Z
Registrar Registration Expiration Date: 2026-04-20T04:09:23Z
Registrar: GoDaddy.com, LLC
Registrar IANA ID: 146
Registrar Abuse Contact Email: abuse@godaddy.com
Registrar Abuse Contact Phone: +1.4806242505
Domain Status: ok https://icann.org/epp#ok
Registry Registrant ID: Not Available From Registry
Registrant Name: Operations Team
Registrant Organization: SendGrid, Inc
Registrant Street: 1801 California Street
Registrant Street: Suite 500
Registrant City: Denver
Registrant State/Province: Colorado
Registrant Postal Code: 80202
Registrant Country: US
Registrant Phone: +1.8779698647
Registrant Phone Ext:
Registrant Fax: 
Registrant Fax Ext:
Registrant Email: domains-abuse@sendgrid.com
Registry Admin ID: Not Available From Registry
Admin Name: Operations Team
Admin Organization: SendGrid, Inc
Admin Street: 1801 California Street
Admin Street: Suite 500
Admin City: Denver
Admin State/Province: Colorado
Admin Postal Code: 80202
Admin Country: US
Admin Phone: +1.8779698647
Admin Phone Ext:
Admin Fax: 
Admin Fax Ext:
Admin Email: domains-abuse@sendgrid.com
Registry Tech ID: Not Available From Registry
Tech Name: Operations Team
Tech Organization: SendGrid, Inc
Tech Street: 1801 California Street
Tech Street: Suite 500
Tech City: Denver
Tech State/Province: Colorado
Tech Postal Code: 80202
Tech Country: US
Tech Phone: +1.8779698647
Tech Phone Ext:
Tech Fax: 
Tech Fax Ext:
Tech Email: domains-abuse@sendgrid.com
Name Server: NS10.DNSMADEEASY.COM
Name Server: NS11.DNSMADEEASY.COM
Name Server: NS12.DNSMADEEASY.COM
Name Server: NS13.DNSMADEEASY.COM
Name Server: NS14.DNSMADEEASY.COM
Name Server: NS15.DNSMADEEASY.COM
DNSSEC: unsigned
URL of the ICANN WHOIS Data Problem Reporting System: http://wdprs.internic.net/
>>> Last update of WHOIS database: 2022-11-17T06:02:51Z <<<
For more information on Whois status codes, please visit https://icann.org/epp

TERMS OF USE: The data contained in this registrar's Whois database, while believed by the
registrar to be reliable, is provided "as is" with no guarantee or warranties regarding its
accuracy. This information is provided for the sole purpose of assisting you in obtaining
information about domain name registration records. Any use of this data for any other purpose
is expressly forbidden without the prior written permission of this registrar. By submitting
an inquiry, you agree to these terms and limitations of warranty. In particular, you agree not
to use this data to allow, enable, or otherwise support the dissemination or collection of this
data, in part or in its entirety, for any purpose, such as transmission by e-mail, telephone,
postal mail, facsimile or other means of mass unsolicited, commercial advertising or solicitations
of any kind, including spam. You further agree not to use this data to enable high volume, automated
or robotic electronic processes designed to collect or compile this data for any purpose, including
mining this data for your own personal or commercial purposes. Failure to comply with these terms
may result in termination of access to the Whois database. These terms may be subject to modification
at any time without notice.

                             

• GET

  200 OK

  https://cdn.jotfor.ms/assets/img/favicons/favicon-2021.svg

• https://u5703377.ct.sendgrid.net/ls/click?upn=7Ya-2FPhprBUn-2Fuf67h71LbY0Vgj1AfQj0raadUELbyJxk-2BtO5gpaes2oxoaKsnUjsgmkEiAQCrQOrmu9FRR-2FPNA-3D-3D1iAn_Zu8CgfnIpVXFBI5dhwwl7XzbuxF4K0wfvlXPE5rXMa5HceNRUWCyU-2F05HlDUNN4z4-2BJPXOZFDvzzn-2FmXX-2BvbMNWkLz-2Bm7MEmEpppdFUgEcL8tgr8FWtdZdiFWC7S5MjVUE7ZJ-2BqsJU5Ww6jur9pTYNoW2VWQAODYkbomMgssTRDEcUfM1Hb69j-2FbrNdvhLfreyorgUYzZfWC4we9wbE-2BWg-3D-3D https://hipaa.jotform.com/210894839288170
• https://www.jotform.com/uploads/tiffanycompounding/form_files/Tiffany-Logo-B-W%20(1)%20(1).6036c95e51cff2.05939698.jpg https://files.jotform.com/jufs/tiffanycompounding/form_files/Tiffany-Logo-B-W%20(1)%20(1).6036c95e51cff2.05939698.jpg?md5=MrLVTzwYlckSrmUuXyQSOA&expires=1668664979

<html class="supernova"><head>
<script>console.warn("Server Side Rendering => render-from ==> \n frontend");</script>

<meta http-equiv="Content-Type" content="text/html; charset=utf-8">
<link rel="alternate" type="application/json+oembed" href="https://www.jotform.com/oembed/?format=json&amp;url=https%3A%2F%2Fform.jotform.com%2F210894839288170" title="oEmbed Form">
<link rel="alternate" type="text/xml+oembed" href="https://www.jotform.com/oembed/?format=xml&amp;url=https%3A%2F%2Fform.jotform.com%2F210894839288170" title="oEmbed Form">
<meta property="og:title" content="COVID Vaccine Consent Form - (Insert store)">
<meta property="og:url" content="https://form.jotform.com/210894839288170">
<meta property="og:description" content="Please click the link to complete this form.">
<meta name="slack-app-id" content="AHNMASS8M">
<meta data-name="preventCloning" content="1">
<link rel="shortcut icon" href="https://cdn.jotfor.ms/assets/img/favicons/favicon-2021.svg">
<meta property="og:image" content="https://cdn.jotfor.ms/assets/img/favicons/favicon-2021.svg">
<link rel="canonical" href="https://form.jotform.com/210894839288170">
<meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=2.0, user-scalable=1">
<meta name="HandheldFriendly" content="true">
<title>COVID Vaccine Consent Form - (Insert store)</title>
<link href="https://cdn01.jotfor.ms/static/formCss.css?3.3.37190" rel="stylesheet" type="text/css">
<style type="text/css">@media print{.form-section{display:inline!important}.form-pagebreak{display:none!important}.form-section-closed{height:auto!important}.page-section{position:initial!important}}</style>
<link type="text/css" rel="stylesheet" href="https://cdn02.jotfor.ms/css/styles/nova.css?3.3.37190">
<link type="text/css" rel="stylesheet" href="https://cdn03.jotfor.ms/themes/CSS/566a91c2977cdfcd478b4567.css?themeRevisionID=5f6c4c83346ec05354558fe8">
<link type="text/css" rel="stylesheet" href="https://cdn01.jotfor.ms/css/styles/payment/payment_feature.css?3.3.37190">
<style type="text/css">
    .form-label-left{
        width:147px;
    }
    .form-line{
        padding-top:0px;
        padding-bottom:0px;
    }
    .form-label-right{
        width:147px;
    }
    body, html{
        margin:0;
        padding:0;
        background:#fff;
    }

    .form-all{
        margin:0px auto;
        padding-top:0px;
        width:690px;
        color:#000000 !important;
        font-family:'Verdana';
        font-size:14px;
    }
    .form-radio-item label, .form-checkbox-item label, .form-grading-label, .form-header{
        color: false;
    }

</style>

<style type="text/css" id="form-designer-style">
    /* Injected CSS Code */
.form-all:after {
  content: "";
  display: table;
  clear: both;
}
.form-all {
  font-family: "Verdana", sans-serif;
}
.form-all {
  width: 690px;
}
.form-label-left,
.form-label-right {
  width: 147px;
}
.form-label {
  white-space: normal;
}
.form-label.form-label-auto {
  display: block;
  float: none;
  word-break: break-word;
  text-align: left;
}
.form-label-left {
  display: inline-block;
  white-space: normal;
  float: left;
  text-align: left;
}
.form-label-right {
  display: inline-block;
  white-space: normal;
  float: left;
  text-align: right;
}
.form-label-top {
  white-space: normal;
  display: block;
  float: none;
  text-align: left;
}
.form-radio-item label:before {
  top: 0;
}
.form-all {
  font-size: 14px;
}
.form-label {
  font-weight: bold;
}
.form-checkbox-item label,
.form-radio-item label {
  font-weight: normal;
}
.supernova {
  background-color: #ffffff;
  background-color: #ed5f93;
}
.supernova body {
  background-color: transparent;
}
/*
@width30: (unit(@formWidth, px) + 60px);
@width60: (unit(@formWidth, px)+ 120px);
@width90: (unit(@formWidth, px)+ 180px);
*/
/* | */
@media screen and (min-width: 480px) {
  .supernova .form-all {
    border: 1px solid #e83174;
    box-shadow: 0 3px 9px rgba(0, 0, 0, 0.1);
  }
}
/* | */
/* | */
@media screen and (max-width: 480px) {
  .jotform-form .form-all {
    margin: 0;
    width: 100%;
  }
}
/* | */
/* | */
@media screen and (min-width: 480px) and (max-width: 767px) {
  .jotform-form .form-all {
    margin: 0;
    width: 100%;
  }
}
/* | */
/* | */
@media screen and (min-width: 480px) and (max-width: 689px) {
  .jotform-form .form-all {
    margin: 0;
    width: 100%;
  }
}
/* | */
/* | */
@media screen and (min-width: 768px) {
  .jotform-form {
    padding: 60px 0;
  }
}
/* | */
/* | */
@media screen and (max-width: 689px) {
  .jotform-form .form-all {
    margin: 0;
    width: 100%;
  }
}
/* | */
.supernova .form-all,
.form-all {
  background-color: #ffffff;
  border: 1px solid transparent;
}
.form-header-group {
  border-color: #e6e6e6;
}
.form-matrix-table tr {
  border-color: #e6e6e6;
}
.form-matrix-table tr:nth-child(2n) {
  background-color: #f2f2f2;
}
.form-all {
  color: #000000;
}
.form-header-group .form-header {
  color: #000000;
}
.form-header-group .form-subHeader {
  color: #1a1a1a;
}
.form-sub-label {
  color: #1a1a1a;
}
.form-label-top,
.form-label-left,
.form-label-right,
.form-html {
  color: #000000;
}
.form-checkbox-item label,
.form-radio-item label {
  color: #1a1a1a;
}
.form-line.form-line-active {
  -webkit-transition-property: all;
  -moz-transition-property: all;
  -ms-transition-property: all;
  -o-transition-property: all;
  transition-property: all;
  -webkit-transition-duration: 0.3s;
  -moz-transition-duration: 0.3s;
  -ms-transition-duration: 0.3s;
  -o-transition-duration: 0.3s;
  transition-duration: 0.3s;
  -webkit-transition-timing-function: ease;
  -moz-transition-timing-function: ease;
  -ms-transition-timing-function: ease;
  -o-transition-timing-function: ease;
  transition-timing-function: ease;
  background-color: #ffffe0;
}
/* omer */
.form-radio-item,
.form-checkbox-item {
  padding-bottom: 0px !important;
}
.form-radio-item:last-child,
.form-checkbox-item:last-child {
  padding-bottom: 0;
}
/* omer */
.form-single-column .form-checkbox-item,
.form-single-column .form-radio-item {
  width: 100%;
}
.form-checkbox-item .editor-container div,
.form-radio-item .editor-container div {
  position: relative;
}
.form-checkbox-item .editor-container div:before,
.form-radio-item .editor-container div:before {
  display: inline-block;
  vertical-align: middle;
  box-sizing: border-box;
  left: 0;
  width: 18px;
  height: 18px;
}
