Your Smile Partners PLLC \u2014 Teledentistry Patient Registration Form<\/title> <meta name=\"viewport\" content=\"width=device-width,initial-scale=1\" \/> <link rel=\"preconnect\" href=\"https:\/\/fonts.googleapis.com\" crossorigin> <link rel=\"preconnect\" href=\"https:\/\/fonts.gstatic.com\" crossorigin> <link href=\"https:\/\/fonts.googleapis.com\/css2?family=Roboto:wght@300;400;500;700;900&display=swap\" rel=\"stylesheet\"> <style> :root{ --bg: #f6faff; --card: #ffffff; --ink: #18223b; --muted: #5c6e8d; --line: #e4ecfb; --accent-1: #4c8fff; --accent-2: #2bd0d6; --accent-3: #6d7cff; --ok: #12a66a; --warn: #f59f00; --field-bg: #ffffff; --field-border: #d6e2fb; --shadow-1: 0 10px 30px rgba(35, 66, 153, 0.10); --r: 16px; --r-sm: 12px; } *,*::before,*::after{ box-sizing:border-box; } html,body{ margin:0; padding:0; } body{ font-family: 'Roboto', system-ui, -apple-system, Segoe UI, Roboto, \"Helvetica Neue\", Arial, \"Apple Color Emoji\",\"Segoe UI Emoji\"; color: var(--ink); background: radial-gradient(900px 400px at 0% -10%, rgba(76,143,255,0.12), transparent 60%), radial-gradient(900px 420px at 100% 0%, rgba(43,208,214,0.10), transparent 60%), var(--bg); 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}\n.toast{\n position: fixed; left: 50%; bottom: 22px; transform: translateX(-50%) translateY(20px);\n background: #0f1b3a; color: #f4f8ff; border: 1px solid #2c4bff22;\n padding: 10px 14px; border-radius: 12px; box-shadow: var(--shadow-1);\n opacity: 0; transition: opacity .25s ease, transform .25s ease; pointer-events: none; z-index: 9999;\n font-size:.95rem;\n}\n.toast.show{ opacity: 1; transform: translateX(-50%) translateY(0); }\n@media print{\n .toolbar, .footer, .edge, .toast{ display:none !important; }\n body{ background:#fff; }\n .card{ box-shadow:none; border:none; }\n .section{ page-break-inside: avoid; }\n}\n<\/style> <\/head> <body> <main class=\"wrap\" role=\"main\"> <section class=\"card\" id=\"form-card\" aria-labelledby=\"title\"> <div class=\"edge\" aria-hidden=\"true\"><\/div>\n <header class=\"app\">\n <div class=\"logo\" aria-hidden=\"true\">\n <svg viewBox=\"0 0 64 64\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" aria-hidden=\"true\">\n <defs>\n <linearGradient id=\"g\" x1=\"0\" y1=\"0\" x2=\"1\" y2=\"1\">\n <stop stop-color=\"#4C8FFF\"\/><stop offset=\"1\" stop-color=\"#2BD0D6\"\/>\n <\/linearGradient>\n <\/defs>\n <path d=\"M32 4l20 8v14c0 14-9.6 26.8-20 30C21.6 52.8 12 40 12 26V12l20-8z\" stroke=\"url(#g)\" stroke-width=\"2.2\" fill=\"#eaf3ff\"\/>\n <path d=\"M22 31.5l7 7L44 24\" stroke=\"#4C8FFF\" stroke-width=\"3\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/>\n <\/svg>\n <\/div>\n <h1 class=\"title\" id=\"title\">Teledentistry Patient Registration Form<\/h1>\n <div class=\"meta\">\n <span class=\"pill\"><strong>Your Smile Partners PLLC<\/strong><\/span>\n <span class=\"pill\">99 Wall St, New York, NY 10005<\/span>\n <span class=\"pill\">Email: <a href=\"mailto:talk@yoursmilepartners.com\">talk@yoursmilepartners.com<\/a><\/span>\n <span class=\"pill\">Phone: (212) 555-SMILE<\/span>\n <\/div>\n <\/header>\n <div class=\"toolbar\" role=\"toolbar\" aria-label=\"Form actions\">\n <button type=\"button\" class=\"btn\" id=\"btnPrint\">Print Form<\/button>\n <button type=\"button\" class=\"btn primary\" id=\"btnSave\">Save PDF to Device<\/button>\n <button type=\"button\" class=\"btn ok\" id=\"btnSubmit\">Submit & Upload to Dropbox<\/button>\n <button type=\"button\" class=\"btn warn\" id=\"btnClear\">Clear All Fields<\/button>\n <\/div>\n <form id=\"reg-form\" novalidate>\n <div class=\"section\">\n <div class=\"grid cols-2\">\n <div>\n <label for=\"regDate\">Registration Date<\/label>\n <div class=\"field\"><input id=\"regDate\" name=\"regDate\" type=\"date\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"patientId\">Patient ID<\/label>\n <div class=\"field\"><input id=\"patientId\" name=\"patientId\" type=\"text\" placeholder=\"Auto\/Office use or patient-supplied\" \/><\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>1. Personal Information<\/h3>\n <div class=\"grid cols-2\">\n <div>\n <label for=\"fullName\">Full Legal Name<\/label>\n <div class=\"field\"><input id=\"fullName\" name=\"fullName\" type=\"text\" required placeholder=\"First Middle Last\" \/><\/div>\n <\/div>\n <div>\n <label for=\"prefName\">Preferred Name<\/label>\n <div class=\"field\"><input id=\"prefName\" name=\"prefName\" type=\"text\" placeholder=\"Optional\" \/><\/div>\n <\/div>\n <div>\n <label for=\"ssn\">Social Security Number<\/label>\n <div class=\"field\"><input id=\"ssn\" name=\"ssn\" type=\"text\" placeholder=\"XXX-XX-XXXX\" pattern=\"^\\\\d{3}-\\\\d{2}-\\\\d{4}$\" \/><\/div>\n <div class=\"hint\">Format: 123-45-6789<\/div>\n <\/div>\n <div>\n <label for=\"dob\">Date of Birth<\/label>\n <div class=\"field\"><input id=\"dob\" name=\"dob\" type=\"date\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"age\">Age<\/label>\n <div class=\"field\"><input id=\"age\" name=\"age\" type=\"number\" min=\"0\" max=\"120\" placeholder=\"Years\" \/><\/div>\n <\/div>\n <div>\n <label>Gender<\/label>\n <div class=\"options\" role=\"radiogroup\" aria-label=\"Gender\">\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Male\" required \/> Male<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Female\" \/> Female<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Non-binary\" \/> Non-binary<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Prefer not to disclose\" \/> Prefer not to disclose<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Other\" \/> Other<\/label>\n <\/div>\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"genderOther\" name=\"genderOther\" type=\"text\" placeholder=\"If Other, specify\" \/><\/div>\n <\/div>\n <div>\n <label>Marital Status<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"marital\" value=\"Single\" \/> Single<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"marital\" value=\"Married\" \/> Married<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"marital\" value=\"Divorced\" \/> Divorced<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"marital\" value=\"Widowed\" \/> Widowed<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"marital\" value=\"Domestic Partner\" \/> Domestic Partner<\/label>\n <\/div>\n <\/div>\n <div>\n <label>Language Preference<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"lang\" value=\"English\" required \/> English<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"lang\" value=\"Spanish\" \/> Spanish<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"lang\" value=\"Other\" \/> Other<\/label>\n <\/div>\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"langOther\" name=\"langOther\" type=\"text\" placeholder=\"If Other, specify\" \/><\/div>\n <\/div>\n <div>\n <label for=\"occupation\">Occupation<\/label>\n <div class=\"field\"><input id=\"occupation\" name=\"occupation\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"employer\">Employer<\/label>\n <div class=\"field\"><input id=\"employer\" name=\"employer\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"workPhone\">Work Phone<\/label>\n <div class=\"field\"><input id=\"workPhone\" name=\"workPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <\/div>\n <div>\n <label for=\"ext\">Extension<\/label>\n <div class=\"field\"><input id=\"ext\" name=\"ext\" type=\"text\" placeholder=\"e.g., 1234\" \/><\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>2. Contact Information<\/h3>\n <p><strong>Primary Address<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div style=\"grid-column:1\/-1\">\n <label for=\"street\">Street<\/label>\n <div class=\"field\"><input id=\"street\" name=\"street\" type=\"text\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"city\">City<\/label>\n <div class=\"field\"><input id=\"city\" name=\"city\" type=\"text\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"state\">State<\/label>\n <div class=\"field\"><input id=\"state\" name=\"state\" type=\"text\" maxlength=\"2\" placeholder=\"NY\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"zip\">ZIP<\/label>\n <div class=\"field\"><input id=\"zip\" name=\"zip\" type=\"text\" pattern=\"\\\\d{5}(-\\\\d{4})?\" placeholder=\"10005\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"yearsAt\">How long at this address? Years<\/label>\n <div class=\"field\"><input id=\"yearsAt\" name=\"yearsAt\" type=\"number\" min=\"0\" placeholder=\"0\" \/><\/div>\n <\/div>\n <div>\n <label for=\"monthsAt\">Months<\/label>\n <div class=\"field\"><input id=\"monthsAt\" name=\"monthsAt\" type=\"number\" min=\"0\" max=\"11\" placeholder=\"0\" \/><\/div>\n <\/div>\n <\/div>\n <p style=\"margin-top:12px;\"><strong>Mailing Address (if different)<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div style=\"grid-column:1\/-1\">\n <label for=\"mailStreet\">Street<\/label>\n <div class=\"field\"><input id=\"mailStreet\" name=\"mailStreet\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"mailCity\">City<\/label>\n <div class=\"field\"><input id=\"mailCity\" name=\"mailCity\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"mailState\">State<\/label>\n <div class=\"field\"><input id=\"mailState\" name=\"mailState\" type=\"text\" maxlength=\"2\" placeholder=\"NY\" \/><\/div>\n <\/div>\n <div>\n <label for=\"mailZip\">ZIP<\/label>\n <div class=\"field\"><input id=\"mailZip\" name=\"mailZip\" type=\"text\" pattern=\"\\\\d{5}(-\\\\d{4})?\" placeholder=\"10005\" \/><\/div>\n <\/div>\n <\/div>\n <p style=\"margin-top:12px;\"><strong>Phone Numbers<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div>\n <label for=\"homePhone\">Home<\/label>\n <div class=\"field\"><input id=\"homePhone\" name=\"homePhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"homeMsg\" \/> May we leave messages?<\/label><\/div>\n <\/div>\n <div>\n <label for=\"cellPhone\">Cell<\/label>\n <div class=\"field\"><input id=\"cellPhone\" name=\"cellPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" required \/><\/div>\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"cellText\" \/> May we text?<\/label><\/div>\n <\/div>\n <div>\n <label for=\"workPhone2\">Work<\/label>\n <div class=\"field\"><input id=\"workPhone2\" name=\"workPhone2\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"workCall\" \/> May we call at work?