Your Smile Partners PLLC \u2014 Teledentistry New Patient Intake 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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This information is kept confidential under HIPAA regulations.<\/h3>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>1. Patient Demographics<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label for=\"fullName\">Full Name<\/label>\r\n <div class=\"field\"><input id=\"fullName\" name=\"fullName\" type=\"text\" required placeholder=\"First and last name\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"prefName\">Preferred Name\/Nickname<\/label>\r\n <div class=\"field\"><input id=\"prefName\" name=\"prefName\" type=\"text\" placeholder=\"Optional\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"dob\">Date of Birth<\/label>\r\n <div class=\"field\"><input id=\"dob\" name=\"dob\" type=\"date\" required \/><\/div>\r\n <\/div>\r\n <div>\r\n <label>Gender<\/label>\r\n <div class=\"options\" role=\"radiogroup\" aria-label=\"Gender\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Male\" required \/> Male<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Female\" \/> Female<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Non-binary\" \/> Non-binary<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Prefer not to say\" \/> Prefer not to say<\/label>\r\n <\/div>\r\n <\/div>\r\n <div style=\"grid-column: 1 \/ -1;\">\r\n <label for=\"address\">Address<\/label>\r\n <div class=\"field\"><input id=\"address\" name=\"address\" type=\"text\" required placeholder=\"Street address\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"city\">City<\/label>\r\n <div class=\"field\"><input id=\"city\" name=\"city\" type=\"text\" required \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"state\">State<\/label>\r\n <div class=\"field\"><input id=\"state\" name=\"state\" type=\"text\" required maxlength=\"2\" placeholder=\"NY\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"zip\">ZIP<\/label>\r\n <div class=\"field\"><input id=\"zip\" name=\"zip\" type=\"text\" required pattern=\"\\\\d{5}(-\\\\d{4})?\" placeholder=\"10005\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"homePhone\">Home Phone<\/label>\r\n <div class=\"field\"><input id=\"homePhone\" name=\"homePhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"cellPhone\">Cell Phone<\/label>\r\n <div class=\"field\"><input id=\"cellPhone\" name=\"cellPhone\" type=\"tel\" required placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"email\">Email Address<\/label>\r\n <div class=\"field\"><input id=\"email\" name=\"email\" type=\"email\" required placeholder=\"you@example.com\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label>Preferred Method of Contact<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"contactPref\" value=\"Phone\" required \/> Phone<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"contactPref\" value=\"SMS\" \/> SMS<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"contactPref\" value=\"Email\" \/> Email<\/label>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>2. Emergency Contact<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label for=\"ecName\">Name<\/label>\r\n <div class=\"field\"><input id=\"ecName\" name=\"ecName\" type=\"text\" required \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"ecRelation\">Relationship<\/label>\r\n <div class=\"field\"><input id=\"ecRelation\" name=\"ecRelation\" type=\"text\" required \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"ecPhone\">Phone<\/label>\r\n <div class=\"field\"><input id=\"ecPhone\" name=\"ecPhone\" type=\"tel\" required placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"ecAltPhone\">Alternate Phone<\/label>\r\n <div class=\"field\"><input id=\"ecAltPhone\" name=\"ecAltPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>3. Insurance Information<\/h3>\r\n <p><strong>Primary Dental Insurance<\/strong><\/p>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label for=\"priInsCo\">Insurance Company<\/label>\r\n <div class=\"field\"><input id=\"priInsCo\" name=\"priInsCo\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"priPolicy\">Policy\/ID Number<\/label>\r\n <div class=\"field\"><input id=\"priPolicy\" name=\"priPolicy\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"priGroup\">Group Number<\/label>\r\n <div class=\"field\"><input id=\"priGroup\" name=\"priGroup\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"priSubName\">Subscriber Name<\/label>\r\n <div class=\"field\"><input id=\"priSubName\" name=\"priSubName\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"priSubDob\">Subscriber Date of Birth<\/label>\r\n <div class=\"field\"><input id=\"priSubDob\" name=\"priSubDob\" type=\"date\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"priEmployer\">Subscriber Employer<\/label>\r\n <div class=\"field\"><input id=\"priEmployer\" name=\"priEmployer\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <p style=\"margin-top:12px;\"><strong>Secondary Dental Insurance (if applicable)<\/strong><\/p>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label for=\"secInsCo\">Insurance Company<\/label>\r\n <div class=\"field\"><input id=\"secInsCo\" name=\"secInsCo\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"secPolicy\">Policy\/ID Number<\/label>\r\n <div class=\"field\"><input id=\"secPolicy\" name=\"secPolicy\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"secGroup\">Group Number<\/label>\r\n <div class=\"field\"><input id=\"secGroup\" name=\"secGroup\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <div class=\"ack\" style=\"margin-top:12px;\">\r\n <input id=\"insAuth\" type=\"checkbox\" \/>\r\n <label for=\"insAuth\">I authorize release of dental information to my insurance carrier and assign benefits directly to Your Smile Partners PLLC.<\/label>\r\n <\/div>\r\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\r\n <div>\r\n <label>Signature (Insurance Authorization)<\/label>\r\n <div class=\"sig-pad\">\r\n <canvas class=\"signature\" id=\"sigIns\" aria-label=\"Insurance authorization signature\"><\/canvas>\r\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigIns\">Clear<\/button><\/div>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"insDate\">Date<\/label>\r\n <div class=\"field\"><input id=\"insDate\" name=\"insDate\" type=\"date\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>4. Medical & Dental History<\/h3>\r\n <h3 style=\"margin-top:6px;\">4.1 Medical History<\/h3>\r\n <p>Have you ever been diagnosed with or had treatment for any of the following? (Check all that apply)<\/p>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Heart disease\/attack\" \/> Heart disease\/attack<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"High blood pressure\" \/> High blood pressure<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Stroke\" \/> Stroke<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Diabetes\" \/> Diabetes<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Thyroid disorder\" \/> Thyroid disorder<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Cancer\" \/> Cancer<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Hepatitis\" \/> Hepatitis<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"HIV\/AIDS\" \/> HIV\/AIDS<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Respiratory