.form-checkbox-item,
.form-radio-item {
  padding-left: 2px;
}
.form-checkbox-item input,
.form-radio-item input {
  margin-top: 2px;
}
.supernova {
  height: 100%;
  background-repeat: no-repeat;
  background-attachment: scroll;
  background-position: center top;
  background-repeat: repeat;
}
.supernova {
  background-image: none;
}
#stage {
  background-image: none;
}
/* | */
.form-all {
  background-repeat: no-repeat;
  background-attachment: scroll;
  background-position: center top;
  background-repeat: repeat;
}
.form-header-group {
  background-repeat: no-repeat;
  background-attachment: scroll;
  background-position: center top;
}
.form-line {
  margin-top: 0px;
  margin-bottom: 0px;
}
.form-line {
  padding: 3px 15px;
}
.form-all {
  border-radius: 6px;
}
.form-section:first-child {
  border-radius: 6px 6px 0 0;
}
.form-section:last-child {
  border-radius: 0 0 6px 6px;
}
.form-all .qq-upload-button,
.form-all .form-submit-button,
.form-all .form-submit-reset,
.form-all .form-submit-print {
  font-size: 1em;
  padding: 9px 15px;
  font-family: "Verdana", sans-serif;
  font-size: 14px;
  font-weight: normal;
}
.form-all .form-pagebreak-back,
.form-all .form-pagebreak-next {
  font-size: 1em;
  padding: 9px 15px;
  font-family: "Verdana", sans-serif;
  font-size: 14px;
  font-weight: normal;
}
/*
& when ( @buttonFontType = google ) {
	@import (css) "@{buttonFontLink}";
}
*/
h2.form-header {
  line-height: 1.618em;
  font-size: 1.714em;
}
h2 ~ .form-subHeader {
  line-height: 1.5em;
  font-size: 1.071em;
}
.form-header-group {
  text-align: left;
}
/*.form-dropdown,
.form-radio-item,
.form-checkbox-item,
.form-radio-other-input,
.form-checkbox-other-input,*/
.form-captcha input,
.form-spinner input,
.form-error-message {
  padding: 4px 3px 2px 3px;
}
.form-header-group {
  font-family: "Verdana", sans-serif;
}
.form-section {
  padding: 0px 0px 0px 0px;
}
.form-header-group {
  margin: 2px 36px 2px 36px;
}
.form-header-group {
  padding: 23px 0px 23px 0px;
}
.form-textbox,
.form-textarea {
  border-style: solid;
  border-color: #cccccc;
  padding: 4px 3px 2px 3px;
}
.form-textbox,
.form-textarea,
.form-radio-other-input,
.form-checkbox-other-input,
.form-captcha input,
.form-spinner input {
  background-color: #ffffff;
}
.form-matrix-row-headers,
.form-matrix-column-headers,
.form-matrix-values {
  padding: 4px;
}
[data-type="control_dropdown"] .form-input,
[data-type="control_dropdown"] .form-input-wide {
  width: 150px;
}
.form-label {
  font-family: "Verdana", sans-serif;
}
li[data-type="control_image"] div {
  text-align: left;
}
li[data-type="control_image"] img {
  border: none;
  border-width: 0px !important;
  border-style: solid !important;
  border-color: false !important;
}
.form-line-column {
  width: auto;
}
.form-line-error {
  overflow: hidden;
  -webkit-transition-property: none;
  -moz-transition-property: none;
  -ms-transition-property: none;
  -o-transition-property: none;
  transition-property: none;
  -webkit-transition-duration: 0.3s;
  -moz-transition-duration: 0.3s;
  -ms-transition-duration: 0.3s;
  -o-transition-duration: 0.3s;
  transition-duration: 0.3s;
  -webkit-transition-timing-function: ease;
  -moz-transition-timing-function: ease;
  -ms-transition-timing-function: ease;
  -o-transition-timing-function: ease;
  transition-timing-function: ease;
  background-color: #fff4f4;
}
.form-line-error .form-error-message {
  background-color: #ff3200;
  clear: both;
  float: none;
}
.form-line-error .form-error-message .form-error-arrow {
  border-bottom-color: #ff3200;
}
.form-line-error input:not(#coupon-input),
.form-line-error textarea,
.form-line-error .form-validation-error {
  border: 1px solid #ff3200;
  box-shadow: 0 0 3px #ff3200;
}
.ie-8 .form-all {
  margin-top: auto;
  margin-top: initial;
}
.ie-8 .form-all:before {
  display: none;
}
[data-type="control_clear"] {
  display: none;
}
/* | */
@media screen and (max-width: 480px), screen and (max-device-width: 767px) and (orientation: portrait), screen and (max-device-width: 415px) and (orientation: landscape) {
  .testOne {
    letter-spacing: 0;
  }
  .form-all {
    border: 0;
    max-width: initial;
  }
  .form-sub-label-container {
    width: 100%;
    margin: 0;
    margin-right: 0;
    float: left;
    box-sizing: border-box;
  }
  span.form-sub-label-container + span.form-sub-label-container {
    margin-right: 0;
  }
  .form-sub-label {
    white-space: normal;
  }
  .form-address-table td,
  .form-address-table th {
    padding: 0 1px 10px;
  }
  .form-submit-button,
  .form-submit-print,
  .form-submit-reset {
    width: 100%;
    margin-left: 0!important;
  }
  div[id*=at_] {
    font-size: 14px;
    font-weight: 700;
    height: 8px;
    margin-top: 6px;
  }
  .showAutoCalendar {
    width: 20px;
  }
  img.form-image {
    max-width: 100%;
    height: auto;
  }
  .form-matrix-row-headers {
    width: 100%;
    word-break: break-all;
    min-width: 80px;
  }
  .form-collapse-table,
  .form-header-group {
    margin: 0;
  }
  .form-collapse-table {
    height: 100%;
    display: inline-block;
    width: 100%;
  }
  .form-collapse-hidden {
    display: none !important;
  }
  .form-input {
    width: 100%;
  }
  .form-label {
    width: 100% !important;
  }
  .form-label-left,
  .form-label-right {
    display: block;
    float: none;
    text-align: left;
    width: auto!important;
  }
  .form-line,
  .form-line.form-line-column {
    padding: 2% 5%;
    box-sizing: border-box;
  }
  input[type=text],
  input[type=email],
  input[type=tel],
  textarea {
    width: 100%;
    box-sizing: border-box;
    max-width: initial !important;
  }
  .form-radio-other-input,
  .form-checkbox-other-input {
    max-width: 55% !important;
  }
  .form-dropdown,
  .form-textarea,
  .form-textbox {
    width: 100%!important;
    box-sizing: border-box;
  }
  .form-input,
  .form-input-wide,
  .form-textarea,
  .form-textbox,
  .form-dropdown {
    max-width: initial!important;
  }
  .form-checkbox-item:not(#foo),
  .form-radio-item:not(#foo) {
    width: 100%;
  }
  .form-address-city,
  .form-address-line,
  .form-address-postal,
  .form-address-state,
  .form-address-table,
  .form-address-table .form-sub-label-container,
  .form-address-table select,
  .form-input {
    width: 100%;
  }
  div.form-header-group {
    padding: 23px 0px !important;
    margin: 0 2px 2% !important;
    margin-left: 5%!important;
    margin-right: 5%!important;
    box-sizing: border-box;
  }
  div.form-header-group.hasImage img {
    max-width: 100%;
  }
  [data-type="control_button"] {
    margin-bottom: 0 !important;
  }
  [data-type=control_fullname] .form-sub-label-container {
    width: 48%;
  }
  [data-type=control_fullname] .form-sub-label-container:first-child {
    margin-right: 4%;
  }
  [data-type=control_phone] .form-sub-label-container {
    width: 65%;
    margin-right: 0;
    margin-left: 0;
    float: left;
  }
  [data-type=control_phone] .form-sub-label-container:first-child {
    width: 31%;
    margin-right: 4%;
  }
  [data-type=control_datetime] .allowTime-container {
    width: 100%;
  }
  [data-type=control_datetime] .allowTime-container .form-sub-label-container {
    width: 24%!important;
    margin-left: 6%;
    margin-right: 0;
  }
  [data-type=control_datetime] .allowTime-container .form-sub-label-container:first-child {
    margin-left: 0;
  }
  [data-type=control_datetime] span + span + span > span:first-child {
    display: block;
    width: 100% !important;
  }
  [data-type=control_birthdate] .form-sub-label-container,
  [data-type=control_time] .form-sub-label-container {
    width: 27.3%!important;
    margin-right: 6% !important;
  }
  [data-type=control_time] .form-sub-label-container:last-child {
    width: 33.3%!important;
    margin-right: 0 !important;
  }
  .form-pagebreak-back-container,
  .form-pagebreak-next-container {
    min-height: 1px;
    width: 50% !important;
  }
  .form-pagebreak-back,
  .form-pagebreak-next,
  .form-product-item.hover-product-item {
    width: 100%;
  }
  .form-pagebreak-back-container {
    padding: 0;
    text-align: right;
  }
  .form-pagebreak-next-container {
    padding: 0;
    text-align: left;
  }
  .form-pagebreak {
    margin: 0 auto;
  }
  .form-buttons-wrapper {
    margin: 0!important;
    margin-left: 0!important;
  }
  .form-buttons-wrapper button {
    width: 100%;
  }
  .form-buttons-wrapper .form-submit-print {
    margin: 0 !important;
  }
  table {
    width: 100%!important;
    max-width: initial!important;
  }
  table td + td {
    padding-left: 3%;
  }
  .form-checkbox-item,
  .form-radio-item {
    white-space: normal!important;
  }
  .form-checkbox-item input,
  .form-radio-item input {
    width: auto;
  }
  .form-collapse-table {
    margin: 0 5%;
    display: block;
    zoom: 1;
    width: auto;
  }
  .form-collapse-table:before,
  .form-collapse-table:after {
    display: table;
    content: '';
    line-height: 0;
  }
  .form-collapse-table:after {
    clear: both;
  }
  .fb-like-box {
    width: 98% !important;
  }
  .form-error-message {
    clear: both;
    bottom: -10px;
  }
  .date-separate,
  .phone-separate {
    display: none;
  }
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span{color:#17255b;font-weight:700}.formAccountBox-line.forLogout{border-top:1px solid #f5f7f8}.fab-link{text-decoration:none;color:#17255b;display:inline-block}.formAccountBox-logout{text-decoration:none;color:#828589;display:inline-block}</style></head>
<body>
<form class="jotform-form" action="https://hipaa.jotform.com/submit/210894839288170/" method="post" enctype="multipart/form-data" name="form_210894839288170" id="210894839288170" accept-charset="utf-8" autocomplete="off" novalidate="true">
  <input type="hidden" name="formID" value="210894839288170">
  <input type="hidden" id="JWTContainer" value="">
  <input type="hidden" id="cardinalOrderNumber" value="">
  <div role="main" class="form-all">
    <ul class="form-section page-section">
      <li id="cid_1" class="form-input-wide" data-type="control_head">
        <div style="display:table;width:100%">
          <div class="form-header-group hasImage header-default" data-imagealign="Left">
            <div class="header-logo">
              <img src="https://www.jotform.com/uploads/tiffanycompounding/form_files/Tiffany-Logo-B-W (1) (1).6036c95e51cff2.05939698.jpg" alt="" class="header-logo-left" width="309">