<\/label><\/div>\n <\/div>\n <\/div>\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\n <div>\n <label for=\"email\">Email Address<\/label>\n <div class=\"field\"><input id=\"email\" name=\"email\" type=\"email\" required placeholder=\"you@example.com\" \/><\/div>\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"emailRem\" \/> Appointment reminders via email<\/label><\/div>\n <\/div>\n <div>\n <label>Preferred method of contact<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"prefContact\" value=\"Phone\" required \/> Phone<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"prefContact\" value=\"Text\" \/> Text<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"prefContact\" value=\"Email\" \/> Email<\/label>\n <\/div>\n <label style=\"margin-top:10px;\">Best time to contact<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"bestTime\" value=\"Morning\" \/> Morning<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"bestTime\" value=\"Afternoon\" \/> Afternoon<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"bestTime\" value=\"Evening\" \/> Evening<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"bestTime\" value=\"Anytime\" \/> Anytime<\/label>\n <\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>3. Emergency Contact Information<\/h3>\n <p><strong>Primary Emergency Contact<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div>\n <label for=\"emName\">Name<\/label>\n <div class=\"field\"><input id=\"emName\" name=\"emName\" type=\"text\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"emRelation\">Relationship<\/label>\n <div class=\"field\"><input id=\"emRelation\" name=\"emRelation\" type=\"text\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"emPhone\">Phone<\/label>\n <div class=\"field\"><input id=\"emPhone\" name=\"emPhone\" type=\"tel\" required placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <\/div>\n <div>\n <label for=\"emAlt\">Alternate<\/label>\n <div class=\"field\"><input id=\"emAlt\" name=\"emAlt\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <\/div>\n <div style=\"grid-column:1\/-1\">\n <label for=\"emAddr\">Address<\/label>\n <div class=\"field\"><input id=\"emAddr\" name=\"emAddr\" type=\"text\" \/><\/div>\n <\/div>\n <\/div>\n <p style=\"margin-top:12px;\"><strong>Secondary Emergency Contact<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div>\n <label for=\"em2Name\">Name<\/label>\n <div class=\"field\"><input id=\"em2Name\" name=\"em2Name\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"em2Relation\">Relationship<\/label>\n <div class=\"field\"><input id=\"em2Relation\" name=\"em2Relation\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"em2Phone\">Phone<\/label>\n <div class=\"field\"><input id=\"em2Phone\" name=\"em2Phone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <\/div>\n <div>\n <label for=\"em2Alt\">Alternate<\/label>\n <div class=\"field\"><input id=\"em2Alt\" name=\"em2Alt\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>4. Insurance Information<\/h3>\n <p><strong>Primary Dental Insurance<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div><label for=\"pInsCo\">Insurance Company<\/label><div class=\"field\"><input id=\"pInsCo\" name=\"pInsCo\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"pInsPhone\">Phone Number<\/label><div class=\"field\"><input id=\"pInsPhone\" name=\"pInsPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div><\/div>\n <div><label for=\"pPolicyId\">Policy\/Member ID<\/label><div class=\"field\"><input id=\"pPolicyId\" name=\"pPolicyId\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"pGroup\">Group Number<\/label><div class=\"field\"><input id=\"pGroup\" name=\"pGroup\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"pSubName\">Subscriber Name<\/label><div class=\"field\"><input id=\"pSubName\" name=\"pSubName\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"pSubDob\">Subscriber DOB<\/label><div class=\"field\"><input id=\"pSubDob\" name=\"pSubDob\" type=\"date\" \/><\/div><\/div>\n <div>\n <label>Relationship to Subscriber<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"pRel\" value=\"Self\" \/> Self<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"pRel\" value=\"Spouse\" \/> Spouse<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"pRel\" value=\"Child\" \/> Child<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"pRel\" value=\"Other\" \/> Other<\/label>\n <\/div>\n <\/div>\n <div><label for=\"pSubEmployer\">Subscriber Employer<\/label><div class=\"field\"><input id=\"pSubEmployer\" name=\"pSubEmployer\" type=\"text\" \/><\/div><\/div>\n <div style=\"grid-column:1\/-1\"><label for=\"pEmpAddr\">Employer Address<\/label><div class=\"field\"><input id=\"pEmpAddr\" name=\"pEmpAddr\" type=\"text\" \/><\/div><\/div>\n <\/div>\n <p style=\"margin-top:12px;\"><strong>Secondary Dental Insurance (if applicable)<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div><label for=\"sInsCo\">Insurance Company<\/label><div class=\"field\"><input id=\"sInsCo\" name=\"sInsCo\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"sInsPhone\">Phone Number<\/label><div class=\"field\"><input id=\"sInsPhone\" name=\"sInsPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div><\/div>\n <div><label for=\"sPolicyId\">Policy\/Member ID<\/label><div class=\"field\"><input id=\"sPolicyId\" name=\"sPolicyId\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"sGroup\">Group Number<\/label><div class=\"field\"><input id=\"sGroup\" name=\"sGroup\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"sSubName\">Subscriber Name<\/label><div class=\"field\"><input id=\"sSubName\" name=\"sSubName\" type=\"text\" \/><\/div><\/div>\n <\/div>\n <p style=\"margin-top:12px;\"><strong>Medical Insurance<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div><label for=\"mInsCo\">Insurance Company<\/label><div class=\"field\"><input id=\"mInsCo\" name=\"mInsCo\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"mPolicyId\">Policy\/Member ID<\/label><div class=\"field\"><input id=\"mPolicyId\" name=\"mPolicyId\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"mGroup\">Group Number<\/label><div class=\"field\"><input id=\"mGroup\" name=\"mGroup\" type=\"text\" \/><\/div><\/div>\n <\/div>\n <div class=\"section\" style=\"margin:12px 0 0 0;\">\n <h3>Insurance Authorization<\/h3>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"authFileClaims\" \/> File insurance claims on my behalf<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"authAssignBenefits\" \/> Accept assignment of benefits<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"authReleaseInfo\" \/> Release necessary information to process claims<\/label>\n <\/div>\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\n <div>\n <label>Signature (Insurance Authorization)<\/label>\n <div class=\"sig-pad\">\n <canvas class=\"signature\" id=\"sigIns\" aria-label=\"Insurance authorization signature\"><\/canvas>\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigIns\">Clear<\/button><\/div>\n <\/div>\n <\/div>\n <div>\n <label for=\"insDate\">Date<\/label>\n <div class=\"field\"><input id=\"insDate\" name=\"insDate\" type=\"date\" \/><\/div>\n <\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>5. Referral Information<\/h3>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Internet search\" \/> Internet search<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Google reviews\" \/> Google reviews<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Social media\" \/> Social media<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Insurance directory\" \/> Insurance directory<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Friend\/family referral\" \/> Friend\/family referral<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Healthcare provider referral\" \/> Healthcare provider referral<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Advertisement\" \/> Advertisement<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Previous patient\" \/> Previous patient<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Other\" \/> Other<\/label>\n <\/div>\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\n <div>\n <label for=\"refOther\">If Other<\/label>\n <div class=\"field\"><input id=\"refOther\" name=\"refOther\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"refName\">Referring person\/practice name<\/label>\n <div class=\"field\"><input id=\"refName\" name=\"refName\" type=\"text\" \/><\/div>\n <div class=\"options\" style=\"margin-top:6px;\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"thankRef\" \/> May we thank them for the referral?<\/label>\n <\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>6. Appointment & Communication Preferences<\/h3>\n <p><strong>Preferred appointment times<\/strong><\/p>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"apptTime\" value=\"Early morning (7-9 AM)\" \/> Early morning (7-9 AM)<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"apptTime\" value=\"Morning (9-11 AM)\" \/> Morning (9-11 AM)<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"apptTime\" value=\"Midday (11 AM-1 PM)\" \/> Midday (11 AM-1 PM)<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"apptTime\" value=\"Afternoon (1-4 PM)\" \/> Afternoon (1-4 PM)<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"apptTime\" value=\"Late afternoon (4-6 PM)\" \/> Late afternoon (4-6 PM)<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"apptTime\" value=\"Evening (6-8 PM)\" \/> Evening (6-8 PM)<\/label>\n <\/div>\n <p style=\"margin-top:10px;\"><strong>Preferred days<\/strong><\/p>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"day\" value=\"Monday\" \/> Monday<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"day\" value=\"Tuesday\" \/> Tuesday<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"day\" value=\"Wednesday\" \/> Wednesday<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"day\" value=\"Thursday\" \/> Thursday<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"day\" value=\"Friday\" \/> Friday<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"day\" value=\"Saturday\" \/> Saturday<\/label>\n <\/div>\n <p style=\"margin-top:10px;\"><strong>Teledentistry platform preferences<\/strong><\/p>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"platform\" value=\"Zoom\" \/> Zoom<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"platform\" value=\"Doxy.me\" \/> Doxy.me<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"platform\" value=\"Microsoft Teams\" \/> Microsoft Teams<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"platform\" value=\"FaceTime\" \/> FaceTime<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"platform\" value=\"No preference\" \/> No preference<\/label>\n <\/div>\n <p style=\"margin-top:10px;\"><strong>Reminder preferences<\/strong><\/p>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"reminder\" value=\"Phone call\" \/> Phone call<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"reminder\" value=\"Text message\" \/> Text message<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"reminder\" value=\"Email\" \/> Email<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"reminder\" value=\"No reminders\" \/> No reminders<\/label>\n <\/div>\n <div class=\"options\" style=\"margin-top:8px;\">\n <label class=\"opt\"><input type=\"radio\" name=\"remindWhen\" value=\"24 hours\" \/> 24 hours<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"remindWhen\" value=\"48 hours\" \/> 48 hours<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"remindWhen\" value=\"1 week\" \/> 1 week<\/label>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>7. Technology Information<\/h3>\n <div class=\"grid cols-2\">\n <div>\n <label>Primary device<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"iPhone\" required \/> iPhone<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Android phone\" \/> Android phone<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"iPad\" \/> iPad<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Android tablet\" \/> Android tablet<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Windows laptop\/desktop\" \/> Windows laptop\/desktop<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Mac laptop\/desktop\" \/> Mac laptop\/desktop<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Chromebook\" \/> Chromebook<\/label>\n <\/div>\n <\/div>\n <div>\n <label>Internet connection<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"High-speed WiFi\" required \/> High-speed WiFi<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"Mobile data\" \/> Mobile data<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"DSL\/Cable\" \/> DSL\/Cable<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"Fiber optic\" \/> Fiber optic<\/label>\n <\/div>\n <\/div>\n <div>\n <label>Camera quality<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"cam\" value=\"HD (1080p)\" \/> HD (1080p)<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"cam\" value=\"4K\" \/> 4K<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"cam\" value=\"Standard\" \/> Standard<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"cam\" value=\"Unsure\" \/> Unsure<\/label>\n <\/div>\n <\/div>\n <div>\n <label>Environment<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"privateSpace\" value=\"Yes\" required \/> I have a quiet, private space<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"privateSpace\" value=\"No\" \/> I do not have a private space<\/label>\n <\/div>\n <div class=\"options\" style=\"margin-top:8px;\">\n <label class=\"opt\"><input type=\"radio\" name=\"techAssist\" value=\"Yes\" \/> I need technical assistance<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"techAssist\" value=\"No\" \/> I do not need assistance<\/label>\n <\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>8. Financial Information<\/h3>\n <div class=\"grid cols-2\">\n <div>\n <label>Employment Status<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"empStatus\" value=\"Full-time\" \/> Full-time<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"empStatus\" value=\"Part-time\" \/> Part-time<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"empStatus\" value=\"Self-employed\" \/> Self-employed<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"empStatus\" value=\"Retired\" \/> Retired<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"empStatus\" value=\"Student\" \/> Student<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"empStatus\" value=\"Unemployed\" \/> Unemployed<\/label>\n <\/div>\n <\/div>\n <div>\n <label>Payment responsibility<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"payResp\" value=\"Self\" \/> Self<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"payResp\" value=\"Parent\/guardian\" \/> Parent\/guardian<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"payResp\" value=\"Spouse\" \/> Spouse<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"payResp\" value=\"Insurance only\" \/> Insurance only<\/label>\n <\/div>\n <\/div>\n <\/div>\n <p style=\"margin-top:10px;\"><strong>Preferred payment method<\/strong><\/p>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"payMethod\" value=\"Cash\" \/> Cash<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"payMethod\" value=\"Check\" \/> Check<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"payMethod\" value=\"Credit card\" \/> Credit card<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"payMethod\" value=\"Debit card\" \/> Debit card<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"payMethod\" value=\"HSA\/FSA\" \/> HSA\/FSA<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"payMethod\" value=\"Payment plan\" \/> Payment plan<\/label>\n <\/div>\n <p style=\"margin-top:10px;\"><strong>Credit card information (for deposits\/copays)<\/strong><\/p>\n <div class=\"grid cols-4\">\n <div style=\"grid-column: span 1;\">\n <label>Card Type<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"ccType\" value=\"Visa\" \/> Visa<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"ccType\" value=\"MasterCard\" \/> MasterCard<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"ccType\" value=\"American Express\" \/> American Express<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"ccType\" value=\"Discover\" \/> Discover<\/label>\n <\/div>\n <\/div>\n <div style=\"grid-column: span 3;\">\n <label for=\"ccNumber\">Number<\/label>\n <div class=\"field\"><input id=\"ccNumber\" name=\"ccNumber\" type=\"text\" inputmode=\"numeric\" placeholder=\"\u2022\u2022\u2022\u2022 \u2022\u2022\u2022\u2022 \u2022\u2022\u2022\u2022 \u2022\u2022\u2022\u2022\" \/><\/div>\n <\/div>\n <div>\n <label for=\"ccExp\">Expiration (MM\/YY)<\/label>\n <div class=\"field\"><input id=\"ccExp\" name=\"ccExp\" type=\"text\" placeholder=\"MM\/YY\" \/><\/div>\n <\/div>\n <div style=\"grid-column: span 2;\">\n <label for=\"ccName\">Name on Card<\/label>\n <div class=\"field\"><input id=\"ccName\" name=\"ccName\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"ccZip\">Billing ZIP<\/label>\n <div class=\"field\"><input id=\"ccZip\" name=\"ccZip\" type=\"text\" pattern=\"\\\\d{5}(-\\\\d{4})?\" placeholder=\"10005\" \/><\/div>\n <\/div>\n <div>\n <label for=\"ccCVV\">CVV<\/label>\n <div class=\"field\"><input id=\"ccCVV\" name=\"ccCVV\" type=\"text\" inputmode=\"numeric\" placeholder=\"3-4 digits\" \/><\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>9. Legal Guardian Information (if patient is minor)<\/h3>\n <div class=\"grid cols-2\">\n <div><label for=\"gName\">Guardian Name<\/label><div class=\"field\"><input id=\"gName\" name=\"gName\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"gRel\">Relationship<\/label><div class=\"field\"><input id=\"gRel\" name=\"gRel\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"gDob\">Date of Birth<\/label><div class=\"field\"><input id=\"gDob\" name=\"gDob\" type=\"date\" \/><\/div><\/div>\n <div><label for=\"gSSN\">SSN<\/label><div class=\"field\"><input id=\"gSSN\" name=\"gSSN\" type=\"text\" placeholder=\"XXX-XX-XXXX\" pattern=\"^\\\\d{3}-\\\\d{2}-\\\\d{4}$\" \/><\/div><\/div>\n <div><label for=\"gEmployer\">Employer<\/label><div class=\"field\"><input id=\"gEmployer\" name=\"gEmployer\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"gWorkPhone\">Work Phone<\/label><div class=\"field\"><input id=\"gWorkPhone\" name=\"gWorkPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div><\/div>\n <\/div>\n <h3 style=\"margin-top:12px;\">Second Guardian\/Parent<\/h3>\n <div class=\"grid cols-2\">\n <div><label for=\"g2Name\">Name<\/label><div class=\"field\"><input id=\"g2Name\" name=\"g2Name\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"g2Rel\">Relationship<\/label><div class=\"field\"><input id=\"g2Rel\" name=\"g2Rel\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"g2Phone\">Phone<\/label><div class=\"field\"><input id=\"g2Phone\" name=\"g2Phone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div><\/div>\n <\/div>\n <h3 style=\"margin-top:12px;\">Custody Information<\/h3>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"custody\" value=\"Both parents have equal rights\" \/> Both parents have equal rights<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"custody\" value=\"Sole custody\" \/> Sole custody (specify)<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"custody\" value=\"Court order on file\" \/> Court order on file<\/label>\n <\/div>\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"custodyDetail\" name=\"custodyDetail\" type=\"text\" placeholder=\"If sole custody or court order, provide details\" \/><\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>10. Marketing & Communication Consent<\/h3>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Appointment reminders\" \/> Appointment reminders<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Treatment follow-up communications\" \/> Treatment follow-up communications<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Oral health education materials\" \/> Oral health education materials<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Practice newsletters\" \/> Practice newsletters<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Promotional offers\" \/> Promotional offers<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Birthday\/holiday greetings\" \/> Birthday\/holiday greetings<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Patient satisfaction surveys\" \/> Patient satisfaction surveys<\/label>\n <\/div>\n <p style=\"margin-top:8px;\"><strong>Preferred communication method for marketing<\/strong><\/p>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"mktMethod\" value=\"Email\" \/> Email<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"mktMethod\" value=\"Text message\" \/> Text message<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"mktMethod\" value=\"Phone call\" \/> Phone call<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"mktMethod\" value=\"Mail\" \/> Mail<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"mktMethod\" value=\"None\" \/> None<\/label>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>11. Authorization & Signature<\/h3>\n <ul class=\"hint\" style=\"padding-left:18px; margin:8px 0;\">\n <li>I certify that the information provided is true and complete.<\/li>\n <li>I am financially responsible for all services provided, and payment is due at time of service unless arranged otherwise.<\/li>\n <li>I will provide 24-hour notice for cancellations; a fee may apply for missed appointments.<\/li>\n <li>I authorize Your Smile Partners PLLC to perform necessary teledentistry services.<\/li>\n <\/ul>\n <div class=\"ack\" style=\"margin:10px 0;\">\n <input id=\"authAck\" type=\"checkbox\" required \/>\n <label for=\"authAck\">I agree to the Authorization statements above.<\/label>\n <\/div>\n <div class=\"grid cols-2\">\n <div>\n <label>Patient Signature<\/label>\n <div class=\"sig-pad\">\n <canvas class=\"signature\" id=\"sigPatient\" aria-label=\"Patient signature\"><\/canvas>\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigPatient\">Clear<\/button><\/div>\n <\/div>\n <\/div>\n <div>\n <label for=\"authDate\">Date<\/label>\n <div class=\"field\"><input id=\"authDate\" name=\"authDate\" type=\"date\" required \/><\/div>\n <\/div>\n <\/div>\n <h3 style=\"margin-top:12px;\">If signed by guardian\/representative<\/h3>\n <div class=\"grid cols-2\">\n <div><label for=\"repName\">Name<\/label><div class=\"field\"><input id=\"repName\" name=\"repName\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"repRel\">Relationship to Patient<\/label><div class=\"field\"><input id=\"repRel\" name=\"repRel\" type=\"text\" \/><\/div><\/div>\n <div>\n <label>Representative Signature<\/label>\n <div class=\"sig-pad\">\n <canvas class=\"signature\" id=\"sigRep\" aria-label=\"Representative signature\"><\/canvas>\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigRep\">Clear<\/button><\/div>\n <\/div>\n <\/div>\n <div><label for=\"repDate\">Date<\/label><div class=\"field\"><input id=\"repDate\" name=\"repDate\" type=\"date\" \/><\/div><\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>12. Office Use Only<\/h3>\n <div class=\"grid cols-3\">\n <div><label for=\"regBy\">Registration completed by<\/label><div class=\"field\"><input id=\"regBy\" name=\"regBy\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"procDate\">Date processed<\/label><div class=\"field\"><input id=\"procDate\" name=\"procDate\" type=\"date\" \/><\/div><\/div>\n <div><label for=\"procTime\">Time<\/label><div class=\"field\"><input id=\"procTime\" name=\"procTime\" type=\"text\" placeholder=\"HH:MM AM\/PM\" \/><\/div><\/div>\n <\/div>\n <div class=\"grid cols-3\" style=\"margin-top:10px;\">\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"insVerified\" \/> Insurance verified<\/label><\/div>\n <div><label for=\"insVerDate\">Date<\/label><div class=\"field\"><input id=\"insVerDate\" name=\"insVerDate\" type=\"date\" \/><\/div><\/div>\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"techTest\" \/> Technology test completed<\/label><\/div>\n <\/div>\n <div class=\"grid cols-3\" style=\"margin-top:10px;\">\n <div><label for=\"techDate\">Tech test date<\/label><div class=\"field\"><input id=\"techDate\" name=\"techDate\" type=\"date\" \/><\/div><\/div>\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"welcomeSent\" \/> Welcome packet sent<\/label><\/div>\n <div><label for=\"welcomeMethod\">Method<\/label><div class=\"field\"><input id=\"welcomeMethod\" name=\"welcomeMethod\" type=\"text\" placeholder=\"Email\/Mail\/Other\" \/><\/div><\/div>\n <\/div>\n <div class=\"grid cols-3\" style=\"margin-top:10px;\">\n <div><label for=\"firstApptDate\">First appointment date<\/label><div class=\"field\"><input id=\"firstApptDate\" name=\"firstApptDate\" type=\"date\" \/><\/div><\/div>\n <div><label for=\"firstApptTime\">Time<\/label><div class=\"field\"><input id=\"firstApptTime\" name=\"firstApptTime\" type=\"text\" placeholder=\"HH:MM\" \/><\/div><\/div>\n <div><label for=\"provider\">Provider assigned<\/label><div class=\"field\"><input id=\"provider\" name=\"provider\" type=\"text\" \/><\/div><\/div>\n <\/div>\n <div style=\"margin-top:10px;\">\n <label for=\"notes\">Notes<\/label>\n <div class=\"field\"><textarea id=\"notes\" name=\"notes\" placeholder=\"Internal notes\"><\/textarea><\/div>\n <\/div>\n <\/div>\n <div class=\"section\">\n <p class=\"note\"><strong>Thank you for choosing Your Smile Partners PLLC<\/strong> for your teledentistry needs. We look forward to providing you with exceptional virtual dental care. If you have any questions, please contact us at <a href=\"mailto:talk@yoursmilepartners.com\">talk@yoursmilepartners.com<\/a>.