disease\" \/> Respiratory disease<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Kidney disease\" \/> Kidney disease<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Liver disease\" \/> Liver disease<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Autoimmune disorder\" \/> Autoimmune disorder<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Psychiatric care\" \/> Psychiatric care<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Joint replacement\" \/> Joint replacement<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Bleeding disorder\" \/> Bleeding disorder<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Sleep apnea\" \/> Sleep apnea<\/label>\r\n <\/div>\r\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\r\n <div>\r\n <label for=\"cancerType\">If Cancer, type<\/label>\r\n <div class=\"field\"><input id=\"cancerType\" name=\"cancerType\" type=\"text\" placeholder=\"Type\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"jointDate\">If Joint replacement, date<\/label>\r\n <div class=\"field\"><input id=\"jointDate\" name=\"jointDate\" type=\"date\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label for=\"medOther\">Other conditions<\/label>\r\n <div class=\"field\"><input id=\"medOther\" name=\"medOther\" type=\"text\" placeholder=\"Describe any other conditions\" \/><\/div>\r\n <\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label for=\"hospitalizations\">List any hospitalizations or surgeries (with dates)<\/label>\r\n <div class=\"field\"><textarea id=\"hospitalizations\" name=\"hospitalizations\" placeholder=\"Procedures and dates\"><\/textarea><\/div>\r\n <\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label for=\"medications\">Current medications (include dosage)<\/label>\r\n <div class=\"field\"><textarea id=\"medications\" name=\"medications\" placeholder=\"Medication name \u2014 dosage \u2014 frequency\"><\/textarea><\/div>\r\n <\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label for=\"allergies\">Allergies (medications, latex, foods, environmental)<\/label>\r\n <div class=\"field\"><textarea id=\"allergies\" name=\"allergies\"><\/textarea><\/div>\r\n <\/div>\r\n <h3 style=\"margin-top:14px;\">4.2 Dental History<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label for=\"visitReason\">Reason for today\u2019s visit<\/label>\r\n <div class=\"field\"><input id=\"visitReason\" name=\"visitReason\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"lastExam\">Date of last dental exam and cleaning<\/label>\r\n <div class=\"field\"><input id=\"lastExam\" name=\"lastExam\" type=\"date\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <p style=\"margin-top:6px;\">Have you experienced any of the following?<\/p>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Tooth pain\" \/> Tooth pain<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Sensitivity to hot\/cold\" \/> Sensitivity to hot\/cold<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Bleeding gums\" \/> Bleeding gums<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Loose teeth\" \/> Loose teeth<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Jaw pain\/locking\" \/> Jaw pain\/locking<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Bruxism\" \/> Bruxism (teeth grinding)<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Difficulty chewing\" \/> Difficulty chewing<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Sores or lesions in mouth\" \/> Sores or lesions in mouth<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Bad breath\" \/> Bad breath<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Dry mouth\" \/> Dry mouth<\/label>\r\n <\/div>\r\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\r\n <div>\r\n <label for=\"ortho\">Previous orthodontic treatment<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"ortho\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"ortho\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"orthoDesc\" name=\"orthoDesc\" type=\"text\" placeholder=\"If yes, describe\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"oralSurg\">Previous oral surgery<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"oralSurg\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"oralSurg\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"oralSurgDesc\" name=\"oralSurgDesc\" type=\"text\" placeholder=\"If yes, describe\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>5. Teledentistry Technology Requirements<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label>Device you will use<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Smartphone\" required \/> Smartphone<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Tablet\" \/> Tablet<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Laptop\/Desktop\" \/> Laptop\/Desktop<\/label>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label>Operating system<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"os\" value=\"iOS\" required \/> iOS<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"os\" value=\"Android\" \/> Android<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"os\" value=\"Windows\" \/> Windows<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"os\" value=\"macOS\" \/> macOS<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"os\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label>Webcam<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"webcam\" value=\"Built-in\" required \/> Built-in<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"webcam\" value=\"External\" \/> External<\/label>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label>Internet connection<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"Wi-Fi\" required \/> Wi-Fi<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"Cellular\" \/> Cellular<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"Ethernet\" \/> Ethernet<\/label>\r\n <\/div>\r\n <\/div>\r\n <div style=\"grid-column: 1 \/ -1;\">\r\n <label>Preferred video platform<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"platform\" value=\"Zoom\" required \/> Zoom<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"platform\" value=\"Doxy.me\" \/> Doxy.me<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"platform\" value=\"Microsoft Teams\" \/> Microsoft Teams<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"platform\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n <div class=\"ack\" style=\"margin-top:12px;\">\r\n <input id=\"techConfirm\" type=\"checkbox\" required \/>\r\n <label for=\"techConfirm\">I confirm I have the required hardware and internet access for a successful teledentistry appointment.<\/label>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>6. Consent for Electronic Communications<\/h3>\r\n <div class=\"ack\">\r\n <input id=\"econsent\" type=\"checkbox\" required \/>\r\n <label for=\"econsent\">I consent to receive appointment reminders, educational materials, and clinical correspondence via my provided phone number and email. I understand message\/data rates may apply. I may revoke this consent at any time by contacting <a href=\"mailto:talk@yoursmilepartners.com\">talk@yoursmilepartners.com<\/a>.