            </div>
            <div class="header-text httal htvam">
              <h2 id="header_1" class="form-header" data-component="header">
                Vaccine Consent Form- Tiffany Natural Pharmacy
              </h2>
              <div id="subHeader_1" class="form-subHeader">
                * Please fill out the required details below
              </div>
            </div>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_69">
        <div id="cid_69" class="form-input-wide">
          <div id="text_69" class="form-html" data-component="text" tabindex="0">
            <p style="text-align: center;"><span style="color: #5084c1; background-color: #ffffff;"><strong>If you have remaining questions, please call us at <span style="background-color: #fffe54;">(908) 233-2200.</span></strong></span></p>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_66">
        <div id="cid_66" class="form-input-wide">
          <div id="text_66" class="form-html" data-component="text" tabindex="0">
            <p style="text-align: center;"><span style="color: #5084c1;"><strong><span style="background-color: #ffffff;"><em>**Vaccine supply is limited. Please <span style="text-decoration: underline;">keep your appointment</span> or call if you need to cancel or change it. Additionally, due to vaccine requirements, we may call you to see if you can come earlier or later. If you miss an appointment, no doses will be held to guarantee your dose.**</em></span></strong>&nbsp;</span></p>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_25">
        <div id="cid_25" class="form-input-wide">
          <div id="text_25" class="form-html" data-component="text" tabindex="0">
            <p><span style="text-decoration:underline;"><strong>Section I. Personal Information</strong></span></p>
          </div>
        </div>
      </li>
      <li class="form-line form-line-column form-col-1 jf-required" data-type="control_fullname" id="id_40">
        <label class="form-label form-label-top" id="label_40" for="first_40">
          Patient's Full Name:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_40" class="form-input-wide jf-required">
          <div data-wrapper-react="true" class="extended">
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
              <input type="text" id="first_40" name="q40_patientsFull[first]" class="form-textbox validate[required]" data-defaultvalue="" autocomplete="section-input_40 given-name" size="10" value="" data-component="first" aria-labelledby="label_40 sublabel_40_first" required="">
              <label class="form-sub-label" for="first_40" id="sublabel_40_first" style="min-height:13px" aria-hidden="false"> First Name </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="middle">
              <input type="text" id="middle_40" name="q40_patientsFull[middle]" class="form-textbox" data-defaultvalue="" autocomplete="section-input_40 additional-name" size="10" value="" data-component="middle" aria-labelledby="label_40 sublabel_40_middle" required="">
              <label class="form-sub-label" for="middle_40" id="sublabel_40_middle" style="min-height:13px" aria-hidden="false"> Ml </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
              <input type="text" id="last_40" name="q40_patientsFull[last]" class="form-textbox validate[required]" data-defaultvalue="" autocomplete="section-input_40 family-name" size="15" value="" data-component="last" aria-labelledby="label_40 sublabel_40_last" required="">
              <label class="form-sub-label" for="last_40" id="sublabel_40_last" style="min-height:13px" aria-hidden="false"> Last Name </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line form-line-column form-col-2 jf-required" data-type="control_datetime" id="id_39">
        <label class="form-label form-label-top" id="label_39" for="lite_mode_39">
          Date of Birth:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_39" class="form-input-wide jf-required">
          <div data-wrapper-react="true">
            <div style="display:none">
              <span class="form-sub-label-container" style="vertical-align:top">
                <input type="tel" class="form-textbox validate[required, limitDate]" id="month_39" name="q39_dateOf[month]" size="2" data-maxlength="2" data-age="" maxlength="2" value="" required="" autocomplete="section-input_39 off" aria-labelledby="label_39 sublabel_39_month">
                <span class="date-separate" aria-hidden="true">
                  &nbsp;/
                </span>
                <label class="form-sub-label" for="month_39" id="sublabel_39_month" style="min-height:13px" aria-hidden="false"> Month </label>
              </span>
              <span class="form-sub-label-container" style="vertical-align:top">
                <input type="tel" class="form-textbox validate[required, limitDate]" id="day_39" name="q39_dateOf[day]" size="2" data-maxlength="2" data-age="" maxlength="2" value="" required="" autocomplete="section-input_39 off" aria-labelledby="label_39 sublabel_39_day">
                <span class="date-separate" aria-hidden="true">
                  &nbsp;/
                </span>
                <label class="form-sub-label" for="day_39" id="sublabel_39_day" style="min-height:13px" aria-hidden="false"> Day </label>
              </span>
              <span class="form-sub-label-container" style="vertical-align:top">
                <input type="tel" class="form-textbox validate[required, limitDate]" id="year_39" name="q39_dateOf[year]" size="4" data-maxlength="4" data-age="" maxlength="4" value="" required="" autocomplete="section-input_39 off" aria-labelledby="label_39 sublabel_39_year">
                <label class="form-sub-label" for="year_39" id="sublabel_39_year" style="min-height:13px" aria-hidden="false"> Year </label>
              </span>
            </div>
            <span class="form-sub-label-container" style="vertical-align:top">
              <input type="text" class="form-textbox validate[required, limitDate, validateLiteDate]" id="lite_mode_39" size="12" data-maxlength="12" maxlength="12" data-age="" value="" required="" data-format="mmddyyyy" data-seperator="/" placeholder="mm/dd/yyyy" autocomplete="section-input_39 off" aria-labelledby="label_39">
              <img class="showAutoCalendar newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_39_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v1">
              <label class="form-sub-label" for="lite_mode_39" id="sublabel_39_litemode" style="min-height:13px" aria-hidden="false">  </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line form-line-column form-col-3 jf-required" data-type="control_textbox" id="id_41">
        <label class="form-label form-label-top" id="label_41" for="input_41">
          Age:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_41" class="form-input-wide jf-required">
          <input type="text" id="input_41" name="q41_age" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" size="20" value="" data-component="textbox" aria-labelledby="label_41" required="">
        </div>
      </li>
      <li class="form-line form-line-column form-col-4 jf-required" data-type="control_textbox" id="id_43">
        <label class="form-label form-label-top" id="label_43" for="input_43">
          Phone Number:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_43" class="form-input-wide jf-required">
          <input type="text" id="input_43" name="q43_phoneNumber" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" size="20" value="" placeholder="555-555-5555" data-component="textbox" aria-labelledby="label_43" required="">
        </div>
      </li>
      <li class="form-line form-line-column form-col-5 jf-required" data-type="control_radio" id="id_38">
        <label class="form-label form-label-top" id="label_38" for="input_38">
          Gender:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_38" class="form-input-wide jf-required">
          <div class="form-single-column" role="group" aria-labelledby="label_38" data-component="radio">
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_38" class="form-radio validate[required]" id="input_38_0" name="q38_gender" value="Male" required="">
              <label id="label_input_38_0" for="input_38_0"> Male </label>
            </span>
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_38" class="form-radio validate[required]" id="input_38_1" name="q38_gender" value="Female" required="">
              <label id="label_input_38_1" for="input_38_1"> Female </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line form-line-column form-col-6 jf-required" data-type="control_textbox" id="id_44">
        <label class="form-label form-label-top" id="label_44" for="input_44">
          Email:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_44" class="form-input-wide jf-required">
          <input type="text" id="input_44" name="q44_email" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" size="20" value="" placeholder="example@example.com" data-component="textbox" aria-labelledby="label_44" required="">
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_address" id="id_111" data-compound-hint="Street Address,,City,Postal/Zip Code,">
        <label class="form-label form-label-top form-label-auto" id="label_111" for="input_111_addr_line1">
          Address:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_111" class="form-input-wide jf-required">
          <div summary="" class="form-address-table jsTest-addressField">
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField">
              <span class="form-address-line form-address-street-line jsTest-address-lineField">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_111_addr_line1" name="q111_address111[addr_line1]" class="form-textbox validate[required] form-address-line" data-defaultvalue="" autocomplete="section-input_111 address-line1" value="" placeholder="Street Address" data-component="address_line_1" aria-labelledby="label_111 sublabel_111_addr_line1" required="">
                  <label class="form-sub-label" for="input_111_addr_line1" id="sublabel_111_addr_line1" style="min-height:13px" aria-hidden="false"> Street Address </label>
                </span>
              </span>