<\/p>\n <\/div>\n <\/form>\n <div class=\"footer\">\n <div class=\"note\">Use \u201cPrint Form\u201d for a paper copy, \u201cSave PDF\u201d to store locally, or \u201cSubmit & Upload\u201d to save a PDF and go to our secure Dropbox page.<\/div>\n <div style=\"display:flex; gap:10px;\">\n <button type=\"button\" class=\"btn\" id=\"btnPrint2\">Print Form<\/button>\n <button type=\"button\" class=\"btn primary\" id=\"btnSave2\">Save PDF<\/button>\n <button type=\"button\" class=\"btn ok\" id=\"btnSubmit2\">Submit & Upload<\/button>\n <\/div>\n <\/div>\n<\/section>\n<\/main> <div class=\"toast\" id=\"toast\" role=\"status\" aria-live=\"polite\" aria-atomic=\"true\">Ready<\/div> <script src=\"https:\/\/cdn.jsdelivr.net\/npm\/html2pdf.js@0.10.1\/dist\/html2pdf.bundle.min.js\" crossorigin=\"anonymous\"><\/script> <script> (function(){ const dropboxURL = 'https:\/\/www.dropbox.com\/request\/gdRmWuwrMys3cW8R8Xua'; const form = document.getElementById('reg-form'); const card = document.getElementById('form-card'); const toast = document.getElementById('toast');\n const btnPrint = document.getElementById('btnPrint');\n const btnPrint2 = document.getElementById('btnPrint2');\n const btnSave = document.getElementById('btnSave');\n const btnSave2 = document.getElementById('btnSave2');\n const btnSubmit = document.getElementById('btnSubmit');\n const btnSubmit2 = document.getElementById('btnSubmit2');\n const btnClear = document.getElementById('btnClear');\n \/\/ Signature pads\n const pads = {\n sigPatient: setupSignaturePad(document.getElementById('sigPatient')),\n sigRep: setupSignaturePad(document.getElementById('sigRep')),\n sigIns: setupSignaturePad(document.getElementById('sigIns'))\n };\n document.querySelectorAll('[data-clear]').forEach(btn=>{\n btn.addEventListener('click', ()=>{\n const id = btn.getAttribute('data-clear');\n pads[id]?.clear();\n });\n });\n \/\/ Default dates to today\n const todayISO = (new Date()).toISOString().slice(0,10);\n const defaultDateIds = ['regDate','authDate','insDate'];\n defaultDateIds.forEach(id => { const el = document.getElementById(id); if(el && !el.value) el.value = todayISO; });\n \/\/ Toast helper\n let tmr;\n function showToast(msg){\n toast.textContent = msg;\n toast.classList.add('show');\n clearTimeout(tmr);\n tmr = setTimeout(()=> toast.classList.remove('show'), 1800);\n }\n \/\/ Print\n function doPrint(){ window.print(); }\n btnPrint.addEventListener('click', doPrint);\n btnPrint2.addEventListener('click', doPrint);\n \/\/ Minimal validation (key fields)\n function validateForm(){\n const must = ['fullName','dob','cellPhone','email','authDate'];\n for(const id of must){\n const el = document.getElementById(id);\n if(!el || (el.value || '').trim() === ''){\n el?.scrollIntoView({behavior:'smooth', block:'center'});\n el?.focus?.({preventScroll:true});\n showToast('Please complete required fields.');\n return false;\n }\n }\n const authAck = document.getElementById('authAck');\n if(authAck && !authAck.checked){\n authAck.scrollIntoView({behavior:'smooth', block:'center'});\n showToast('Please agree to the authorization.');\n return false;\n }\n if(pads.sigPatient && pads.sigPatient.isBlank()){\n document.getElementById('sigPatient').scrollIntoView({behavior:'smooth', block:'center'});\n showToast('Please add your signature.');\n return false;\n }\n return true;\n }\n function makeFileName(){\n const name = (document.getElementById('fullName').value || 'Patient').trim().replace(\/\\s+\/g,'_');\n const date = (document.getElementById('authDate').value || todayISO);\n return `Teledentistry_Registration_${name}_${date}.pdf`;\n }\n \/\/ Save PDF\n async function savePDF(){\n await ensureSignatures();\n const opt = {\n margin: 0.4,\n filename: makeFileName(),\n image: { type: 'jpeg', quality: 0.98 },\n html2canvas: { scale: 2, useCORS: true, backgroundColor: '#ffffff' },\n jsPDF: { unit: 'in', format: 'letter', orientation: 'portrait' },\n pagebreak: { mode: ['css','legacy'] }\n };\n await html2pdf().from(card).set(opt).save();\n }\n btnSave.addEventListener('click', async ()=>{\n if(!validateForm()) return;\n await savePDF();\n showToast('PDF saved to your device.');\n });\n btnSave2.addEventListener('click', async ()=>{\n if(!validateForm()) return;\n await savePDF();\n showToast('PDF saved to your device.');\n });\n \/\/ Submit & Upload: save then redirect to Dropbox Request\n async function submitAndUpload(){\n if(!validateForm()) return;\n \/\/ Pre-open a tab to avoid popup blockers\n let uploadWin;\n try{\n uploadWin = window.open('about:blank', '_blank');\n if(uploadWin){\n uploadWin.document.write('<!DOCTYPE html><title>Redirecting\u2026<\/title><p style=\"font-family:Roboto,system-ui;padding:20px;\">Preparing your PDF\u2026 You will be redirected to our secure Dropbox upload.<\/p>');\n }\n }catch(e){}\n try{\n await savePDF();\n showToast('PDF saved. Redirecting to Dropbox\u2026');\n }catch(err){\n console.error(err);\n showToast('PDF error. Opening print dialog instead.');\n window.print();\n }\n try{\n if(uploadWin && !uploadWin.closed){\n uploadWin.location.href = dropboxURL;\n uploadWin.focus();\n }else{\n window.open(dropboxURL, '_blank');\n }\n }catch(e){\n window.open(dropboxURL, '_blank');\n }\n }\n btnSubmit.addEventListener('click', submitAndUpload);\n btnSubmit2.addEventListener('click', submitAndUpload);\n \/\/ Clear\n btnClear.addEventListener('click', ()=>{\n if(!confirm('Clear all fields and signatures?')) return;\n form.reset();\n defaultDateIds.forEach(id => { const el = document.getElementById(id); if(el) el.value = todayISO; });\n pads.sigPatient?.clear(); pads.sigRep?.clear(); pads.sigIns?.clear();\n showToast('Form cleared.');\n });\n \/\/ Placeholder (can extend if needed)\n async function ensureSignatures(){ return true; }\n \/\/ Lightweight signature pad\n function setupSignaturePad(canvas){\n const ctx = canvas.getContext('2d');\n const state = { drawing:false, blank:true, lastX:0, lastY:0 };\n function resize(){\n const ratio = Math.max(window.devicePixelRatio || 1, 1);\n const rect = canvas.getBoundingClientRect();\n canvas.width = rect.width * ratio;\n canvas.height = rect.height * ratio;\n ctx.setTransform(ratio, 0, 0, ratio, 0, 0);\n ctx.lineCap = 'round';\n ctx.lineJoin = 'round';\n ctx.lineWidth = 2.2;\n ctx.strokeStyle = '#18223b';\n ctx.clearRect(0,0,canvas.width,canvas.height);\n state.blank = true;\n }\n window.addEventListener('resize', resize, { passive:true });\n resize();\n function getPos(e){\n const r = canvas.getBoundingClientRect();\n const p = e.touches ? e.touches[0] : e;\n return { x: p.clientX - r.left, y: p.clientY - r.top };\n }\n function start(e){ e.preventDefault(); state.drawing=true; const p=getPos(e); state.lastX=p.x; state.lastY=p.y; }\n function move(e){\n if(!state.drawing) return;\n e.preventDefault();\n const p = getPos(e);\n ctx.beginPath(); ctx.moveTo(state.lastX, state.lastY); ctx.lineTo(p.x,p.y); ctx.stroke();\n state.lastX = p.x; state.lastY = p.y; state.blank = false;\n }\n function end(){ state.drawing=false; }\n canvas.addEventListener('mousedown', start);\n canvas.addEventListener('mousemove', move);\n window.addEventListener('mouseup', end);\n canvas.addEventListener('touchstart', start, { passive:false });\n canvas.addEventListener('touchmove', move, { passive:false });\n canvas.addEventListener('touchend', end);\n function clear(){ ctx.clearRect(0,0,canvas.width,canvas.height); state.blank = true; }\n function isBlank(){ return state.blank; }\n return { clear, isBlank };\n }\n})();\n<\/script> <\/body> <\/html>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Your Smile Partners PLLC \u2014 Teledentistry Patient Registration Form Teledentistry Patient Registration Form Your Smile Partners PLLC 99 Wall St, New York, NY 10005 Email: talk@yoursmilepartners.com Phone: (212) 555-SMILE Print Form Save PDF to Device Submit & Upload to Dropbox Clear All Fields Registration Date Patient ID 1. Personal Information Full Legal Name Preferred Name…<\/p>\n<p><a class=\"btn btn-outline-dark btn-sm anzu-read-more-link\" href=\"https:\/\/stephanie.openteledentistry.com\/?page_id=807\">Continue Reading<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"content-type":"","footnotes":""},"class_list":["post-807","page","type-page","status-publish","hentry"],"_hostinger_reach_plugin_has_subscription_block":false,"_hostinger_reach_plugin_is_elementor":false,"_links":{"self":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/807","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=807"}],"version-history":[{"count":4,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/807\/revisions"}],"predecessor-version":[{"id":811,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/807\/revisions\/811"}],"wp:attachment":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=807"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}

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\n\t\t\t\t\t Your Smile Partners PLLC \u2014 Teledentistry Patient Registration Form<\/title> <meta name=\"viewport\" content=\"width=device-width,initial-scale=1\" \/> <link rel=\"preconnect\" href=\"https:\/\/fonts.googleapis.com\" crossorigin> <link rel=\"preconnect\" href=\"https:\/\/fonts.gstatic.com\" crossorigin> <link href=\"https:\/\/fonts.googleapis.com\/css2?family=Roboto:wght@300;400;500;700;900&display=swap\" rel=\"stylesheet\"> <style> :root{ --bg: #f6faff; --card: #ffffff; --ink: #18223b; --muted: #5c6e8d; --line: #e4ecfb; --accent-1: #4c8fff; --accent-2: #2bd0d6; --accent-3: #6d7cff; --ok: #12a66a; --warn: #f59f00; --field-bg: #ffffff; --field-border: #d6e2fb; --shadow-1: 0 10px 30px rgba(35, 66, 153, 0.10); --r: 16px; --r-sm: 12px; } *,*::before,*::after{ box-sizing:border-box; } html,body{ margin:0; padding:0; } body{ font-family: 'Roboto', system-ui, -apple-system, Segoe UI, Roboto, \"Helvetica Neue\", Arial, \"Apple Color Emoji\",\"Segoe UI Emoji\"; color: var(--ink); background: radial-gradient(900px 400px at 0% -10%, rgba(76,143,255,0.12), transparent 60%), radial-gradient(900px 420px at 100% 0%, rgba(43,208,214,0.10), transparent 60%), var(--bg); line-height:1.55; } .wrap{ max-width: 1100px; margin: 24px auto; padding: 16px; } .card{ background: var(--card); border: 1px solid var(--line); border-radius: var(--r); box-shadow: var(--shadow-1); overflow: clip; position:relative; isolation:isolate; } .edge{ position:absolute; inset:0; pointer-events:none; padding:1px; border-radius:inherit; opacity:.9; background: conic-gradient(from 180deg at 50% 50%, rgba(76,143,255,0.0), rgba(76,143,255,0.25), rgba(43,208,214,0.25), rgba(109,124,255,0.25), rgba(76,143,255,0.0)); -webkit-mask: linear-gradient(#000 0 0) content-box, linear-gradient(#000 0 0); -webkit-mask-composite: xor; mask-composite: exclude; animation: spin 12s linear infinite; } @keyframes spin{ to{ transform: rotate(360deg); } }\nheader.app{\n display:grid; gap:14px; align-items:center;\n grid-template-columns: auto 1fr;\n padding: 20px 20px 10px 20px;\n background: linear-gradient(180deg, rgba(76,143,255,.08), rgba(43,208,214,.04));\n border-bottom: 1px solid var(--line);\n}\n.logo{\n width:56px;height:56px;border-radius:14px;display:grid;place-items:center;\n background: linear-gradient(145deg, rgba(76,143,255,.18), rgba(43,208,214,.14));\n border:1px solid #cfe2ff;\n}\n.logo svg{ width:30px;height:30px }\n.title{ margin:0; font-size: clamp(1.15rem, 2.6vw, 1.7rem); line-height:1.25; font-weight:900; letter-spacing:.2px; }\n.meta{ grid-column: 1 \/ -1; display:flex; flex-wrap:wrap; gap:10px; padding-bottom:10px; color: var(--muted); font-size:.96rem; }\n.pill{ display:inline-flex; align-items:center; gap:8px; padding:6px 10px; border-radius:999px; background:#f1f6ff; border:1px solid var(--line); }\n.toolbar{\n display:flex; flex-wrap:wrap; gap:10px; padding: 12px 20px; border-bottom: 1px dashed var(--line);\n background: linear-gradient(180deg, #ffffff, #f8fbff);\n}\n.btn{\n appearance:none; -webkit-tap-highlight-color: transparent; user-select:none;\n border:1px solid #cfe0ff; background: linear-gradient(135deg, #f7fbff, #eef6ff);\n color: var(--ink); font-weight:700; letter-spacing:.2px; font-size:.95rem;\n padding:10px 14px; border-radius: 12px; cursor:pointer;\n transition: transform .15s ease, box-shadow .15s ease, border-color .2s ease, background .2s ease;\n box-shadow: 0 6px 16px rgba(76,143,255,.12);\n}\n.btn:hover{ transform: translateY(-1px); box-shadow: 0 10px 24px rgba(76,143,255,.18); }\n.btn:active{ transform: translateY(0); }\n.btn.primary{ border-color: #8dc2ff; background: linear-gradient(135deg, #e5f1ff, #e6fffb); }\n.btn.ok{ border-color:#a6efd6; background: linear-gradient(135deg, #eafff6, #efffff); }\n.btn.warn{ border-color:#ffd98a; background: linear-gradient(135deg, #fff7ea, #fffdf3); }\nform#reg-form{ padding: 20px; }\n.section{\n border: 1px solid var(--line);\n border-radius: var(--r-sm);\n background: linear-gradient(180deg, #ffffff, #f9fbff);\n padding: 16px; margin: 16px 0;\n}\n.section h3{\n margin:0 0 8px 0; font-size: 1.05rem; letter-spacing:.2px; color: #1b2b55;\n display:flex; align-items:center; gap:10px;\n}\n.section p{ margin: 8px 0; color: var(--muted); }\n.grid{ display:grid; gap:12px; }\n@media(min-width: 780px){\n .grid.cols-2{ grid-template-columns: 1fr 1fr; }\n .grid.cols-3{ grid-template-columns: repeat(3, 1fr); }\n .grid.cols-4{ grid-template-columns: repeat(4, 1fr); }\n}\nlabel{ font-weight:600; font-size:.93rem; color:#1e315c; }\n.field{\n margin-top:6px; display:flex; align-items:center; gap:10px;\n background: var(--field-bg); border:1px solid var(--field-border); border-radius: 12px; padding: 10px 12px;\n transition: border-color .2s ease, box-shadow .2s ease, background .2s ease;\n}\n.field:focus-within{\n border-color:#9bc6ff; box-shadow: 0 0 0 4px rgba(76,143,255,.12);\n background:#ffffff;\n}\ninput[type=\"text\"], input[type=\"email\"], input[type=\"tel\"], input[type=\"date\"], input[type=\"number\"], textarea, select{\n width:100%; border:none; outline:none; background: transparent; color: var(--ink); font: inherit; font-size: .98rem;\n}\ninput[type=\"number\"]::-webkit-outer-spin-button, input[type=\"number\"]::-webkit-inner-spin-button{ -webkit-appearance: none; margin: 0; }\ntextarea{ resize: vertical; min-height: 92px; }\n.options{ display:flex; flex-wrap:wrap; gap:10px 18px; margin-top:8px; }\n.opt{ display:inline-flex; align-items:center; gap:8px; color: var(--ink); }\n.opt input{ transform: translateY(1px); }\n.hint{ font-size:.85rem; color: var(--muted); margin-top:4px; }\n.sig-pad{\n background: repeating-linear-gradient(0deg, #ffffff, #ffffff 28px, #f2f6ff 28px, #f2f6ff 29px);\n border: 1px dashed #c5d6fb; border-radius: 12px; padding: 10px;\n}\n.sig-tools{ display:flex; gap:10px; margin-top:8px; }\n.sig-tools .btn{ font-size:.88rem; padding:8px 10px; }\ncanvas.signature{\n width: 100%; height: 160px; display:block; background:#fff; border-radius: 10px; border:1px solid #e6eeff;\n touch-action: none;\n}\n.ack{\n display:flex; align-items:flex-start; gap:10px; background:#f8fbff; border:1px solid var(--line); border-radius:12px; padding:12px;\n}\n.ack input{ margin-top: 4px; }\n.footer{\n display:flex; flex-wrap:wrap; align-items:center; justify-content:space-between; gap:12px;\n padding: 12px 20px 20px 20px;\n border-top: 1px solid var(--line);\n background: linear-gradient(180deg, #f9fbff, #ffffff);\n}\n.note{ color: var(--muted); font-size:.94rem; }\n.toast{\n position: fixed; left: 50%; bottom: 22px; transform: translateX(-50%) translateY(20px);\n background: #0f1b3a; color: #f4f8ff; border: 1px solid #2c4bff22;\n padding: 10px 14px; border-radius: 12px; box-shadow: var(--shadow-1);\n opacity: 0; transition: opacity .25s ease, transform .25s ease; pointer-events: none; z-index: 9999;\n font-size:.95rem;\n}\n.toast.show{ opacity: 1; transform: translateX(-50%) translateY(0); }\n@media print{\n .toolbar, .footer, .edge, .toast{ display:none !important; }\n body{ background:#fff; }\n .card{ box-shadow:none; border:none; }\n .section{ page-break-inside: avoid; }\n}\n<\/style> <\/head> <body> <main class=\"wrap\" role=\"main\"> <section class=\"card\" id=\"form-card\" aria-labelledby=\"title\"> <div class=\"edge\" aria-hidden=\"true\"><\/div>\n <header class=\"app\">\n <div class=\"logo\" aria-hidden=\"true\">\n <svg viewBox=\"0 0 64 64\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" aria-hidden=\"true\">\n <defs>\n <linearGradient id=\"g\" x1=\"0\" y1=\"0\" x2=\"1\" y2=\"1\">\n <stop stop-color=\"#4C8FFF\"\/><stop offset=\"1\" stop-color=\"#2BD0D6\"\/>\n <\/linearGradient>\n <\/defs>\n <path d=\"M32 4l20 8v14c0 14-9.6 26.8-20 30C21.6 52.8 12 40 12 26V12l20-8z\" stroke=\"url(#g)\" stroke-width=\"2.2\" fill=\"#eaf3ff\"\/>\n <path d=\"M22 31.5l7 7L44 24\" stroke=\"#4C8FFF\" stroke-width=\"3\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/>\n <\/svg>\n <\/div>\n <h1 class=\"title\" id=\"title\">Teledentistry Patient Registration Form<\/h1>\n <div class=\"meta\">\n <span class=\"pill\"><strong>Your Smile Partners PLLC<\/strong><\/span>\n <span class=\"pill\">99 Wall St, New York, NY 10005<\/span>\n <span class=\"pill\">Email: <a href=\"mailto:talk@yoursmilepartners.com\">talk@yoursmilepartners.com<\/a><\/span>\n <span class=\"pill\">Phone: (212) 555-SMILE<\/span>\n <\/div>\n <\/header>\n <div class=\"toolbar\" role=\"toolbar\" aria-label=\"Form actions\">\n <button type=\"button\" class=\"btn\" id=\"btnPrint\">Print Form<\/button>\n <button type=\"button\" class=\"btn primary\" id=\"btnSave\">Save PDF to Device<\/button>\n <button type=\"button\" class=\"btn ok\" id=\"btnSubmit\">Submit & Upload to Dropbox<\/button>\n <button type=\"button\" class=\"btn warn\" id=\"btnClear\">Clear All Fields<\/button>\n <\/div>\n <form id=\"reg-form\" novalidate>\n <div class=\"section\">\n <div class=\"grid cols-2\">\n <div>\n <label for=\"regDate\">Registration Date<\/label>\n <div class=\"field\"><input id=\"regDate\" name=\"regDate\" type=\"date\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"patientId\">Patient ID<\/label>\n <div class=\"field\"><input id=\"patientId\" name=\"patientId\" type=\"text\" placeholder=\"Auto\/Office use or patient-supplied\" \/><\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>1. Personal Information<\/h3>\n <div class=\"grid cols-2\">\n <div>\n <label for=\"fullName\">Full Legal Name<\/label>\n <div class=\"field\"><input id=\"fullName\" name=\"fullName\" type=\"text\" required placeholder=\"First Middle Last\" \/><\/div>\n <\/div>\n <div>\n <label for=\"prefName\">Preferred Name<\/label>\n <div class=\"field\"><input id=\"prefName\" name=\"prefName\" type=\"text\" placeholder=\"Optional\" \/><\/div>\n <\/div>\n <div>\n <label for=\"ssn\">Social Security Number<\/label>\n <div class=\"field\"><input id=\"ssn\" name=\"ssn\" type=\"text\" placeholder=\"XXX-XX-XXXX\" pattern=\"^\\\\d{3}-\\\\d{2}-\\\\d{4}$\" \/><\/div>\n <div class=\"hint\">Format: 123-45-6789<\/div>\n <\/div>\n <div>\n <label for=\"dob\">Date of Birth<\/label>\n <div class=\"field\"><input id=\"dob\" name=\"dob\" type=\"date\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"age\">Age<\/label>\n <div class=\"field\"><input id=\"age\" name=\"age\" type=\"number\" min=\"0\" max=\"120\" placeholder=\"Years\" \/><\/div>\n <\/div>\n <div>\n <label>Gender<\/label>\n <div class=\"options\" role=\"radiogroup\" aria-label=\"Gender\">\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Male\" required \/> Male<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Female\" \/> Female<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Non-binary\" \/> Non-binary<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Prefer not to disclose\" \/> Prefer not to disclose<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Other\" \/> Other<\/label>\n <\/div>\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"genderOther\" name=\"genderOther\" type=\"text\" placeholder=\"If Other, specify\" \/><\/div>\n <\/div>\n <div>\n <label>Marital Status<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"marital\" value=\"Single\" \/> Single<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"marital\" value=\"Married\" \/> Married<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"marital\" value=\"Divorced\" \/> Divorced<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"marital\" value=\"Widowed\" \/> Widowed<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"marital\" value=\"Domestic Partner\" \/> Domestic Partner<\/label>\n <\/div>\n <\/div>\n <div>\n <label>Language Preference<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"lang\" value=\"English\" required \/> English<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"lang\" value=\"Spanish\" \/> Spanish<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"lang\" value=\"Other\" \/> Other<\/label>\n <\/div>\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"langOther\" name=\"langOther\" type=\"text\" placeholder=\"If Other, specify\" \/><\/div>\n <\/div>\n <div>\n <label for=\"occupation\">Occupation<\/label>\n <div class=\"field\"><input id=\"occupation\" name=\"occupation\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"employer\">Employer<\/label>\n <div class=\"field\"><input id=\"employer\" name=\"employer\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"workPhone\">Work Phone<\/label>\n <div class=\"field\"><input id=\"workPhone\" name=\"workPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <\/div>\n <div>\n <label for=\"ext\">Extension<\/label>\n <div class=\"field\"><input id=\"ext\" name=\"ext\" type=\"text\" placeholder=\"e.g., 1234\" \/><\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>2. Contact Information<\/h3>\n <p><strong>Primary Address<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div style=\"grid-column:1\/-1\">\n <label for=\"street\">Street<\/label>\n <div class=\"field\"><input id=\"street\" name=\"street\" type=\"text\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"city\">City<\/label>\n <div class=\"field\"><input id=\"city\" name=\"city\" type=\"text\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"state\">State<\/label>\n <div class=\"field\"><input id=\"state\" name=\"state\" type=\"text\" maxlength=\"2\" placeholder=\"NY\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"zip\">ZIP<\/label>\n <div class=\"field\"><input id=\"zip\" name=\"zip\" type=\"text\" pattern=\"\\\\d{5}(-\\\\d{4})?\" placeholder=\"10005\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"yearsAt\">How long at this address? Years<\/label>\n <div class=\"field\"><input id=\"yearsAt\" name=\"yearsAt\" type=\"number\" min=\"0\" placeholder=\"0\" \/><\/div>\n <\/div>\n <div>\n <label for=\"monthsAt\">Months<\/label>\n <div class=\"field\"><input id=\"monthsAt\" name=\"monthsAt\" type=\"number\" min=\"0\" max=\"11\" placeholder=\"0\" \/><\/div>\n <\/div>\n <\/div>\n <p style=\"margin-top:12px;\"><strong>Mailing Address (if different)<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div style=\"grid-column:1\/-1\">\n <label for=\"mailStreet\">Street<\/label>\n <div class=\"field\"><input id=\"mailStreet\" name=\"mailStreet\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"mailCity\">City<\/label>\n <div class=\"field\"><input id=\"mailCity\" name=\"mailCity\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"mailState\">State<\/label>\n <div class=\"field\"><input id=\"mailState\" name=\"mailState\" type=\"text\" maxlength=\"2\" placeholder=\"NY\" \/><\/div>\n <\/div>\n <div>\n <label for=\"mailZip\">ZIP<\/label>\n <div class=\"field\"><input id=\"mailZip\" name=\"mailZip\" type=\"text\" pattern=\"\\\\d{5}(-\\\\d{4})?