<\/label>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>7. COVID-19 & Health Screening<\/h3>\r\n <p>Within the past 14 days, have you experienced any of the following? (Check all that apply)<\/p>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Fever or chills\" \/> Fever or chills<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Cough\" \/> Cough<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Shortness of breath\" \/> Shortness of breath<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Loss of taste\/smell\" \/> Loss of taste\/smell<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Sore throat\" \/> Sore throat<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Muscle aches\" \/> Muscle aches<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Headache\" \/> Headache<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Gastrointestinal symptoms\" \/> Gastrointestinal symptoms<\/label>\r\n <\/div>\r\n <div class=\"grid cols-3\" style=\"margin-top:10px;\">\r\n <div>\r\n <label>Tested positive for COVID-19 in the past 30 days?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"covidPos\" value=\"Yes\" required \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"covidPos\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label>Vaccinated for COVID-19?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"covidVax\" value=\"Yes\" required \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"covidVax\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"vaxDates\">Vaccine dates (if applicable)<\/label>\r\n <div class=\"field\"><input id=\"vaxDates\" name=\"vaxDates\" type=\"text\" placeholder=\"MM\/DD\/YYYY, MM\/DD\/YYYY\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>8. Privacy Notice & HIPAA Acknowledgment<\/h3>\r\n <p>Your Smile Partners PLLC protects your health information under HIPAA. Our Notice of Privacy Practices describes how we may use and disclose your protected health information. A copy is available upon request or at arrival to your first appointment.<\/p>\r\n <div class=\"ack\">\r\n <input id=\"hipaaAck\" type=\"checkbox\" required \/>\r\n <label for=\"hipaaAck\">I acknowledge receipt of the Privacy Notice & HIPAA information.<\/label>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>9. Signature & Authorization<\/h3>\r\n <p>I certify that the information provided is complete and accurate to the best of my knowledge. I understand that withholding information may be detrimental to my health. I authorize the dental team of Your Smile Partners PLLC to perform teledentistry services, diagnostic procedures, and treatments as deemed necessary.<\/p>\r\n <div class=\"ack\" style=\"margin-bottom:10px;\">\r\n <input id=\"certify\" type=\"checkbox\" required \/>\r\n <label for=\"certify\">I agree to the above authorization.<\/label>\r\n <\/div>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label>Patient Signature<\/label>\r\n <div class=\"sig-pad\">\r\n <canvas class=\"signature\" id=\"sigPatient\" aria-label=\"Draw your signature\"><\/canvas>\r\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigPatient\">Clear<\/button><\/div>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"sigDate\">Date<\/label>\r\n <div class=\"field\"><input id=\"sigDate\" name=\"sigDate\" type=\"date\" required \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <h3 style=\"margin-top:14px;\">If signed by a representative<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label for=\"repName\">Representative Name<\/label>\r\n <div class=\"field\"><input id=\"repName\" name=\"repName\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"repRelation\">Relationship to Patient<\/label>\r\n <div class=\"field\"><input id=\"repRelation\" name=\"repRelation\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label>Representative Signature<\/label>\r\n <div class=\"sig-pad\">\r\n <canvas class=\"signature\" id=\"sigRep\" aria-label=\"Representative signature\"><\/canvas>\r\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigRep\">Clear<\/button><\/div>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"repDate\">Date<\/label>\r\n <div class=\"field\"><input id=\"repDate\" name=\"repDate\" type=\"date\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n <div class=\"section\">\r\n <p class=\"note\"><strong>Thank you for choosing Your Smile Partners PLLC.<\/strong> We look forward to providing you with exceptional virtual dental care.<\/p>\r\n <\/div>\r\n <\/form>\r\n <div class=\"footer\">\r\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>\r\n <div style=\"display:flex; gap:10px;\">\r\n <button type=\"button\" class=\"btn\" id=\"btnPrint2\">Print Form<\/button>\r\n <button type=\"button\" class=\"btn primary\" id=\"btnSave2\">Save PDF<\/button>\r\n <button type=\"button\" class=\"btn ok\" id=\"btnSubmit2\">Submit & Upload<\/button>\r\n <\/div>\r\n <\/div>\r\n<\/section>\r\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('intake-form'); const card = document.getElementById('form-card'); const toast = document.getElementById('toast');\r\n const btnPrint = document.getElementById('btnPrint');\r\n const btnPrint2 = document.getElementById('btnPrint2');\r\n const btnSave = document.getElementById('btnSave');\r\n const btnSave2 = document.getElementById('btnSave2');\r\n const btnSubmit = document.getElementById('btnSubmit');\r\n const btnSubmit2 = document.getElementById('btnSubmit2');\r\n const btnClear = document.getElementById('btnClear');\r\n \/\/ Signature pads\r\n const pads = {\r\n sigPatient: setupSignaturePad(document.getElementById('sigPatient')),\r\n sigRep: setupSignaturePad(document.getElementById('sigRep')),\r\n sigIns: setupSignaturePad(document.getElementById('sigIns'))\r\n };\r\n document.querySelectorAll('[data-clear]').forEach(btn=>{\r\n btn.addEventListener('click', ()=>{\r\n const id = btn.getAttribute('data-clear');\r\n pads[id]?.clear();\r\n });\r\n });\r\n \/\/ Default dates\r\n const todayISO = (new Date()).toISOString().slice(0,10);\r\n document.getElementById('sigDate').value = todayISO;\r\n document.getElementById('insDate').value = todayISO;\r\n \/\/ Toast helper\r\n let tmr;\r\n function showToast(msg){\r\n toast.textContent = msg;\r\n toast.classList.add('show');\r\n clearTimeout(tmr);\r\n tmr = setTimeout(()=> toast.classList.remove('show'), 1800);\r\n }\r\n \/\/ Print\r\n function doPrint(){ window.print(); }\r\n btnPrint.addEventListener('click', doPrint);\r\n btnPrint2.addEventListener('click', doPrint);\r\n \/\/ Basic validation\r\n function validateForm(){\r\n const required = form.querySelectorAll('[required]');\r\n for(const el of required){\r\n if((el.type === 'checkbox' && !el.checked) || (el.type === 'radio' && !form.querySelector(`input[name=\"${el.name}\"]:checked`)) || (el.value || '').trim() === ''){\r\n el.scrollIntoView({behavior:'smooth', block:'center'});\r\n el.focus?.