            </div>
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField" style="display:none">
              <span class="form-address-line form-address-street-line jsTest-address-lineField">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_111_addr_line2" name="q111_address111[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="section-input_111 off" value="" data-component="address_line_2" aria-labelledby="label_111 sublabel_111_addr_line2">
                  <label class="form-sub-label" for="input_111_addr_line2" id="sublabel_111_addr_line2" style="min-height:13px" aria-hidden="false"> Street Address Line 2 </label>
                </span>
              </span>
            </div>
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField">
              <span class="form-address-line form-address-city-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_111_city" name="q111_address111[city]" class="form-textbox validate[required] form-address-city" data-defaultvalue="" autocomplete="section-input_111 address-level2" value="" placeholder="City" data-component="city" aria-labelledby="label_111 sublabel_111_city" required="">
                  <label class="form-sub-label" for="input_111_city" id="sublabel_111_city" style="min-height:13px" aria-hidden="false"> City </label>
                </span>
              </span>
              <span class="form-address-line form-address-state-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <select class="form-dropdown validate[required] form-address-state" name="q111_address111[state]" id="input_111_state" data-component="state" required="" aria-labelledby="label_111 sublabel_111_state" autocomplete="section-input_111 address-level1">
                    <option selected="" value=""> Please Select </option>
                    <option value="Alabama"> Alabama </option>
                    <option value="Alaska"> Alaska </option>
                    <option value="Arizona"> Arizona </option>
                    <option value="Arkansas"> Arkansas </option>
                    <option value="California"> California </option>
                    <option value="Colorado"> Colorado </option>
                    <option value="Connecticut"> Connecticut </option>
                    <option value="Delaware"> Delaware </option>
                    <option value="District of Columbia"> District of Columbia </option>
                    <option value="Florida"> Florida </option>
                    <option value="Georgia"> Georgia </option>
                    <option value="Hawaii"> Hawaii </option>
                    <option value="Idaho"> Idaho </option>
                    <option value="Illinois"> Illinois </option>
                    <option value="Indiana"> Indiana </option>
                    <option value="Iowa"> Iowa </option>
                    <option value="Kansas"> Kansas </option>
                    <option value="Kentucky"> Kentucky </option>
                    <option value="Louisiana"> Louisiana </option>
                    <option value="Maine"> Maine </option>
                    <option value="Maryland"> Maryland </option>
                    <option value="Massachusetts"> Massachusetts </option>
                    <option value="Michigan"> Michigan </option>
                    <option value="Minnesota"> Minnesota </option>
                    <option value="Mississippi"> Mississippi </option>
                    <option value="Missouri"> Missouri </option>
                    <option value="Montana"> Montana </option>
                    <option value="Nebraska"> Nebraska </option>
                    <option value="Nevada"> Nevada </option>
                    <option value="New Hampshire"> New Hampshire </option>
                    <option value="New Jersey"> New Jersey </option>
                    <option value="New Mexico"> New Mexico </option>
                    <option value="New York"> New York </option>
                    <option value="North Carolina"> North Carolina </option>
                    <option value="North Dakota"> North Dakota </option>
                    <option value="Ohio"> Ohio </option>
                    <option value="Oklahoma"> Oklahoma </option>
                    <option value="Oregon"> Oregon </option>
                    <option value="Pennsylvania"> Pennsylvania </option>
                    <option value="Puerto Rico"> Puerto Rico </option>
                    <option value="Rhode Island"> Rhode Island </option>
                    <option value="South Carolina"> South Carolina </option>
                    <option value="South Dakota"> South Dakota </option>
                    <option value="Tennessee"> Tennessee </option>
                    <option value="Texas"> Texas </option>
                    <option value="Utah"> Utah </option>
                    <option value="Vermont"> Vermont </option>
                    <option value="Virgin Islands"> Virgin Islands </option>
                    <option value="Virginia"> Virginia </option>
                    <option value="Washington"> Washington </option>
                    <option value="West Virginia"> West Virginia </option>
                    <option value="Wisconsin"> Wisconsin </option>
                    <option value="Wyoming"> Wyoming </option>
                  </select>
                  <label class="form-sub-label" for="input_111_state" id="sublabel_111_state" style="min-height:13px" aria-hidden="false"> State </label>
                </span>
              </span>
            </div>
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField">
              <span class="form-address-line form-address-zip-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_111_postal" name="q111_address111[postal]" class="form-textbox validate[required] form-address-postal" data-defaultvalue="" autocomplete="section-input_111 postal-code" value="" placeholder="Postal/Zip Code" data-component="zip" aria-labelledby="label_111 sublabel_111_postal" required="">
                  <label class="form-sub-label" for="input_111_postal" id="sublabel_111_postal" style="min-height:13px" aria-hidden="false"> Zip Code </label>
                </span>
              </span>
            </div>
          </div>
        </div>
      </li>
      <li class="form-line form-line-column form-col-1 jf-required" data-type="control_radio" id="id_53">
        <label class="form-label form-label-top" id="label_53" for="input_53">
          Race:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_53" class="form-input-wide jf-required">
          <div class="form-single-column" role="group" aria-labelledby="label_53" data-component="radio">
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_53" class="form-radio validate[required]" id="input_53_0" name="q53_race53" value="American Indian/Alaska Native" required="">
              <label id="label_input_53_0" for="input_53_0"> American Indian/Alaska Native </label>
            </span>
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_53" class="form-radio validate[required]" id="input_53_1" name="q53_race53" value="Asian" required="">
              <label id="label_input_53_1" for="input_53_1"> Asian </label>
            </span>
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_53" class="form-radio validate[required]" id="input_53_2" name="q53_race53" value="Black/African American" required="">
              <label id="label_input_53_2" for="input_53_2"> Black/African American </label>
            </span>
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_53" class="form-radio validate[required]" id="input_53_3" name="q53_race53" value="Caucasian" required="">
              <label id="label_input_53_3" for="input_53_3"> Caucasian </label>
            </span>
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_53" class="form-radio validate[required]" id="input_53_4" name="q53_race53" value="Native Hawaiian/Other Pacific Islander" required="">
              <label id="label_input_53_4" for="input_53_4"> Native Hawaiian/Other Pacific Islander </label>
            </span>
            <span class="form-radio-item" style="clear:left">
              <input type="radio" class="form-radio-other form-radio validate[required]" name="q53_race53" id="other_53" value="other" tabindex="0" aria-label="Other">
              <label id="label_other_53" style="text-indent:0" for="other_53">  </label>
              <input type="text" class="form-radio-other-input form-textbox" name="q53_race53[other]" data-otherhint="Other" size="15" id="input_53" placeholder="Other">
              <br>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line form-line-column form-col-2 jf-required" data-type="control_radio" id="id_52">
        <label class="form-label form-label-top" id="label_52" for="input_52">
          Ethnicity:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_52" class="form-input-wide jf-required">
          <div class="form-single-column" role="group" aria-labelledby="label_52" data-component="radio">
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_52" class="form-radio validate[required]" id="input_52_0" name="q52_ethnicity52" value="Hispanic or Latino" required="">
              <label id="label_input_52_0" for="input_52_0"> Hispanic or Latino </label>
            </span>
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_52" class="form-radio validate[required]" id="input_52_1" name="q52_ethnicity52" value="Non Hispanic/Latino" required="">
              <label id="label_input_52_1" for="input_52_1"> Non Hispanic/Latino </label>
            </span>
            <span class="form-radio-item" style="clear:left">
              <input type="radio" class="form-radio-other form-radio validate[required]" name="q52_ethnicity52" id="other_52" value="other" tabindex="0" aria-label="Other">
              <label id="label_other_52" style="text-indent:0" for="other_52">  </label>
              <input type="text" class="form-radio-other-input form-textbox" name="q52_ethnicity52[other]" data-otherhint="Other" size="15" id="input_52" placeholder="Other">
              <br>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_textbox" id="id_106">
        <label class="form-label form-label-top form-label-auto" id="label_106" for="input_106">