\" placeholder=\"10005\" \/><\/div>\n <\/div>\n <\/div>\n <p style=\"margin-top:12px;\"><strong>Phone Numbers<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div>\n <label for=\"homePhone\">Home<\/label>\n <div class=\"field\"><input id=\"homePhone\" name=\"homePhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"homeMsg\" \/> May we leave messages?<\/label><\/div>\n <\/div>\n <div>\n <label for=\"cellPhone\">Cell<\/label>\n <div class=\"field\"><input id=\"cellPhone\" name=\"cellPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" required \/><\/div>\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"cellText\" \/> May we text?<\/label><\/div>\n <\/div>\n <div>\n <label for=\"workPhone2\">Work<\/label>\n <div class=\"field\"><input id=\"workPhone2\" name=\"workPhone2\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"workCall\" \/> May we call at work?<\/label><\/div>\n <\/div>\n <\/div>\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\n <div>\n <label for=\"email\">Email Address<\/label>\n <div class=\"field\"><input id=\"email\" name=\"email\" type=\"email\" required placeholder=\"you@example.com\" \/><\/div>\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"emailRem\" \/> Appointment reminders via email<\/label><\/div>\n <\/div>\n <div>\n <label>Preferred method of contact<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"prefContact\" value=\"Phone\" required \/> Phone<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"prefContact\" value=\"Text\" \/> Text<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"prefContact\" value=\"Email\" \/> Email<\/label>\n <\/div>\n <label style=\"margin-top:10px;\">Best time to contact<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"bestTime\" value=\"Morning\" \/> Morning<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"bestTime\" value=\"Afternoon\" \/> Afternoon<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"bestTime\" value=\"Evening\" \/> Evening<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"bestTime\" value=\"Anytime\" \/> Anytime<\/label>\n <\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>3. Emergency Contact Information<\/h3>\n <p><strong>Primary Emergency Contact<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div>\n <label for=\"emName\">Name<\/label>\n <div class=\"field\"><input id=\"emName\" name=\"emName\" type=\"text\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"emRelation\">Relationship<\/label>\n <div class=\"field\"><input id=\"emRelation\" name=\"emRelation\" type=\"text\" required \/><\/div>\n <\/div>\n <div>\n <label for=\"emPhone\">Phone<\/label>\n <div class=\"field\"><input id=\"emPhone\" name=\"emPhone\" type=\"tel\" required placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <\/div>\n <div>\n <label for=\"emAlt\">Alternate<\/label>\n <div class=\"field\"><input id=\"emAlt\" name=\"emAlt\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <\/div>\n <div style=\"grid-column:1\/-1\">\n <label for=\"emAddr\">Address<\/label>\n <div class=\"field\"><input id=\"emAddr\" name=\"emAddr\" type=\"text\" \/><\/div>\n <\/div>\n <\/div>\n <p style=\"margin-top:12px;\"><strong>Secondary Emergency Contact<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div>\n <label for=\"em2Name\">Name<\/label>\n <div class=\"field\"><input id=\"em2Name\" name=\"em2Name\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"em2Relation\">Relationship<\/label>\n <div class=\"field\"><input id=\"em2Relation\" name=\"em2Relation\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"em2Phone\">Phone<\/label>\n <div class=\"field\"><input id=\"em2Phone\" name=\"em2Phone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <\/div>\n <div>\n <label for=\"em2Alt\">Alternate<\/label>\n <div class=\"field\"><input id=\"em2Alt\" name=\"em2Alt\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>4. Insurance Information<\/h3>\n <p><strong>Primary Dental Insurance<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div><label for=\"pInsCo\">Insurance Company<\/label><div class=\"field\"><input id=\"pInsCo\" name=\"pInsCo\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"pInsPhone\">Phone Number<\/label><div class=\"field\"><input id=\"pInsPhone\" name=\"pInsPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div><\/div>\n <div><label for=\"pPolicyId\">Policy\/Member ID<\/label><div class=\"field\"><input id=\"pPolicyId\" name=\"pPolicyId\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"pGroup\">Group Number<\/label><div class=\"field\"><input id=\"pGroup\" name=\"pGroup\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"pSubName\">Subscriber Name<\/label><div class=\"field\"><input id=\"pSubName\" name=\"pSubName\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"pSubDob\">Subscriber DOB<\/label><div class=\"field\"><input id=\"pSubDob\" name=\"pSubDob\" type=\"date\" \/><\/div><\/div>\n <div>\n <label>Relationship to Subscriber<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"pRel\" value=\"Self\" \/> Self<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"pRel\" value=\"Spouse\" \/> Spouse<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"pRel\" value=\"Child\" \/> Child<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"pRel\" value=\"Other\" \/> Other<\/label>\n <\/div>\n <\/div>\n <div><label for=\"pSubEmployer\">Subscriber Employer<\/label><div class=\"field\"><input id=\"pSubEmployer\" name=\"pSubEmployer\" type=\"text\" \/><\/div><\/div>\n <div style=\"grid-column:1\/-1\"><label for=\"pEmpAddr\">Employer Address<\/label><div class=\"field\"><input id=\"pEmpAddr\" name=\"pEmpAddr\" type=\"text\" \/><\/div><\/div>\n <\/div>\n <p style=\"margin-top:12px;\"><strong>Secondary Dental Insurance (if applicable)<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div><label for=\"sInsCo\">Insurance Company<\/label><div class=\"field\"><input id=\"sInsCo\" name=\"sInsCo\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"sInsPhone\">Phone Number<\/label><div class=\"field\"><input id=\"sInsPhone\" name=\"sInsPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div><\/div>\n <div><label for=\"sPolicyId\">Policy\/Member ID<\/label><div class=\"field\"><input id=\"sPolicyId\" name=\"sPolicyId\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"sGroup\">Group Number<\/label><div class=\"field\"><input id=\"sGroup\" name=\"sGroup\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"sSubName\">Subscriber Name<\/label><div class=\"field\"><input id=\"sSubName\" name=\"sSubName\" type=\"text\" \/><\/div><\/div>\n <\/div>\n <p style=\"margin-top:12px;\"><strong>Medical Insurance<\/strong><\/p>\n <div class=\"grid cols-2\">\n <div><label for=\"mInsCo\">Insurance Company<\/label><div class=\"field\"><input id=\"mInsCo\" name=\"mInsCo\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"mPolicyId\">Policy\/Member ID<\/label><div class=\"field\"><input id=\"mPolicyId\" name=\"mPolicyId\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"mGroup\">Group Number<\/label><div class=\"field\"><input id=\"mGroup\" name=\"mGroup\" type=\"text\" \/><\/div><\/div>\n <\/div>\n <div class=\"section\" style=\"margin:12px 0 0 0;\">\n <h3>Insurance Authorization<\/h3>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"authFileClaims\" \/> File insurance claims on my behalf<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"authAssignBenefits\" \/> Accept assignment of benefits<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"authReleaseInfo\" \/> Release necessary information to process claims<\/label>\n <\/div>\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\n <div>\n <label>Signature (Insurance Authorization)<\/label>\n <div class=\"sig-pad\">\n <canvas class=\"signature\" id=\"sigIns\" aria-label=\"Insurance authorization signature\"><\/canvas>\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigIns\">Clear<\/button><\/div>\n <\/div>\n <\/div>\n <div>\n <label for=\"insDate\">Date<\/label>\n <div class=\"field\"><input id=\"insDate\" name=\"insDate\" type=\"date\" \/><\/div>\n <\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>5. Referral Information<\/h3>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Internet search\" \/> Internet search<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Google reviews\" \/> Google reviews<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Social media\" \/> Social media<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Insurance directory\" \/> Insurance directory<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Friend\/family referral\" \/> Friend\/family referral<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Healthcare provider referral\" \/> Healthcare provider referral<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Advertisement\" \/> Advertisement<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Previous patient\" \/> Previous patient<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"ref\" value=\"Other\" \/> Other<\/label>\n <\/div>\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\n <div>\n <label for=\"refOther\">If Other<\/label>\n <div class=\"field\"><input id=\"refOther\" name=\"refOther\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"refName\">Referring person\/practice name<\/label>\n <div class=\"field\"><input id=\"refName\" name=\"refName\" type=\"text\" \/><\/div>\n <div class=\"options\" style=\"margin-top:6px;\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"thankRef\" \/> May we thank them for the referral?<\/label>\n <\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>6. Appointment & Communication Preferences<\/h3>\n <p><strong>Preferred appointment times<\/strong><\/p>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"apptTime\" value=\"Early morning (7-9 AM)\" \/> Early morning (7-9 AM)<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"apptTime\" value=\"Morning (9-11 AM)\" \/> Morning (9-11 AM)<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"apptTime\" value=\"Midday (11 AM-1 PM)\" \/> Midday (11 AM-1 PM)<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"apptTime\" value=\"Afternoon (1-4 PM)\" \/> Afternoon (1-4 PM)<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"apptTime\" value=\"Late afternoon (4-6 PM)\" \/> Late afternoon (4-6 PM)<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"apptTime\" value=\"Evening (6-8 PM)\" \/> Evening (6-8 PM)<\/label>\n <\/div>\n <p style=\"margin-top:10px;\"><strong>Preferred days<\/strong><\/p>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"day\" value=\"Monday\" \/> Monday<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"day\" value=\"Tuesday\" \/> Tuesday<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"day\" value=\"Wednesday\" \/> Wednesday<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"day\" value=\"Thursday\" \/> Thursday<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"day\" value=\"Friday\" \/> Friday<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"day\" value=\"Saturday\" \/> Saturday<\/label>\n <\/div>\n <p style=\"margin-top:10px;\"><strong>Teledentistry platform preferences<\/strong><\/p>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"platform\" value=\"Zoom\" \/> Zoom<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"platform\" value=\"Doxy.me\" \/> Doxy.me<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"platform\" value=\"Microsoft Teams\" \/> Microsoft Teams<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"platform\" value=\"FaceTime\" \/> FaceTime<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"platform\" value=\"No preference\" \/> No preference<\/label>\n <\/div>\n <p style=\"margin-top:10px;\"><strong>Reminder preferences<\/strong><\/p>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"reminder\" value=\"Phone