({preventScroll:true});\r\n showToast('Please complete required fields.');\r\n return false;\r\n }\r\n }\r\n if(pads.sigPatient.isBlank()){\r\n document.getElementById('sigPatient').scrollIntoView({behavior:'smooth', block:'center'});\r\n showToast('Please add your signature.');\r\n return false;\r\n }\r\n return true;\r\n }\r\n \/\/ Filename\r\n function makeFileName(){\r\n const name = (document.getElementById('fullName').value || 'Patient').trim().replace(\/\\s+\/g,'_');\r\n const date = (document.getElementById('sigDate').value || todayISO);\r\n return `Teledentistry_Intake_${name}_${date}.pdf`;\r\n }\r\n \/\/ Save PDF\r\n async function savePDF(){\r\n await ensureSignatures();\r\n const opt = {\r\n margin: 0.4,\r\n filename: makeFileName(),\r\n image: { type: 'jpeg', quality: 0.98 },\r\n html2canvas: { scale: 2, useCORS: true, backgroundColor: '#ffffff' },\r\n jsPDF: { unit: 'in', format: 'letter', orientation: 'portrait' },\r\n pagebreak: { mode: ['css','legacy'] }\r\n };\r\n await html2pdf().from(card).set(opt).save();\r\n }\r\n btnSave.addEventListener('click', async ()=>{\r\n if(!validateForm()) return;\r\n await savePDF();\r\n showToast('PDF saved to your device.');\r\n });\r\n btnSave2.addEventListener('click', async ()=>{\r\n if(!validateForm()) return;\r\n await savePDF();\r\n showToast('PDF saved to your device.');\r\n });\r\n \/\/ Submit & Upload: save then redirect to Dropbox Request\r\n async function submitAndUpload(){\r\n if(!validateForm()) return;\r\n \/\/ Pre-open a tab to avoid popup blockers\r\n let uploadWin;\r\n try{\r\n uploadWin = window.open('about:blank', '_blank');\r\n if(uploadWin){\r\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>');\r\n }\r\n }catch(e){}\r\n try{\r\n await savePDF();\r\n showToast('PDF saved. Redirecting to Dropbox\u2026');\r\n }catch(err){\r\n console.error(err);\r\n showToast('PDF error. Opening print dialog instead.');\r\n window.print();\r\n }\r\n try{\r\n if(uploadWin && !uploadWin.closed){\r\n uploadWin.location.href = dropboxURL;\r\n uploadWin.focus();\r\n }else{\r\n window.open(dropboxURL, '_blank');\r\n }\r\n }catch(e){\r\n window.open(dropboxURL, '_blank');\r\n }\r\n }\r\n btnSubmit.addEventListener('click', submitAndUpload);\r\n btnSubmit2.addEventListener('click', submitAndUpload);\r\n \/\/ Clear\r\n btnClear.addEventListener('click', ()=>{\r\n if(!confirm('Clear all fields and signatures?')) return;\r\n form.reset();\r\n document.getElementById('sigDate').value = todayISO;\r\n document.getElementById('insDate').value = todayISO;\r\n pads.sigPatient.clear(); pads.sigRep.clear(); pads.sigIns.clear();\r\n showToast('Form cleared.');\r\n });\r\n \/\/ Ensure canvases are painted (already are; this is a placeholder for html2canvas compatibility)\r\n async function ensureSignatures(){ return true; }\r\n \/\/ Lightweight signature pad\r\n function setupSignaturePad(canvas){\r\n const ctx = canvas.getContext('2d');\r\n const state = { drawing:false, blank:true, lastX:0, lastY:0 };\r\n function resize(){\r\n const ratio = Math.max(window.devicePixelRatio || 1, 1);\r\n const rect = canvas.getBoundingClientRect();\r\n canvas.width = rect.width * ratio;\r\n canvas.height = rect.height * ratio;\r\n ctx.setTransform(ratio, 0, 0, ratio, 0, 0);\r\n ctx.lineCap = 'round';\r\n ctx.lineJoin = 'round';\r\n ctx.lineWidth = 2.2;\r\n ctx.strokeStyle = '#18223b';\r\n ctx.clearRect(0,0,canvas.width,canvas.height);\r\n state.blank = true;\r\n }\r\n window.addEventListener('resize', resize, { passive:true });\r\n resize();\r\n function getPos(e){\r\n const r = canvas.getBoundingClientRect();\r\n const p = e.touches ? e.touches[0] : e;\r\n return { x: p.clientX - r.left, y: p.clientY - r.top };\r\n }\r\n function start(e){ e.preventDefault(); state.drawing=true; const p=getPos(e); state.lastX=p.x; state.lastY=p.y; }\r\n function move(e){\r\n if(!state.drawing) return;\r\n e.preventDefault();\r\n const p = getPos(e);\r\n ctx.beginPath(); ctx.moveTo(state.lastX, state.lastY); ctx.lineTo(p.x,p.y); ctx.stroke();\r\n state.lastX = p.x; state.lastY = p.y; state.blank = false;\r\n }\r\n function end(){ state.drawing=false; }\r\n canvas.addEventListener('mousedown', start);\r\n canvas.addEventListener('mousemove', move);\r\n window.addEventListener('mouseup', end);\r\n canvas.addEventListener('touchstart', start, { passive:false });\r\n canvas.addEventListener('touchmove', move, { passive:false });\r\n canvas.addEventListener('touchend', end);\r\n function clear(){ ctx.clearRect(0,0,canvas.width,canvas.height); state.blank = true; }\r\n function isBlank(){ return state.blank; }\r\n return { clear, isBlank };\r\n }\r\n})();\r\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 New Patient Intake Form Teledentistry New Patient Intake Form Your Smile Partners PLLC 99 Wall St, New York, NY 10005 Email: talk@yoursmilepartners.com Print Form Save PDF to Device Submit & Upload Clear All Fields Please complete all sections accurately. This information is kept confidential under HIPAA regulations. 1. Patient…<\/p>\n<p><a class=\"btn btn-outline-dark btn-sm anzu-read-more-link\" href=\"https:\/\/stephanie.openteledentistry.com\/?page_id=812\">Continue Reading<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"content-type":"","footnotes":""},"class_list":["post-812","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\/812","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=812"}],"version-history":[{"count":3,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/812\/revisions"}],"predecessor-version":[{"id":815,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/812\/revisions\/815"}],"wp:attachment":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=812"}],"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 New Patient Intake 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: 1040px; 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); } }\r\nheader.app{\r\n display:grid; gap:14px; align-items:center;\r\n grid-template-columns: auto 1fr;\r\n padding: 20px 20px 10px 20px;\r\n background: linear-gradient(180deg, rgba(76,143,255,.08), rgba(43,208,214,.04));\r\n border-bottom: 1px solid var(--line);\r\n}\r\n.logo{\r\n width:56px;height:56px;border-radius:14px;display:grid;place-items:center;\r\n background: linear-gradient(145deg, rgba(76,143,255,.18), rgba(43,208,214,.14));\r\n border:1px solid #cfe2ff;\r\n}\r\n.logo svg{ width:30px;height:30px }\r\n.title{ margin:0; font-size: clamp(1.15rem, 2.6vw, 1.7rem); line-height:1.25; font-weight:900; letter-spacing:.2px; }\r\n.meta{ grid-column: 1 \/ -1; display:flex; flex-wrap:wrap; gap:10px; padding-bottom:10px; color: var(--muted); font-size:.96rem; }\r\n.pill{ display:inline-flex; align-items:center; gap:8px; padding:6px 10px; border-radius:999px; background:#f1f6ff; border:1px solid var(--line); }\r\n.toolbar{\r\n display:flex; flex-wrap:wrap; gap:10px; padding: 12px 20px; border-bottom: 1px dashed var(--line);\r\n background: linear-gradient(180deg, #ffffff, #f8fbff);\r\n}\r\n.btn{\r\n appearance:none; -webkit-tap-highlight-color: transparent; user-select:none;\r\n border:1px solid #cfe0ff; background: linear-gradient(135deg, #f7fbff, #eef6ff);\r\n color: var(--ink); font-weight:700; letter-spacing:.2px; font-size:.95rem;\r\n padding:10px 14px; border-radius: 12px; cursor:pointer;\r\n transition: transform .15s ease, box-shadow .15s ease, border-color .2s ease, background .2s ease;\r\n box-shadow: 0 6px 16px rgba(76,143,255,.12);\r\n}\r\n.btn:hover{ transform: translateY(-1px); box-shadow: 