          Primary Care Physician:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_106" class="form-input-wide jf-required">
          <input type="text" id="input_106" name="q106_primaryCare" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" size="20" value="" data-component="textbox" aria-labelledby="label_106" required="">
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_textbox" id="id_107">
        <label class="form-label form-label-top form-label-auto" id="label_107" for="input_107">
          Phone Number:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_107" class="form-input-wide jf-required">
          <input type="text" id="input_107" name="q107_phoneNumber107" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" size="20" value="" placeholder="555-555-5555" data-component="textbox" aria-labelledby="label_107" required="">
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_address" id="id_112" data-compound-hint="Street Address,,City,Postal/Zip Code,">
        <label class="form-label form-label-top form-label-auto" id="label_112" for="input_112_addr_line1">
          Address:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_112" class="form-input-wide jf-required">
          <div summary="" class="form-address-table jsTest-addressField">
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField">
              <span class="form-address-line form-address-street-line jsTest-address-lineField">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_112_addr_line1" name="q112_address[addr_line1]" class="form-textbox validate[required] form-address-line" data-defaultvalue="" autocomplete="section-input_112 address-line1" value="" placeholder="Street Address" data-component="address_line_1" aria-labelledby="label_112 sublabel_112_addr_line1" required="">
                  <label class="form-sub-label" for="input_112_addr_line1" id="sublabel_112_addr_line1" style="min-height:13px" aria-hidden="false"> Street Address </label>
                </span>
              </span>
            </div>
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField" style="display:none">
              <span class="form-address-line form-address-street-line jsTest-address-lineField">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_112_addr_line2" name="q112_address[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="section-input_112 off" value="" data-component="address_line_2" aria-labelledby="label_112 sublabel_112_addr_line2">
                  <label class="form-sub-label" for="input_112_addr_line2" id="sublabel_112_addr_line2" style="min-height:13px" aria-hidden="false"> Street Address Line 2 </label>
                </span>
              </span>
            </div>
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField">
              <span class="form-address-line form-address-city-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_112_city" name="q112_address[city]" class="form-textbox validate[required] form-address-city" data-defaultvalue="" autocomplete="section-input_112 address-level2" value="" placeholder="City" data-component="city" aria-labelledby="label_112 sublabel_112_city" required="">
                  <label class="form-sub-label" for="input_112_city" id="sublabel_112_city" style="min-height:13px" aria-hidden="false"> City </label>
                </span>
              </span>
              <span class="form-address-line form-address-state-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <select class="form-dropdown validate[required] form-address-state" name="q112_address[state]" id="input_112_state" data-component="state" required="" aria-labelledby="label_112 sublabel_112_state" autocomplete="section-input_112 address-level1">
                    <option selected="" value=""> Please Select </option>
                    <option value="Alabama"> Alabama </option>
                    <option value="Alaska"> Alaska </option>
                    <option value="Arizona"> Arizona </option>
                    <option value="Arkansas"> Arkansas </option>
                    <option value="California"> California </option>
                    <option value="Colorado"> Colorado </option>
                    <option value="Connecticut"> Connecticut </option>
                    <option value="Delaware"> Delaware </option>
                    <option value="District of Columbia"> District of Columbia </option>
                    <option value="Florida"> Florida </option>
                    <option value="Georgia"> Georgia </option>
                    <option value="Hawaii"> Hawaii </option>
                    <option value="Idaho"> Idaho </option>
                    <option value="Illinois"> Illinois </option>
                    <option value="Indiana"> Indiana </option>
                    <option value="Iowa"> Iowa </option>
                    <option value="Kansas"> Kansas </option>
                    <option value="Kentucky"> Kentucky </option>
                    <option value="Louisiana"> Louisiana </option>
                    <option value="Maine"> Maine </option>
                    <option value="Maryland"> Maryland </option>
                    <option value="Massachusetts"> Massachusetts </option>
                    <option value="Michigan"> Michigan </option>
                    <option value="Minnesota"> Minnesota </option>
                    <option value="Mississippi"> Mississippi </option>
                    <option value="Missouri"> Missouri </option>
                    <option value="Montana"> Montana </option>
                    <option value="Nebraska"> Nebraska </option>
                    <option value="Nevada"> Nevada </option>
                    <option value="New Hampshire"> New Hampshire </option>
                    <option value="New Jersey"> New Jersey </option>
                    <option value="New Mexico"> New Mexico </option>
                    <option value="New York"> New York </option>
                    <option value="North Carolina"> North Carolina </option>
                    <option value="North Dakota"> North Dakota </option>
                    <option value="Ohio"> Ohio </option>
                    <option value="Oklahoma"> Oklahoma </option>
                    <option value="Oregon"> Oregon </option>
                    <option value="Pennsylvania"> Pennsylvania </option>
                    <option value="Puerto Rico"> Puerto Rico </option>
                    <option value="Rhode Island"> Rhode Island </option>
                    <option value="South Carolina"> South Carolina </option>
                    <option value="South Dakota"> South Dakota </option>
                    <option value="Tennessee"> Tennessee </option>
                    <option value="Texas"> Texas </option>
                    <option value="Utah"> Utah </option>
                    <option value="Vermont"> Vermont </option>
                    <option value="Virgin Islands"> Virgin Islands </option>
                    <option value="Virginia"> Virginia </option>
                    <option value="Washington"> Washington </option>
                    <option value="West Virginia"> West Virginia </option>
                    <option value="Wisconsin"> Wisconsin </option>
                    <option value="Wyoming"> Wyoming </option>
                  </select>
                  <label class="form-sub-label" for="input_112_state" id="sublabel_112_state" style="min-height:13px" aria-hidden="false"> State </label>
                </span>
              </span>
            </div>
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField">
              <span class="form-address-line form-address-zip-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_112_postal" name="q112_address[postal]" class="form-textbox validate[required] form-address-postal" data-defaultvalue="" autocomplete="section-input_112 postal-code" value="" placeholder="Postal/Zip Code" data-component="zip" aria-labelledby="label_112 sublabel_112_postal" required="">
                  <label class="form-sub-label" for="input_112_postal" id="sublabel_112_postal" style="min-height:13px" aria-hidden="false"> Zip Code </label>
                </span>
              </span>
            </div>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_radio" id="id_72">
        <label class="form-label form-label-top form-label-auto" id="label_72" for="input_72">
          Are you a current customer of Tiffany Natural Pharmacy?
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_72" class="form-input-wide jf-required">
          <div class="form-single-column" role="group" aria-labelledby="label_72" data-component="radio">
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_72" class="form-radio validate[required]" id="input_72_0" name="q72_areYou72" value="Yes" required="">
              <label id="label_input_72_0" for="input_72_0"> Yes </label>
            </span>
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_72" class="form-radio validate[required]" id="input_72_1" name="q72_areYou72" value="No" required="">
              <label id="label_input_72_1" for="input_72_1"> No </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_radio" id="id_118">
        <label class="form-label form-label-top form-label-auto" id="label_118" for="input_118">
          Are you 18 years of age or older?
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_118" class="form-input-wide jf-required">
          <div class="form-single-column" role="group" aria-labelledby="label_118" data-component="radio">
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_118" class="form-radio validate[required]" id="input_118_0" name="q118_areYou" value="Yes" required="">
              <label id="label_input_118_0" for="input_118_0"> Yes </label>
            </span>
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" aria-describedby="label_118" class="form-radio validate[required]" id="input_118_1" name="q118_areYou" value="No" required="">
              <label id="label_input_118_1" for="input_118_1"> No </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_dropdown" id="id_94">
        <label class="form-label form-label-top form-label-auto" id="label_94" for="input_94">
          Which of the following best describes your work setting?