call\" \/> Phone call<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"reminder\" value=\"Text message\" \/> Text message<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"reminder\" value=\"Email\" \/> Email<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"reminder\" value=\"No reminders\" \/> No reminders<\/label>\n <\/div>\n <div class=\"options\" style=\"margin-top:8px;\">\n <label class=\"opt\"><input type=\"radio\" name=\"remindWhen\" value=\"24 hours\" \/> 24 hours<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"remindWhen\" value=\"48 hours\" \/> 48 hours<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"remindWhen\" value=\"1 week\" \/> 1 week<\/label>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>7. Technology Information<\/h3>\n <div class=\"grid cols-2\">\n <div>\n <label>Primary device<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"iPhone\" required \/> iPhone<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Android phone\" \/> Android phone<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"iPad\" \/> iPad<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Android tablet\" \/> Android tablet<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Windows laptop\/desktop\" \/> Windows laptop\/desktop<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Mac laptop\/desktop\" \/> Mac laptop\/desktop<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Chromebook\" \/> Chromebook<\/label>\n <\/div>\n <\/div>\n <div>\n <label>Internet connection<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"High-speed WiFi\" required \/> High-speed WiFi<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"Mobile data\" \/> Mobile data<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"DSL\/Cable\" \/> DSL\/Cable<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"Fiber optic\" \/> Fiber optic<\/label>\n <\/div>\n <\/div>\n <div>\n <label>Camera quality<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"cam\" value=\"HD (1080p)\" \/> HD (1080p)<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"cam\" value=\"4K\" \/> 4K<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"cam\" value=\"Standard\" \/> Standard<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"cam\" value=\"Unsure\" \/> Unsure<\/label>\n <\/div>\n <\/div>\n <div>\n <label>Environment<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"privateSpace\" value=\"Yes\" required \/> I have a quiet, private space<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"privateSpace\" value=\"No\" \/> I do not have a private space<\/label>\n <\/div>\n <div class=\"options\" style=\"margin-top:8px;\">\n <label class=\"opt\"><input type=\"radio\" name=\"techAssist\" value=\"Yes\" \/> I need technical assistance<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"techAssist\" value=\"No\" \/> I do not need assistance<\/label>\n <\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>8. Financial Information<\/h3>\n <div class=\"grid cols-2\">\n <div>\n <label>Employment Status<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"empStatus\" value=\"Full-time\" \/> Full-time<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"empStatus\" value=\"Part-time\" \/> Part-time<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"empStatus\" value=\"Self-employed\" \/> Self-employed<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"empStatus\" value=\"Retired\" \/> Retired<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"empStatus\" value=\"Student\" \/> Student<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"empStatus\" value=\"Unemployed\" \/> Unemployed<\/label>\n <\/div>\n <\/div>\n <div>\n <label>Payment responsibility<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"payResp\" value=\"Self\" \/> Self<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"payResp\" value=\"Parent\/guardian\" \/> Parent\/guardian<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"payResp\" value=\"Spouse\" \/> Spouse<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"payResp\" value=\"Insurance only\" \/> Insurance only<\/label>\n <\/div>\n <\/div>\n <\/div>\n <p style=\"margin-top:10px;\"><strong>Preferred payment method<\/strong><\/p>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"payMethod\" value=\"Cash\" \/> Cash<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"payMethod\" value=\"Check\" \/> Check<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"payMethod\" value=\"Credit card\" \/> Credit card<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"payMethod\" value=\"Debit card\" \/> Debit card<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"payMethod\" value=\"HSA\/FSA\" \/> HSA\/FSA<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"payMethod\" value=\"Payment plan\" \/> Payment plan<\/label>\n <\/div>\n <p style=\"margin-top:10px;\"><strong>Credit card information (for deposits\/copays)<\/strong><\/p>\n <div class=\"grid cols-4\">\n <div style=\"grid-column: span 1;\">\n <label>Card Type<\/label>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"ccType\" value=\"Visa\" \/> Visa<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"ccType\" value=\"MasterCard\" \/> MasterCard<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"ccType\" value=\"American Express\" \/> American Express<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"ccType\" value=\"Discover\" \/> Discover<\/label>\n <\/div>\n <\/div>\n <div style=\"grid-column: span 3;\">\n <label for=\"ccNumber\">Number<\/label>\n <div class=\"field\"><input id=\"ccNumber\" name=\"ccNumber\" type=\"text\" inputmode=\"numeric\" placeholder=\"\u2022\u2022\u2022\u2022 \u2022\u2022\u2022\u2022 \u2022\u2022\u2022\u2022 \u2022\u2022\u2022\u2022\" \/><\/div>\n <\/div>\n <div>\n <label for=\"ccExp\">Expiration (MM\/YY)<\/label>\n <div class=\"field\"><input id=\"ccExp\" name=\"ccExp\" type=\"text\" placeholder=\"MM\/YY\" \/><\/div>\n <\/div>\n <div style=\"grid-column: span 2;\">\n <label for=\"ccName\">Name on Card<\/label>\n <div class=\"field\"><input id=\"ccName\" name=\"ccName\" type=\"text\" \/><\/div>\n <\/div>\n <div>\n <label for=\"ccZip\">Billing ZIP<\/label>\n <div class=\"field\"><input id=\"ccZip\" name=\"ccZip\" type=\"text\" pattern=\"\\\\d{5}(-\\\\d{4})?\" placeholder=\"10005\" \/><\/div>\n <\/div>\n <div>\n <label for=\"ccCVV\">CVV<\/label>\n <div class=\"field\"><input id=\"ccCVV\" name=\"ccCVV\" type=\"text\" inputmode=\"numeric\" placeholder=\"3-4 digits\" \/><\/div>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>9. Legal Guardian Information (if patient is minor)<\/h3>\n <div class=\"grid cols-2\">\n <div><label for=\"gName\">Guardian Name<\/label><div class=\"field\"><input id=\"gName\" name=\"gName\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"gRel\">Relationship<\/label><div class=\"field\"><input id=\"gRel\" name=\"gRel\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"gDob\">Date of Birth<\/label><div class=\"field\"><input id=\"gDob\" name=\"gDob\" type=\"date\" \/><\/div><\/div>\n <div><label for=\"gSSN\">SSN<\/label><div class=\"field\"><input id=\"gSSN\" name=\"gSSN\" type=\"text\" placeholder=\"XXX-XX-XXXX\" pattern=\"^\\\\d{3}-\\\\d{2}-\\\\d{4}$\" \/><\/div><\/div>\n <div><label for=\"gEmployer\">Employer<\/label><div class=\"field\"><input id=\"gEmployer\" name=\"gEmployer\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"gWorkPhone\">Work Phone<\/label><div class=\"field\"><input id=\"gWorkPhone\" name=\"gWorkPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div><\/div>\n <\/div>\n <h3 style=\"margin-top:12px;\">Second Guardian\/Parent<\/h3>\n <div class=\"grid cols-2\">\n <div><label for=\"g2Name\">Name<\/label><div class=\"field\"><input id=\"g2Name\" name=\"g2Name\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"g2Rel\">Relationship<\/label><div class=\"field\"><input id=\"g2Rel\" name=\"g2Rel\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"g2Phone\">Phone<\/label><div class=\"field\"><input id=\"g2Phone\" name=\"g2Phone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div><\/div>\n <\/div>\n <h3 style=\"margin-top:12px;\">Custody Information<\/h3>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"custody\" value=\"Both parents have equal rights\" \/> Both parents have equal rights<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"custody\" value=\"Sole custody\" \/> Sole custody (specify)<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"custody\" value=\"Court order on file\" \/> Court order on file<\/label>\n <\/div>\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"custodyDetail\" name=\"custodyDetail\" type=\"text\" placeholder=\"If sole custody or court order, provide details\" \/><\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>10. Marketing & Communication Consent<\/h3>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Appointment reminders\" \/> Appointment reminders<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Treatment follow-up communications\" \/> Treatment follow-up communications<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Oral health education materials\" \/> Oral health education materials<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Practice newsletters\" \/> Practice newsletters<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Promotional offers\" \/> Promotional offers<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Birthday\/holiday greetings\" \/> Birthday\/holiday greetings<\/label>\n <label class=\"opt\"><input type=\"checkbox\" name=\"mkt\" value=\"Patient satisfaction surveys\" \/> Patient satisfaction surveys<\/label>\n <\/div>\n <p style=\"margin-top:8px;\"><strong>Preferred communication method for marketing<\/strong><\/p>\n <div class=\"options\">\n <label class=\"opt\"><input type=\"radio\" name=\"mktMethod\" value=\"Email\" \/> Email<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"mktMethod\" value=\"Text message\" \/> Text message<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"mktMethod\" value=\"Phone call\" \/> Phone call<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"mktMethod\" value=\"Mail\" \/> Mail<\/label>\n <label class=\"opt\"><input type=\"radio\" name=\"mktMethod\" value=\"None\" \/> None<\/label>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>11. Authorization & Signature<\/h3>\n <ul class=\"hint\" style=\"padding-left:18px; margin:8px 0;\">\n <li>I certify that the information provided is true and complete.<\/li>\n <li>I am financially responsible for all services provided, and payment is due at time of service unless arranged otherwise.<\/li>\n <li>I will provide 24-hour notice for cancellations; a fee may apply for missed appointments.<\/li>\n <li>I authorize Your Smile Partners PLLC to perform necessary teledentistry services.<\/li>\n <\/ul>\n <div class=\"ack\" style=\"margin:10px 0;\">\n <input id=\"authAck\" type=\"checkbox\" required \/>\n <label for=\"authAck\">I agree to the Authorization statements above.