0 10px 24px rgba(76,143,255,.18); }\r\n.btn:active{ transform: translateY(0); }\r\n.btn.primary{ border-color: #8dc2ff; background: linear-gradient(135deg, #e5f1ff, #e6fffb); }\r\n.btn.ok{ border-color:#a6efd6; background: linear-gradient(135deg, #eafff6, #efffff); }\r\n.btn.warn{ border-color:#ffd98a; background: linear-gradient(135deg, #fff7ea, #fffdf3); }\r\nform#intake-form{ padding: 20px; }\r\n.section{\r\n border: 1px solid var(--line);\r\n border-radius: var(--r-sm);\r\n background: linear-gradient(180deg, #ffffff, #f9fbff);\r\n padding: 16px; margin-bottom: 16px;\r\n}\r\n.section h3{\r\n margin:0 0 8px 0; font-size: 1.05rem; letter-spacing:.2px; color: #1b2b55;\r\n display:flex; align-items:center; gap:10px;\r\n}\r\n.section p{ margin: 8px 0; color: var(--muted); }\r\n.grid{ display:grid; gap:12px; }\r\n@media(min-width: 720px){\r\n .grid.cols-2{ grid-template-columns: 1fr 1fr; }\r\n .grid.cols-3{ grid-template-columns: repeat(3, 1fr); }\r\n}\r\nlabel{ font-weight:600; font-size:.93rem; color:#1e315c; }\r\n.field{\r\n margin-top:6px; display:flex; align-items:center; gap:10px;\r\n background: var(--field-bg); border:1px solid var(--field-border); border-radius: 12px; padding: 10px 12px;\r\n transition: border-color .2s ease, box-shadow .2s ease, background .2s ease;\r\n}\r\n.field:focus-within{\r\n border-color:#9bc6ff; box-shadow: 0 0 0 4px rgba(76,143,255,.12);\r\n background:#ffffff;\r\n}\r\ninput[type=\"text\"], input[type=\"email\"], input[type=\"tel\"], input[type=\"date\"], textarea, select{\r\n width:100%; border:none; outline:none; background: transparent; color: var(--ink); font: inherit; font-size: .98rem;\r\n}\r\ntextarea{ resize: vertical; min-height: 92px; }\r\n.options{ display:flex; flex-wrap:wrap; gap:10px 18px; margin-top:8px; }\r\n.opt{ display:inline-flex; align-items:center; gap:8px; color: var(--ink); }\r\n.opt input{ transform: translateY(1px); }\r\n.sig-pad{\r\n background: repeating-linear-gradient(0deg, #ffffff, #ffffff 28px, #f2f6ff 28px, #f2f6ff 29px);\r\n border: 1px dashed #c5d6fb; border-radius: 12px; padding: 10px;\r\n}\r\n.sig-tools{ display:flex; gap:10px; margin-top:8px; }\r\n.sig-tools .btn{ font-size:.88rem; padding:8px 10px; }\r\ncanvas.signature{\r\n width: 100%; height: 160px; display:block; background:#fff; border-radius: 10px; border:1px solid #e6eeff;\r\n touch-action: none;\r\n}\r\n.ack{\r\n display:flex; align-items:flex-start; gap:10px; background:#f8fbff; border:1px solid var(--line); border-radius:12px; padding:12px;\r\n}\r\n.ack input{ margin-top: 4px; }\r\n.footer{\r\n display:flex; flex-wrap:wrap; align-items:center; justify-content:space-between; gap:12px;\r\n padding: 12px 20px 20px 20px;\r\n border-top: 1px solid var(--line);\r\n background: linear-gradient(180deg, #f9fbff, #ffffff);\r\n}\r\n.note{ color: var(--muted); font-size:.94rem; }\r\n.toast{\r\n position: fixed; left: 50%; bottom: 22px; transform: translateX(-50%) translateY(20px);\r\n background: #0f1b3a; color: #f4f8ff; border: 1px solid #2c4bff22;\r\n padding: 10px 14px; border-radius: 12px; box-shadow: var(--shadow-1);\r\n opacity: 0; transition: opacity .25s ease, transform .25s ease; pointer-events: none; z-index: 9999;\r\n font-size:.95rem;\r\n}\r\n.toast.show{ opacity: 1; transform: translateX(-50%) translateY(0); }\r\n@media print{\r\n .toolbar, .footer, .edge, .toast{ display:none !important; }\r\n body{ background:#fff; }\r\n .card{ box-shadow:none; border:none; }\r\n .section{ page-break-inside: avoid; }\r\n}\r\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> \r\n<header class=\"app\">\r\n <div class=\"logo\" aria-hidden=\"true\">\r\n <svg viewBox=\"0 0 64 64\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" aria-hidden=\"true\">\r\n <defs>\r\n <linearGradient id=\"g\" x1=\"0\" y1=\"0\" x2=\"1\" y2=\"1\">\r\n <stop stop-color=\"#4C8FFF\"\/><stop offset=\"1\" stop-color=\"#2BD0D6\"\/>\r\n <\/linearGradient>\r\n <\/defs>\r\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\"\/>\r\n <path d=\"M22 31.5l7 7L44 24\" stroke=\"#4C8FFF\" stroke-width=\"3\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/>\r\n <\/svg>\r\n <\/div>\r\n <h1 class=\"title\" id=\"title\">Teledentistry New Patient Intake Form<\/h1>\r\n <div class=\"meta\">\r\n <span class=\"pill\"><strong>Your Smile Partners PLLC<\/strong><\/span>\r\n <span class=\"pill\">99 Wall St, New York, NY 10005<\/span>\r\n <span class=\"pill\">Email: <a href=\"mailto:talk@yoursmilepartners.com\">talk@yoursmilepartners.com<\/a><\/span>\r\n <\/div>\r\n <\/header>\r\n <div class=\"toolbar\" role=\"toolbar\" aria-label=\"Form actions\">\r\n <button type=\"button\" class=\"btn\" id=\"btnPrint\">Print Form<\/button>\r\n <button type=\"button\" class=\"btn primary\" id=\"btnSave\">Save PDF to Device<\/button>\r\n <button type=\"button\" class=\"btn ok\" id=\"btnSubmit\">Submit & Upload<\/button>\r\n <button type=\"button\" class=\"btn warn\" id=\"btnClear\">Clear All Fields<\/button>\r\n <\/div>\r\n <form id=\"intake-form\" novalidate>\r\n <div class=\"section\">\r\n <h3>Please complete all sections accurately. This information is kept confidential under HIPAA regulations.<\/h3>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>1. Patient Demographics<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label for=\"fullName\">Full Name<\/label>\r\n <div class=\"field\"><input id=\"fullName\" name=\"fullName\" type=\"text\" required placeholder=\"First and last name\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"prefName\">Preferred Name\/Nickname<\/label>\r\n <div class=\"field\"><input id=\"prefName\" name=\"prefName\" type=\"text\" placeholder=\"Optional\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"dob\">Date of Birth<\/label>\r\n <div class=\"field\"><input id=\"dob\" name=\"dob\" type=\"date\" required \/><\/div>\r\n <\/div>\r\n <div>\r\n <label>Gender<\/label>\r\n <div class=\"options\" role=\"radiogroup\" aria-label=\"Gender\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Male\" required \/> Male<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Female\" \/> Female<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Non-binary\" \/> Non-binary<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"gender\" value=\"Prefer not to say\" \/> Prefer not to say<\/label>\r\n <\/div>\r\n <\/div>\r\n <div style=\"grid-column: 1 \/ -1;\">\r\n <label for=\"address\">Address<\/label>\r\n <div class=\"field\"><input id=\"address\" name=\"address\" type=\"text\" required placeholder=\"Street address\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"city\">City<\/label>\r\n <div class=\"field\"><input id=\"city\" name=\"city\" type=\"text\" required \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"state\">State<\/label>\r\n <div class=\"field\"><input id=\"state\" name=\"state\" type=\"text\" required maxlength=\"2\" placeholder=\"NY\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"zip\">ZIP<\/label>\r\n <div class=\"field\"><input id=\"zip\" name=\"zip\" type=\"text\" required pattern=\"\\\\d{5}(-\\\\d{4})?