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_94" class="form-input-wide jf-required">
          <select class="form-dropdown validate[required]" id="input_94" name="q94_whichOf94" style="width:150px" data-component="dropdown" required="">
            <option value="">  </option>
            <option value="Agriculture"> Agriculture </option>
            <option value="Education"> Education </option>
            <option value="First responder"> First responder </option>
            <option value="Food service"> Food service </option>
            <option value="Healthcare"> Healthcare </option>
            <option value="Home services"> Home services </option>
            <option value="Hospitality"> Hospitality </option>
            <option value="Long term care or other group setting "> Long term care or other group setting </option>
            <option value="Postal/shipping service"> Postal/shipping service </option>
            <option value="Public safety"> Public safety </option>
            <option value="Real estate"> Real estate </option>
            <option value="Retail finance"> Retail finance </option>
            <option value="Sanitation"> Sanitation </option>
            <option value="Social services"> Social services </option>
            <option value="Transportation"> Transportation </option>
            <option value="Utilities"> Utilities </option>
            <option value="Warehousing/logistics"> Warehousing/logistics </option>
            <option value="None of the above"> None of the above </option>
          </select>
        </div>
      </li>
      <li class="form-line always-hidden jf-required" data-type="control_dropdown" id="id_95">
        <label class="form-label form-label-top form-label-auto" id="label_95" for="input_95">
          Which of the following best describes your health status?
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_95" class="form-input-wide always-hidden jf-required">
          <select class="form-dropdown validate[required]" id="input_95" name="q95_whichOf" style="width:150px" data-component="dropdown" required="">
            <option value="">  </option>
            <option value="Person over age 55"> Person over age 55 </option>
            <option value="Person age 18-54 with chronic condition(s)"> Person age 18-54 with chronic condition(s) </option>
            <option value="None of the above"> None of the above </option>
          </select>
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_73">
        <label class="form-label form-label-top form-label-auto" id="label_73" for="input_73"> If resident of a care facility or other group setting, please indicate facility name and room #: </label>
        <div id="cid_73" class="form-input-wide">
          <input type="text" id="input_73" name="q73_ifResident73" data-type="input-textbox" class="form-textbox" data-defaultvalue="" size="20" value="" data-component="textbox" aria-labelledby="label_73">
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_24">
        <div id="cid_24" class="form-input-wide">
          <div id="text_24" class="form-html" data-component="text" tabindex="0">
            <p><span style="text-decoration:underline;"><strong>Section II. Questionnaire for Immunization</strong></span></p>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_matrix" id="id_7">
        <label class="form-label form-label-top" id="label_7" for="input_7">
          Please select the correct option below:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_7" class="form-input-wide jf-required">
          <table summary="" aria-labelledby="label_7" class="form-matrix-table" data-component="matrix" cellspacing="0" cellpadding="4">
            <tbody><tr class="form-matrix-tr form-matrix-header-tr">
              <th class="form-matrix-th" style="border:none">
                &nbsp;
              </th>
              <th scope="col" class="form-matrix-headers form-matrix-column-headers form-matrix-column_0">
                <label id="label_7_col_0"> Yes </label>
              </th>
              <th scope="col" class="form-matrix-headers form-matrix-column-headers form-matrix-column_1">
                <label id="label_7_col_1"> No </label>
              </th>
              <th scope="col" class="form-matrix-headers form-matrix-column-headers form-matrix-column_2">
                <label id="label_7_col_2"> Don't know or N/A </label>
              </th>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_7 label_7_row_0">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers">
                <label id="label_7_row_0">
                  <span style="font-size: 11.004px; display: inline !important;">
                    <b>
                      COVID-19 Screening Questions:
                    </b>
                    <br>
                    In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
                  </span>
                </label>
              </th>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_0_0" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[0]" value="Yes" aria-labelledby="label_7_col_0 label_7_row_0">
                <label for="input_7_0_0" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_0_1" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[0]" value=" No  " aria-labelledby="label_7_col_1 label_7_row_0">
                <label for="input_7_0_1" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_0_2" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[0]" value="Don\'t know or N/A" aria-labelledby="label_7_col_2 label_7_row_0">
                <label for="input_7_0_2" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_7 label_7_row_1">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers">
                <label id="label_7_row_1">
                  <span style="font-size: 11.004px; display: inline !important;">
                    In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
                  </span>
                </label>
              </th>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_1_0" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[1]" value="Yes" aria-labelledby="label_7_col_0 label_7_row_1">
                <label for="input_7_1_0" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_1_1" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[1]" value=" No  " aria-labelledby="label_7_col_1 label_7_row_1">
                <label for="input_7_1_1" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_1_2" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[1]" value="Don\'t know or N/A" aria-labelledby="label_7_col_2 label_7_row_1">
                <label for="input_7_1_2" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_7 label_7_row_2">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers">
                <label id="label_7_row_2">
                  <span style="font-size: 11.004px; display: inline !important;">
                    Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
                  </span>
                </label>
              </th>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_2_0" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[2]" value="Yes" aria-labelledby="label_7_col_0 label_7_row_2">
                <label for="input_7_2_0" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_2_1" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[2]" value=" No  " aria-labelledby="label_7_col_1 label_7_row_2">
                <label for="input_7_2_1" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_2_2" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[2]" value="Don\'t know or N/A" aria-labelledby="label_7_col_2 label_7_row_2">
                <label for="input_7_2_2" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_7 label_7_row_3">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers">
                <label id="label_7_row_3">
                  <span style="font-size: 11.004px; display: inline !important;">
                    <b>
                      Questionnaire for Immunization:
                    </b>
                    <br>
                    Do you feel sick today? (For example: a cold, fever, acute illness)
                  </span>
                </label>
              </th>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_3_0" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[3]" value="Yes" aria-labelledby="label_7_col_0 label_7_row_3">
                <label for="input_7_3_0" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_3_1" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[3]" value=" No  " aria-labelledby="label_7_col_1 label_7_row_3">
                <label for="input_7_3_1" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_3_2" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[3]" value="Don\'t know or N/A" aria-labelledby="label_7_col_2 label_7_row_3">
                <label for="input_7_3_2" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_7 label_7_row_4">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers">
                <label id="label_7_row_4">
                  <span style="font-size: 11.004px; display: inline !important;">
                    Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
                  </span>
                </label>
              </th>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_4_0" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[4]" value="Yes" aria-labelledby="label_7_col_0 label_7_row_4">
                <label for="input_7_4_0" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_4_1" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[4]" value=" No  " aria-labelledby="label_7_col_1 label_7_row_4">
                <label for="input_7_4_1" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_4_2" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[4]" value="Don\'t know or N/A" aria-labelledby="label_7_col_2 label_7_row_4">
                <label for="input_7_4_2" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_7 label_7_row_5">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers">
                <label id="label_7_row_5">
                  <span style="font-size: 11.004px; display: inline !important;">
                    Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorder?