<\/label>\n <\/div>\n <div class=\"grid cols-2\">\n <div>\n <label>Patient Signature<\/label>\n <div class=\"sig-pad\">\n <canvas class=\"signature\" id=\"sigPatient\" aria-label=\"Patient signature\"><\/canvas>\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigPatient\">Clear<\/button><\/div>\n <\/div>\n <\/div>\n <div>\n <label for=\"authDate\">Date<\/label>\n <div class=\"field\"><input id=\"authDate\" name=\"authDate\" type=\"date\" required \/><\/div>\n <\/div>\n <\/div>\n <h3 style=\"margin-top:12px;\">If signed by guardian\/representative<\/h3>\n <div class=\"grid cols-2\">\n <div><label for=\"repName\">Name<\/label><div class=\"field\"><input id=\"repName\" name=\"repName\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"repRel\">Relationship to Patient<\/label><div class=\"field\"><input id=\"repRel\" name=\"repRel\" type=\"text\" \/><\/div><\/div>\n <div>\n <label>Representative Signature<\/label>\n <div class=\"sig-pad\">\n <canvas class=\"signature\" id=\"sigRep\" aria-label=\"Representative signature\"><\/canvas>\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigRep\">Clear<\/button><\/div>\n <\/div>\n <\/div>\n <div><label for=\"repDate\">Date<\/label><div class=\"field\"><input id=\"repDate\" name=\"repDate\" type=\"date\" \/><\/div><\/div>\n <\/div>\n <\/div>\n \n <div class=\"section\">\n <h3>12. Office Use Only<\/h3>\n <div class=\"grid cols-3\">\n <div><label for=\"regBy\">Registration completed by<\/label><div class=\"field\"><input id=\"regBy\" name=\"regBy\" type=\"text\" \/><\/div><\/div>\n <div><label for=\"procDate\">Date processed<\/label><div class=\"field\"><input id=\"procDate\" name=\"procDate\" type=\"date\" \/><\/div><\/div>\n <div><label for=\"procTime\">Time<\/label><div class=\"field\"><input id=\"procTime\" name=\"procTime\" type=\"text\" placeholder=\"HH:MM AM\/PM\" \/><\/div><\/div>\n <\/div>\n <div class=\"grid cols-3\" style=\"margin-top:10px;\">\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"insVerified\" \/> Insurance verified<\/label><\/div>\n <div><label for=\"insVerDate\">Date<\/label><div class=\"field\"><input id=\"insVerDate\" name=\"insVerDate\" type=\"date\" \/><\/div><\/div>\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"techTest\" \/> Technology test completed<\/label><\/div>\n <\/div>\n <div class=\"grid cols-3\" style=\"margin-top:10px;\">\n <div><label for=\"techDate\">Tech test date<\/label><div class=\"field\"><input id=\"techDate\" name=\"techDate\" type=\"date\" \/><\/div><\/div>\n <div class=\"options\"><label class=\"opt\"><input type=\"checkbox\" name=\"welcomeSent\" \/> Welcome packet sent<\/label><\/div>\n <div><label for=\"welcomeMethod\">Method<\/label><div class=\"field\"><input id=\"welcomeMethod\" name=\"welcomeMethod\" type=\"text\" placeholder=\"Email\/Mail\/Other\" \/><\/div><\/div>\n <\/div>\n <div class=\"grid cols-3\" style=\"margin-top:10px;\">\n <div><label for=\"firstApptDate\">First appointment date<\/label><div class=\"field\"><input id=\"firstApptDate\" name=\"firstApptDate\" type=\"date\" \/><\/div><\/div>\n <div><label for=\"firstApptTime\">Time<\/label><div class=\"field\"><input id=\"firstApptTime\" name=\"firstApptTime\" type=\"text\" placeholder=\"HH:MM\" \/><\/div><\/div>\n <div><label for=\"provider\">Provider assigned<\/label><div class=\"field\"><input id=\"provider\" name=\"provider\" type=\"text\" \/><\/div><\/div>\n <\/div>\n <div style=\"margin-top:10px;\">\n <label for=\"notes\">Notes<\/label>\n <div class=\"field\"><textarea id=\"notes\" name=\"notes\" placeholder=\"Internal notes\"><\/textarea><\/div>\n <\/div>\n <\/div>\n <div class=\"section\">\n <p class=\"note\"><strong>Thank you for choosing Your Smile Partners PLLC<\/strong> for your teledentistry needs. We look forward to providing you with exceptional virtual dental care. If you have any questions, please contact us at <a href=\"mailto:talk@yoursmilepartners.com\">talk@yoursmilepartners.com<\/a>.<\/p>\n <\/div>\n <\/form>\n <div class=\"footer\">\n <div class=\"note\">Use \u201cPrint Form\u201d for a paper copy, \u201cSave PDF\u201d to store locally, or \u201cSubmit & Upload\u201d to save a PDF and go to our secure Dropbox page.<\/div>\n <div style=\"display:flex; gap:10px;\">\n <button type=\"button\" class=\"btn\" id=\"btnPrint2\">Print Form<\/button>\n <button type=\"button\" class=\"btn primary\" id=\"btnSave2\">Save PDF<\/button>\n <button type=\"button\" class=\"btn ok\" id=\"btnSubmit2\">Submit & Upload<\/button>\n <\/div>\n <\/div>\n<\/section>\n<\/main> <div class=\"toast\" id=\"toast\" role=\"status\" aria-live=\"polite\" aria-atomic=\"true\">Ready<\/div> <script src=\"https:\/\/cdn.jsdelivr.net\/npm\/html2pdf.js@0.10.1\/dist\/html2pdf.bundle.min.js\" crossorigin=\"anonymous\"><\/script> <script> (function(){ const dropboxURL = 'https:\/\/www.dropbox.com\/request\/gdRmWuwrMys3cW8R8Xua'; const form = document.getElementById('reg-form'); const card = document.getElementById('form-card'); const toast = document.getElementById('toast');\n const btnPrint = document.getElementById('btnPrint');\n const btnPrint2 = document.getElementById('btnPrint2');\n const btnSave = document.getElementById('btnSave');\n const btnSave2 = document.getElementById('btnSave2');\n const btnSubmit = document.getElementById('btnSubmit');\n const btnSubmit2 = document.getElementById('btnSubmit2');\n const btnClear = document.getElementById('btnClear');\n \/\/ Signature pads\n const pads = {\n sigPatient: setupSignaturePad(document.getElementById('sigPatient')),\n sigRep: setupSignaturePad(document.getElementById('sigRep')),\n sigIns: setupSignaturePad(document.getElementById('sigIns'))\n };\n document.querySelectorAll('[data-clear]').forEach(btn=>{\n btn.addEventListener('click', ()=>{\n const id = btn.getAttribute('data-clear');\n pads[id]?.clear();\n });\n });\n \/\/ Default dates to today\n const todayISO = (new Date()).toISOString().slice(0,10);\n const defaultDateIds = ['regDate','authDate','insDate'];\n defaultDateIds.forEach(id => { const el = document.getElementById(id); if(el && !el.value) el.value = todayISO; });\n \/\/ Toast helper\n let tmr;\n function showToast(msg){\n toast.textContent = msg;\n toast.classList.add('show');\n clearTimeout(tmr);\n tmr = setTimeout(()=> toast.classList.remove('show'), 1800);\n }\n \/\/ Print\n function doPrint(){ window.print(); }\n btnPrint.addEventListener('click', doPrint);\n btnPrint2.addEventListener('click', doPrint);\n \/\/ Minimal validation (key fields)\n function validateForm(){\n const must = ['fullName','dob','cellPhone','email','authDate'];\n for(const id of must){\n const el = document.getElementById(id);\n if(!el || (el.value || '').trim() === ''){\n el?.scrollIntoView({behavior:'smooth', block:'center'});\n el?.focus?.({preventScroll:true});\n showToast('Please complete required fields.');\n return false;\n }\n }\n const authAck = document.getElementById('authAck');\n if(authAck && !authAck.checked){\n authAck.scrollIntoView({behavior:'smooth', block:'center'});\n showToast('Please agree to the authorization.');\n return false;\n }\n if(pads.sigPatient && pads.sigPatient.isBlank()){\n document.getElementById('sigPatient').scrollIntoView({behavior:'smooth', block:'center'});\n showToast('Please add your signature.');\n return false;\n }\n return true;\n }\n function makeFileName(){\n const name = (document.getElementById('fullName').value || 'Patient').trim().replace(\/\\s+\/g,'_');\n const date = (document.getElementById('authDate').value || todayISO);\n return `Teledentistry_Registration_${name}_${date}.pdf`;\n }\n \/\/ Save PDF\n async function savePDF(){\n await ensureSignatures();\n const opt = {\n margin: 0.4,\n filename: makeFileName(),\n image: { type: 'jpeg', quality: 0.98 },\n html2canvas: { scale: 2, useCORS: true, backgroundColor: '#ffffff' },\n jsPDF: { unit: 'in', format: 'letter', orientation: 'portrait' },\n pagebreak: { mode: ['css','legacy'] }\n };\n await html2pdf().from(card).set(opt).save();\n }\n btnSave.addEventListener('click', async ()=>{\n if(!validateForm()) return;\n await savePDF();\n showToast('PDF saved to your device.');\n });\n btnSave2.addEventListener('click', async ()=>{\n if(!validateForm()) return;\n await savePDF();\n showToast('PDF saved to your device.');\n });\n \/\/ Submit & Upload: save then redirect to Dropbox Request\n async function submitAndUpload(){\n if(!validateForm()) return;\n \/\/ Pre-open a tab to avoid popup blockers\n let uploadWin;\n try{\n uploadWin = window.open('about:blank', '_blank');\n if(uploadWin){\n uploadWin.document.write('<!DOCTYPE html><title>Redirecting\u2026<\/title><p style=\"font-family:Roboto,system-ui;padding:20px;\">Preparing your PDF\u2026 You will be redirected to our secure Dropbox upload.<\/p>');\n }\n }catch(e){}\n try{\n await savePDF();\n showToast('PDF saved. Redirecting to Dropbox\u2026');\n }catch(err){\n console.error(err);\n showToast('PDF error. Opening print dialog instead.');\n window.print();\n }\n try{\n if(uploadWin && !uploadWin.closed){\n uploadWin.location.href = dropboxURL;\n uploadWin.focus();\n }else{\n window.open(dropboxURL, '_blank');\n }\n }catch(e){\n window.open(dropboxURL, '_blank');\n }\n }\n btnSubmit.addEventListener('click', submitAndUpload);\n btnSubmit2.addEventListener('click', submitAndUpload);\n \/\/ Clear\n btnClear.addEventListener('click', ()=>{\n if(!confirm('Clear all fields and signatures?')) return;\n form.reset();\n defaultDateIds.forEach(id => { const el = document.getElementById(id); if(el) el.value = todayISO; });\n pads.sigPatient?.clear(); pads.sigRep?.clear(); pads.sigIns?.clear();\n showToast('Form cleared.');\n });\n \/\/ Placeholder (can extend if needed)\n async function ensureSignatures(){ return true; }\n \/\/ Lightweight signature pad\n function setupSignaturePad(canvas){\n const ctx = canvas.getContext('2d');\n const state = { drawing:false, blank:true, lastX:0, lastY:0 };\n function resize(){\n const ratio = Math.max(window.devicePixelRatio || 1, 1);\n const rect = canvas.getBoundingClientRect();\n canvas.width = rect.width * ratio;\n canvas.height = rect.height * ratio;\n ctx.setTransform(ratio, 0, 0, ratio, 0, 0);\n ctx.lineCap = 'round';\n ctx.lineJoin = 'round';\n ctx.lineWidth = 2.2;\n ctx.strokeStyle = '#18223b';\n ctx.clearRect(0,0,canvas.width,canvas.height);\n state.blank = true;\n }\n window.addEventListener('resize', resize, { passive:true });\n resize();\n function getPos(e){\n const r = canvas.getBoundingClientRect();\n const p = e.touches ? e.touches[0] : e;\n return { x: p.clientX - r.left, y: p.clientY - r.top };\n }\n function start(e){ e.preventDefault(); state.drawing=true; const p=getPos(e); state.lastX=p.x; state.lastY=p.y; }\n function move(e){\n if(!state.drawing) return;\n e.preventDefault();\n const p = getPos(e);\n ctx.beginPath(); ctx.moveTo(state.lastX, state.lastY); ctx.lineTo(p.x,p.y); ctx.stroke();\n state.lastX = p.x; state.lastY = p.y; state.blank = false;\n }\n function end(){ state.drawing=false; }\n canvas.addEventListener('mousedown', start);\n canvas.addEventListener('mousemove', move);\n window.addEventListener('mouseup', end);\n canvas.addEventListener('touchstart', start, { passive:false });\n canvas.addEventListener('touchmove', move, { passive:false });\n canvas.addEventListener('touchend', end);\n function clear(){ ctx.clearRect(0,0,canvas.width,canvas.height); state.blank = true; }\n function isBlank(){ return state.blank; }\n return { clear, isBlank };\n }\n})();\n<\/script> <\/body> <\/html>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Your Smile Partners PLLC \u2014 Teledentistry Patient Registration Form Teledentistry Patient Registration Form Your Smile Partners PLLC 99 Wall St, New York, NY 10005 Email: talk@yoursmilepartners.com Phone: (212) 555-SMILE Print Form Save PDF to Device Submit & Upload to Dropbox Clear All Fields Registration Date Patient ID 1. Personal Information Full Legal Name Preferred Name…<\/p>\n<p><a class=\"btn btn-outline-dark btn-sm anzu-read-more-link\" href=\"https:\/\/stephanie.openteledentistry.com\/?page_id=807\">Continue Reading<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"content-type":"","footnotes":""},"class_list":["post-807","page","type-page","status-publish","hentry"],"_hostinger_reach_plugin_has_subscription_block":false,"_hostinger_reach_plugin_is_elementor":false,"_links":{"self":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/807","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=807"}],"version-history":[{"count":4,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/807\/revisions"}],"predecessor-version":[{"id":811,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/807\/revisions\/811"}],"wp:attachment":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=807"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}