\" placeholder=\"10005\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"homePhone\">Home Phone<\/label>\r\n <div class=\"field\"><input id=\"homePhone\" name=\"homePhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"cellPhone\">Cell Phone<\/label>\r\n <div class=\"field\"><input id=\"cellPhone\" name=\"cellPhone\" type=\"tel\" required placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"email\">Email Address<\/label>\r\n <div class=\"field\"><input id=\"email\" name=\"email\" type=\"email\" required placeholder=\"you@example.com\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label>Preferred Method of Contact<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"contactPref\" value=\"Phone\" required \/> Phone<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"contactPref\" value=\"SMS\" \/> SMS<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"contactPref\" value=\"Email\" \/> Email<\/label>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>2. Emergency Contact<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label for=\"ecName\">Name<\/label>\r\n <div class=\"field\"><input id=\"ecName\" name=\"ecName\" type=\"text\" required \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"ecRelation\">Relationship<\/label>\r\n <div class=\"field\"><input id=\"ecRelation\" name=\"ecRelation\" type=\"text\" required \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"ecPhone\">Phone<\/label>\r\n <div class=\"field\"><input id=\"ecPhone\" name=\"ecPhone\" type=\"tel\" required placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"ecAltPhone\">Alternate Phone<\/label>\r\n <div class=\"field\"><input id=\"ecAltPhone\" name=\"ecAltPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>3. Insurance Information<\/h3>\r\n <p><strong>Primary Dental Insurance<\/strong><\/p>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label for=\"priInsCo\">Insurance Company<\/label>\r\n <div class=\"field\"><input id=\"priInsCo\" name=\"priInsCo\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"priPolicy\">Policy\/ID Number<\/label>\r\n <div class=\"field\"><input id=\"priPolicy\" name=\"priPolicy\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"priGroup\">Group Number<\/label>\r\n <div class=\"field\"><input id=\"priGroup\" name=\"priGroup\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"priSubName\">Subscriber Name<\/label>\r\n <div class=\"field\"><input id=\"priSubName\" name=\"priSubName\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"priSubDob\">Subscriber Date of Birth<\/label>\r\n <div class=\"field\"><input id=\"priSubDob\" name=\"priSubDob\" type=\"date\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"priEmployer\">Subscriber Employer<\/label>\r\n <div class=\"field\"><input id=\"priEmployer\" name=\"priEmployer\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <p style=\"margin-top:12px;\"><strong>Secondary Dental Insurance (if applicable)<\/strong><\/p>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label for=\"secInsCo\">Insurance Company<\/label>\r\n <div class=\"field\"><input id=\"secInsCo\" name=\"secInsCo\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"secPolicy\">Policy\/ID Number<\/label>\r\n <div class=\"field\"><input id=\"secPolicy\" name=\"secPolicy\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"secGroup\">Group Number<\/label>\r\n <div class=\"field\"><input id=\"secGroup\" name=\"secGroup\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <div class=\"ack\" style=\"margin-top:12px;\">\r\n <input id=\"insAuth\" type=\"checkbox\" \/>\r\n <label for=\"insAuth\">I authorize release of dental information to my insurance carrier and assign benefits directly to Your Smile Partners PLLC.<\/label>\r\n <\/div>\r\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\r\n <div>\r\n <label>Signature (Insurance Authorization)<\/label>\r\n <div class=\"sig-pad\">\r\n <canvas class=\"signature\" id=\"sigIns\" aria-label=\"Insurance authorization signature\"><\/canvas>\r\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigIns\">Clear<\/button><\/div>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"insDate\">Date<\/label>\r\n <div class=\"field\"><input id=\"insDate\" name=\"insDate\" type=\"date\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>4. Medical & Dental History<\/h3>\r\n <h3 style=\"margin-top:6px;\">4.1 Medical History<\/h3>\r\n <p>Have you ever been diagnosed with or had treatment for any of the following? (Check all that apply)<\/p>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Heart disease\/attack\" \/> Heart disease\/attack<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"High blood pressure\" \/> High blood pressure<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Stroke\" \/> Stroke<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Diabetes\" \/> Diabetes<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Thyroid disorder\" \/> Thyroid disorder<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Cancer\" \/> Cancer<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Hepatitis\" \/> Hepatitis<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"HIV\/AIDS\" \/> HIV\/AIDS<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Respiratory disease\" \/> Respiratory disease<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Kidney disease\" \/> Kidney disease<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Liver disease\" \/> Liver disease<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Autoimmune disorder\" \/> Autoimmune disorder<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Psychiatric care\" \/> Psychiatric care<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Joint replacement\" \/> Joint replacement<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Bleeding disorder\" \/> Bleeding disorder<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"medHx\" value=\"Sleep apnea\" \/> Sleep apnea<\/label>\r\n <\/div>\r\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\r\n <div>\r\n <label for=\"cancerType\">If Cancer, type<\/label>\r\n <div class=\"field\"><input id=\"cancerType\" name=\"cancerType\" type=\"text\" placeholder=\"Type\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"jointDate\">If Joint replacement, date<\/label>\r\n <div class=\"field\"><input id=\"jointDate\" name=\"jointDate\" type=\"date\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label for=\"medOther\">Other conditions<\/label>\r\n <div class=\"field\"><input id=\"medOther\" name=\"medOther\" type=\"text\" placeholder=\"Describe any other conditions\" \/><\/div>\r\n <\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label for=\"hospitalizations\">List any hospitalizations or surgeries (with dates)<\/label>\r\n <div class=\"field\"><textarea id=\"hospitalizations\" name=\"hospitalizations\" placeholder=\"Procedures and dates\"><\/textarea><\/div>\r\n <\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label for=\"medications\">Current medications (include dosage)<\/label>\r\n <div class=\"field\"><textarea id=\"medications\" name=\"medications\" placeholder=\"Medication name \u2014 dosage \u2014 frequency\"><\/textarea><\/div>\r\n <\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label for=\"allergies\">Allergies (medications, latex, foods, environmental)<\/label>\r\n <div class=\"field\"><textarea id=\"allergies\" name=\"allergies\"><\/textarea><\/div>\r\n <\/div>\r\n <h3 style=\"margin-top:14px;\">4.2 Dental History<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label for=\"visitReason\">Reason for today\u2019s visit<\/label>\r\n <div class=\"field\"><input id=\"visitReason\" name=\"visitReason\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"lastExam\">Date of last dental exam and cleaning<\/label>\r\n <div class=\"field\"><input id=\"lastExam\" name=\"lastExam\" type=\"date\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <p style=\"margin-top:6px;\">Have you experienced any of the following?