                  </span>
                  <br>
                </label>
              </th>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_5_0" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[5]" value="Yes" aria-labelledby="label_7_col_0 label_7_row_5">
                <label for="input_7_5_0" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_5_1" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[5]" value=" No  " aria-labelledby="label_7_col_1 label_7_row_5">
                <label for="input_7_5_1" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_5_2" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[5]" value="Don\'t know or N/A" aria-labelledby="label_7_col_2 label_7_row_5">
                <label for="input_7_5_2" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_7 label_7_row_6">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers">
                <label id="label_7_row_6">
                  <span style="display: inline !important;">
                    Do you have cancer, leukemia, AIDS, or any other immune system problem?
                  </span>
                  <br>
                </label>
              </th>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_6_0" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[6]" value="Yes" aria-labelledby="label_7_col_0 label_7_row_6">
                <label for="input_7_6_0" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_6_1" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[6]" value=" No  " aria-labelledby="label_7_col_1 label_7_row_6">
                <label for="input_7_6_1" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_6_2" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[6]" value="Don\'t know or N/A" aria-labelledby="label_7_col_2 label_7_row_6">
                <label for="input_7_6_2" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_7 label_7_row_7">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers">
                <label id="label_7_row_7">
                  <span style="display: inline !important;">
                    Have you ever had a serious reaction or fainted after receiving any vaccination?
                  </span>
                  <br>
                </label>
              </th>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_7_0" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[7]" value="Yes" aria-labelledby="label_7_col_0 label_7_row_7">
                <label for="input_7_7_0" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_7_1" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[7]" value=" No  " aria-labelledby="label_7_col_1 label_7_row_7">
                <label for="input_7_7_1" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_7_2" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[7]" value="Don\'t know or N/A" aria-labelledby="label_7_col_2 label_7_row_7">
                <label for="input_7_7_2" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_7 label_7_row_8">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers">
                <label id="label_7_row_8">
                  <span style="display: inline !important;">
                    Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
                  </span>
                  <br>
                </label>
              </th>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_8_0" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[8]" value="Yes" aria-labelledby="label_7_col_0 label_7_row_8">
                <label for="input_7_8_0" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_8_1" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[8]" value=" No  " aria-labelledby="label_7_col_1 label_7_row_8">
                <label for="input_7_8_1" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_8_2" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[8]" value="Don\'t know or N/A" aria-labelledby="label_7_col_2 label_7_row_8">
                <label for="input_7_8_2" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_7 label_7_row_9">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers">
                <label id="label_7_row_9"> Have you received any other immunizations in the past 4 weeks? </label>
              </th>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_9_0" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[9]" value="Yes" aria-labelledby="label_7_col_0 label_7_row_9">
                <label for="input_7_9_0" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_9_1" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[9]" value=" No  " aria-labelledby="label_7_col_1 label_7_row_9">
                <label for="input_7_9_1" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_9_2" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[9]" value="Don\'t know or N/A" aria-labelledby="label_7_col_2 label_7_row_9">
                <label for="input_7_9_2" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_7 label_7_row_10">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers">
                <label id="label_7_row_10">
                  <b style="cursor: default;">
                    For women:
                  </b>
                  <span style="cursor: default; display: inline !important;">
                    Are you pregnant or are you planning on becoming pregnant during the next month?
                  </span>
                </label>
              </th>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_10_0" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[10]" value="Yes" aria-labelledby="label_7_col_0 label_7_row_10">
                <label for="input_7_10_0" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_10_1" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[10]" value=" No  " aria-labelledby="label_7_col_1 label_7_row_10">
                <label for="input_7_10_1" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
              <td class="form-matrix-values">
                <input type="radio" id="input_7_10_2" class="form-radio validate[required, requireOneAnswer]" name="q7_pleaseSelect[10]" value="Don\'t know or N/A" aria-labelledby="label_7_col_2 label_7_row_10">
                <label for="input_7_10_2" class="matrix-choice-label matrix-radio-label">  </label>
              </td>
            </tr>
          </tbody></table>
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_89">
        <label class="form-label form-label-top form-label-auto" id="label_89" for="input_89"> Please specify allergies, if applicable: </label>
        <div id="cid_89" class="form-input-wide">
          <input type="text" id="input_89" name="q89_pleaseSpecify" data-type="input-textbox" class="form-textbox" data-defaultvalue="" size="20" value="" data-component="textbox" aria-labelledby="label_89">
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_87">
        <label class="form-label form-label-top form-label-auto" id="label_87" for="input_87"> Please specify chronic condition(s), if applicable: </label>
        <div id="cid_87" class="form-input-wide">
          <input type="text" id="input_87" name="q87_pleaseSpecify87" data-type="input-textbox" class="form-textbox" data-defaultvalue="" size="20" value="" placeholder="diabetes, asthma, COPD" data-component="textbox" aria-labelledby="label_87">
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_88">
        <label class="form-label form-label-top form-label-auto" id="label_88" for="input_88"> Please list other vaccines received in the last 4 weeks and their dates of administration, if applicable: </label>
        <div id="cid_88" class="form-input-wide">
          <input type="text" id="input_88" name="q88_pleaseList88" data-type="input-textbox" class="form-textbox" data-defaultvalue="" size="20" value="" data-component="textbox" aria-labelledby="label_88">
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_14">
        <div id="cid_14" class="form-input-wide">
          <div id="text_14" class="form-html" data-component="text" tabindex="0">
            <p><span style="text-decoration: underline;"><strong>Section III. Signatures</strong></span></p>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_fileupload" id="id_116">
        <label class="form-label form-label-top form-label-auto" id="label_116" for="input_116"> In order to best facilitate your vaccine experience, please upload pictures of the front &amp; back of Medicare Part B, prescription, and medical insurance card(s) for billing purposes. Otherwise, please bring these cards with you to your appointment. </label>
        <div id="cid_116" class="form-input-wide">
          <div data-wrapper-react="true">
            <div data-wrapper-react="true" class="validate[multipleUpload]"><div class="qq-uploader"><div class="qq-upload-drop-area" style="display: none;"><span>Drop files here to upload</span></div><div class="qq-upload-button form-submit-button-simple_blue" aria-hidden="true" style="position: relative; overflow: hidden; direction: ltr;">
                Browse Files
              </div><div class="inputContainer" role="button" aria-label="Browse Files" tabindex="0"><input multiple="multiple" class="fileupload-input" id="input_116" type="file" name="file" aria-labelledby="label_116" aria-hidden="true" tabindex="-1"></div><label class="form-sub-label" for="inOrder" id="label_inOrder"></label><span style="display:none" class="multipleFileUploadLabels cancelText">
              Cancel
            </span><span style="display:none" class="multipleFileUploadLabels ofText">