<\/p>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Tooth pain\" \/> Tooth pain<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Sensitivity to hot\/cold\" \/> Sensitivity to hot\/cold<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Bleeding gums\" \/> Bleeding gums<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Loose teeth\" \/> Loose teeth<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Jaw pain\/locking\" \/> Jaw pain\/locking<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Bruxism\" \/> Bruxism (teeth grinding)<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Difficulty chewing\" \/> Difficulty chewing<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Sores or lesions in mouth\" \/> Sores or lesions in mouth<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Bad breath\" \/> Bad breath<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"dentHx\" value=\"Dry mouth\" \/> Dry mouth<\/label>\r\n <\/div>\r\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\r\n <div>\r\n <label for=\"ortho\">Previous orthodontic treatment<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"ortho\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"ortho\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"orthoDesc\" name=\"orthoDesc\" type=\"text\" placeholder=\"If yes, describe\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"oralSurg\">Previous oral surgery<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"oralSurg\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"oralSurg\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"oralSurgDesc\" name=\"oralSurgDesc\" type=\"text\" placeholder=\"If yes, describe\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>5. Teledentistry Technology Requirements<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label>Device you will use<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Smartphone\" required \/> Smartphone<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Tablet\" \/> Tablet<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"device\" value=\"Laptop\/Desktop\" \/> Laptop\/Desktop<\/label>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label>Operating system<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"os\" value=\"iOS\" required \/> iOS<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"os\" value=\"Android\" \/> Android<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"os\" value=\"Windows\" \/> Windows<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"os\" value=\"macOS\" \/> macOS<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"os\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label>Webcam<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"webcam\" value=\"Built-in\" required \/> Built-in<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"webcam\" value=\"External\" \/> External<\/label>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label>Internet connection<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"Wi-Fi\" required \/> Wi-Fi<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"Cellular\" \/> Cellular<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"net\" value=\"Ethernet\" \/> Ethernet<\/label>\r\n <\/div>\r\n <\/div>\r\n <div style=\"grid-column: 1 \/ -1;\">\r\n <label>Preferred video platform<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"platform\" value=\"Zoom\" required \/> Zoom<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"platform\" value=\"Doxy.me\" \/> Doxy.me<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"platform\" value=\"Microsoft Teams\" \/> Microsoft Teams<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"platform\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n <div class=\"ack\" style=\"margin-top:12px;\">\r\n <input id=\"techConfirm\" type=\"checkbox\" required \/>\r\n <label for=\"techConfirm\">I confirm I have the required hardware and internet access for a successful teledentistry appointment.<\/label>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>6. Consent for Electronic Communications<\/h3>\r\n <div class=\"ack\">\r\n <input id=\"econsent\" type=\"checkbox\" required \/>\r\n <label for=\"econsent\">I consent to receive appointment reminders, educational materials, and clinical correspondence via my provided phone number and email. I understand message\/data rates may apply. I may revoke this consent at any time by contacting <a href=\"mailto:talk@yoursmilepartners.com\">talk@yoursmilepartners.com<\/a>.<\/label>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>7. COVID-19 & Health Screening<\/h3>\r\n <p>Within the past 14 days, have you experienced any of the following? (Check all that apply)<\/p>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Fever or chills\" \/> Fever or chills<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Cough\" \/> Cough<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Shortness of breath\" \/> Shortness of breath<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Loss of taste\/smell\" \/> Loss of taste\/smell<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Sore throat\" \/> Sore throat<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Muscle aches\" \/> Muscle aches<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Headache\" \/> Headache<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"covid\" value=\"Gastrointestinal symptoms\" \/> Gastrointestinal symptoms<\/label>\r\n <\/div>\r\n <div class=\"grid cols-3\" style=\"margin-top:10px;\">\r\n <div>\r\n <label>Tested positive for COVID-19 in the past 30 days?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"covidPos\" value=\"Yes\" required \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"covidPos\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label>Vaccinated for COVID-19?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"covidVax\" value=\"Yes\" required \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"covidVax\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"vaxDates\">Vaccine dates (if applicable)<\/label>\r\n <div class=\"field\"><input id=\"vaxDates\" name=\"vaxDates\" type=\"text\" placeholder=\"MM\/DD\/YYYY, MM\/DD\/YYYY\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>8. Privacy Notice & HIPAA Acknowledgment<\/h3>\r\n <p>Your Smile Partners PLLC protects your health information under HIPAA. Our Notice of Privacy Practices describes how we may use and disclose your protected health information. A copy is available upon request or at arrival to your first appointment.<\/p>\r\n <div class=\"ack\">\r\n <input id=\"hipaaAck\" type=\"checkbox\" required \/>\r\n <label for=\"hipaaAck\">I acknowledge receipt of the Privacy Notice & HIPAA information.