              of
            </span><ul class="qq-upload-list" aria-label="Uploaded files"></ul></div></div>
            <span style="display:none" class="cancelText">
              Cancel
            </span>
            <span style="display:none" class="ofText">
              of
            </span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_19">
        <div id="cid_19" class="form-input-wide">
          <div id="text_19" class="form-html" data-component="text" tabindex="0">
            <p>Please read <strong><span style="text-decoration: underline;">EACH</span></strong> of the following statements. If consent is given, please sign and date below.</p>
            <p><em>1) I have acknowledged that I have received the provider's Inc Notice of Privacy Practices which may be provided at my request. (click <a href="https://tiffanynaturalpharmacy.com/docs/privacy_policy.pdf" target="_blank" rel="nofollow">here</a> to download)</em></p>
            <p><em>2) For Medicare, Medicaid, or Insurance Billing: I authorize this provider to release information and request payment. I understand that the information given by me in applying for payment is correct.</em></p>
            <p><em>3) I authorize the release of all records to act on this request and I request that payment of benefits be made on my behalf. </em></p>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_signature" id="id_20">
        <label class="form-label form-label-top form-label-auto" id="label_20" for="input_20">
          Signature of Acknowledgment of Notice of Privacy Practices:
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_20" class="form-input-wide jf-required">
          <div data-wrapper-react="true">
            <div id="signature_pad_20" class="signature-pad-wrapper" style="width:602px;height:152px">
              <div data-wrapper-react="true">
                <!--[if IE 7]>
                  <script type="text/javascript" src="/js/vendor/json2.js"></script>
                <![endif]-->
              </div>
              <div class="signature-line signature-wrapper signature-placeholder" data-component="signature" style="width:602px;height:152px;position:relative">
                <div id="sig_pad_20" data-width="600" data-height="150" data-id="20" data-required="true" class="pad validate[required]" aria-labelledby="label_20" style="width: 600px; height: 150px;">
                <div style="padding:0; margin:0;width: 100%; height: 0; -ms-touch-action: none; touch-action: none;margin-top:-1em; margin-bottom:1em"></div><canvas style="margin: 0px; padding: 0px; height: 150px; width: 600px; touch-action: none;" class="jSignature" role="application" aria-label="E-Signature Field" tabindex="0" width="600" height="150"></canvas><div style="padding:0; margin:0;width: 100%; height: 0; -ms-touch-action: none; touch-action: none;margin-top:-1.5em; margin-bottom:1.5em; position: relative;"></div></div>
                <input type="hidden" name="q20_signatureOf" class="output4" id="input_20">
              </div>
              <span class="clear-pad-btn clear-pad" role="button" tabindex="0">
                Clear
              </span>
            </div>
            <div data-wrapper-react="true">
              <script type="text/javascript">
              window.signatureForm = true
              </script>
            </div>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_datetime" id="id_85">
        <label class="form-label form-label-top form-label-auto" id="label_85" for="lite_mode_85">
          Date
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_85" class="form-input-wide jf-required">
          <div data-wrapper-react="true">
            <div style="display:none">
              <span class="form-sub-label-container" style="vertical-align:top">
                <input type="tel" class="form-textbox validate[required, limitDate]" id="month_85" name="q85_date[month]" size="2" data-maxlength="2" data-age="" maxlength="2" value="" required="" autocomplete="section-input_85 off" aria-labelledby="label_85 sublabel_85_month">
                <span class="date-separate" aria-hidden="true">
                  &nbsp;-
                </span>
                <label class="form-sub-label" for="month_85" id="sublabel_85_month" style="min-height:13px" aria-hidden="false"> Month </label>
              </span>
              <span class="form-sub-label-container" style="vertical-align:top">
                <input type="tel" class="form-textbox validate[required, limitDate]" id="day_85" name="q85_date[day]" size="2" data-maxlength="2" data-age="" maxlength="2" value="" required="" autocomplete="section-input_85 off" aria-labelledby="label_85 sublabel_85_day">
                <span class="date-separate" aria-hidden="true">
                  &nbsp;-
                </span>
                <label class="form-sub-label" for="day_85" id="sublabel_85_day" style="min-height:13px" aria-hidden="false"> Day </label>
              </span>
              <span class="form-sub-label-container" style="vertical-align:top">
                <input type="tel" class="form-textbox validate[required, limitDate]" id="year_85" name="q85_date[year]" size="4" data-maxlength="4" data-age="" maxlength="4" value="" required="" autocomplete="section-input_85 off" aria-labelledby="label_85 sublabel_85_year">
                <label class="form-sub-label" for="year_85" id="sublabel_85_year" style="min-height:13px" aria-hidden="false"> Year </label>
              </span>
            </div>
            <span class="form-sub-label-container" style="vertical-align:top">
              <input type="text" class="form-textbox validate[required, limitDate, validateLiteDate]" id="lite_mode_85" size="12" data-maxlength="12" maxlength="12" data-age="" value="" required="" data-format="mmddyyyy" data-seperator="-" placeholder="mm-dd-yyyy" autocomplete="section-input_85 off" aria-labelledby="label_85 sublabel_85_litemode">
              <img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_85_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v1">
              <label class="form-sub-label" for="lite_mode_85" id="sublabel_85_litemode" style="min-height:13px" aria-hidden="false"> Date </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_82">
        <div id="cid_82" class="form-input-wide">
          <div id="text_82" class="form-html" data-component="text" tabindex="0">
            <p>&nbsp;</p>
            <p>Please read <strong><span style="text-decoration: underline;">EACH</span></strong> of the following statements. If consent is given, please sign and date below.</p>
            <p><em>1) I have been provided with the Vaccine Information Sheet (VIS) and/or been provided with information regarding to the vaccine I am receiving. (click&nbsp;<a href="https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf" target="_blank" rel="nofollow">Moderna</a>,&nbsp;<a href="https://www.fda.gov/media/159309/download" rel="nofollow">Moderna 6mo-5yo</a>&nbsp;<a href="https://www.fda.gov/media/159310/download" rel="nofollow">Moderna 6yo-11yo</a>&nbsp;<a href="https://www.fda.gov/media/153716/download" rel="nofollow">Pfizer 12 and older</a>&nbsp;&nbsp;<a href="https://www.fda.gov/media/153717/download" rel="nofollow">Pfizer Pediatric 5-11</a>&nbsp;<a href="https://www.fda.gov/media/159313/download" rel="nofollow">Pfizer Pediatric 6mo-4yo</a>&nbsp;<a href="http://www.janssenlabels.com/emergency-use-authorization/Janssen+COVID-19+Vaccine-HCP-fact-sheet.pdf" rel="nofollow">Janssen (J&amp;J)</a>&nbsp;to download)&nbsp;</em></p>
            <p><em>2) I understand all the benefits and risks of the vaccine and have had the chance to ask questions regarding it. I voluntarily assume full responsibility for any reactions that may result.</em></p>
            <p><em>3) I request the vaccine be given to me and authorize and direct this health care provider to use or disclose my health information during the term of this Authorization to the physician responsible for this protocol of specific health information of people vaccinated by this provider (standing order practitioner (Dr. __________________), my Primary Care Physician (PCP), my insurance plan and/or state federal registries, where required for purposes of treatment, payment or other health care operations. This only allows this provider to disclose the following medical records: only documents related to the vaccination received today. This authorization will remain in effect until my health care provider discloses my health information to the recipient identified above; my health care provider cannot guarantee that the recipient will not disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information. I understand that I may refuse or revoke this Authorization at any time. I understand that this authorization will remain in effect until the term of this authorization expires or I provide a written notice of revocation to my health care provider. The revocation will be effective immediately upon my health care provider’s receipt of my written notice.</em></p>
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              <input type="checkbox" aria-describedby="label_117" class="form-checkbox" id="input_117_0" name="q117_ifUninsured[]" value="I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan.">
              <label id="label_input_117_0" for="input_117_0"> I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan. </label>
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