<\/label>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>9. Signature & Authorization<\/h3>\r\n <p>I certify that the information provided is complete and accurate to the best of my knowledge. I understand that withholding information may be detrimental to my health. I authorize the dental team of Your Smile Partners PLLC to perform teledentistry services, diagnostic procedures, and treatments as deemed necessary.<\/p>\r\n <div class=\"ack\" style=\"margin-bottom:10px;\">\r\n <input id=\"certify\" type=\"checkbox\" required \/>\r\n <label for=\"certify\">I agree to the above authorization.<\/label>\r\n <\/div>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label>Patient Signature<\/label>\r\n <div class=\"sig-pad\">\r\n <canvas class=\"signature\" id=\"sigPatient\" aria-label=\"Draw your signature\"><\/canvas>\r\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigPatient\">Clear<\/button><\/div>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"sigDate\">Date<\/label>\r\n <div class=\"field\"><input id=\"sigDate\" name=\"sigDate\" type=\"date\" required \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <h3 style=\"margin-top:14px;\">If signed by a representative<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label for=\"repName\">Representative Name<\/label>\r\n <div class=\"field\"><input id=\"repName\" name=\"repName\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"repRelation\">Relationship to Patient<\/label>\r\n <div class=\"field\"><input id=\"repRelation\" name=\"repRelation\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label>Representative Signature<\/label>\r\n <div class=\"sig-pad\">\r\n <canvas class=\"signature\" id=\"sigRep\" aria-label=\"Representative signature\"><\/canvas>\r\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigRep\">Clear<\/button><\/div>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"repDate\">Date<\/label>\r\n <div class=\"field\"><input id=\"repDate\" name=\"repDate\" type=\"date\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n <div class=\"section\">\r\n <p class=\"note\"><strong>Thank you for choosing Your Smile Partners PLLC.<\/strong> We look forward to providing you with exceptional virtual dental care.<\/p>\r\n <\/div>\r\n <\/form>\r\n <div class=\"footer\">\r\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>\r\n <div style=\"display:flex; gap:10px;\">\r\n <button type=\"button\" class=\"btn\" id=\"btnPrint2\">Print Form<\/button>\r\n <button type=\"button\" class=\"btn primary\" id=\"btnSave2\">Save PDF<\/button>\r\n <button type=\"button\" class=\"btn ok\" id=\"btnSubmit2\">Submit & Upload<\/button>\r\n <\/div>\r\n <\/div>\r\n<\/section>\r\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('intake-form'); const card = document.getElementById('form-card'); const toast = document.getElementById('toast');\r\n const btnPrint = document.getElementById('btnPrint');\r\n const btnPrint2 = document.getElementById('btnPrint2');\r\n const btnSave = document.getElementById('btnSave');\r\n const btnSave2 = document.getElementById('btnSave2');\r\n const btnSubmit = document.getElementById('btnSubmit');\r\n const btnSubmit2 = document.getElementById('btnSubmit2');\r\n const btnClear = document.getElementById('btnClear');\r\n \/\/ Signature pads\r\n const pads = {\r\n sigPatient: setupSignaturePad(document.getElementById('sigPatient')),\r\n sigRep: setupSignaturePad(document.getElementById('sigRep')),\r\n sigIns: setupSignaturePad(document.getElementById('sigIns'))\r\n };\r\n document.querySelectorAll('[data-clear]').forEach(btn=>{\r\n btn.addEventListener('click', ()=>{\r\n const id = btn.getAttribute('data-clear');\r\n pads[id]?.clear();\r\n });\r\n });\r\n \/\/ Default dates\r\n const todayISO = (new Date()).toISOString().slice(0,10);\r\n document.getElementById('sigDate').value = todayISO;\r\n document.getElementById('insDate').value = todayISO;\r\n \/\/ Toast helper\r\n let tmr;\r\n function showToast(msg){\r\n toast.textContent = msg;\r\n toast.classList.add('show');\r\n clearTimeout(tmr);\r\n tmr = setTimeout(()=> toast.classList.remove('show'), 1800);\r\n }\r\n \/\/ Print\r\n function doPrint(){ window.print(); }\r\n btnPrint.addEventListener('click', doPrint);\r\n btnPrint2.addEventListener('click', doPrint);\r\n \/\/ Basic validation\r\n function validateForm(){\r\n const required = form.querySelectorAll('[required]');\r\n for(const el of required){\r\n if((el.type === 'checkbox' && !el.checked) || (el.type === 'radio' && !form.querySelector(`input[name=\"${el.name}\"]:checked`)) || (el.value || '').trim() === ''){\r\n el.scrollIntoView({behavior:'smooth', block:'center'});\r\n el.focus?.({preventScroll:true});\r\n showToast('Please complete required fields.');\r\n return false;\r\n }\r\n }\r\n if(pads.sigPatient.isBlank()){\r\n document.getElementById('sigPatient').scrollIntoView({behavior:'smooth', block:'center'});\r\n showToast('Please add your signature.');\r\n return false;\r\n }\r\n return true;\r\n }\r\n \/\/ Filename\r\n function makeFileName(){\r\n const name = (document.getElementById('fullName').value || 'Patient').trim().replace(\/\\s+\/g,'_');\r\n const date = (document.getElementById('sigDate').value || todayISO);\r\n return `Teledentistry_Intake_${name}_${date}.pdf`;\r\n }\r\n \/\/ Save PDF\r\n async function savePDF(){\r\n await ensureSignatures();\r\n const opt = {\r\n margin: 0.4,\r\n filename: makeFileName(),\r\n image: { type: 'jpeg', quality: 0.98 },\r\n html2canvas: { scale: 2, useCORS: true, backgroundColor: '#ffffff' },\r\n jsPDF: { unit: 'in', format: 'letter', orientation: 'portrait' },\r\n pagebreak: { mode: ['css','legacy'] }\r\n };\r\n await html2pdf().from(card).set(opt).save();\r\n }\r\n btnSave.addEventListener('click', async ()=>{\r\n if(!validateForm()) return;\r\n await savePDF();\r\n showToast('PDF saved to your device.');\r\n });\r\n btnSave2.addEventListener('click', async ()=>{\r\n if(!validateForm()) return;\r\n await savePDF();\r\n showToast('PDF saved to your device.');\r\n });\r\n \/\/ Submit & Upload: save then redirect to Dropbox Request\r\n async function submitAndUpload(){\r\n if(!validateForm()) return;\r\n \/\/ Pre-open a tab to avoid popup blockers\r\n let uploadWin;\r\n try{\r\n uploadWin = window.open('about:blank', '_blank');\r\n if(uploadWin){\r\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>');\r\n }\r\n }catch(e){}\r\n try{\r\n await savePDF();\r\n showToast('PDF saved. Redirecting to Dropbox\u2026');\r\n }catch(err){\r\n console.error(err);\r\n showToast('PDF error. Opening print dialog instead.');\r\n window.print();\r\n }\r\n try{\r\n if(uploadWin && !uploadWin.closed){\r\n uploadWin.location.href = dropboxURL;\r\n uploadWin.focus();\r\n }else{\r\n window.open(dropboxURL, '_blank');\r\n }\r\n }catch(e){\r\n window.open(dropboxURL, '_blank');\r\n }\r\n }\r\n btnSubmit.addEventListener('click', submitAndUpload);\r\n btnSubmit2.addEventListener('click', submitAndUpload);\r\n \/\/ Clear\r\n btnClear.addEventListener('click', ()=>{\r\n if(!confirm('Clear all fields and signatures?')) return;\r\n form.reset();\r\n document.getElementById('sigDate').value = todayISO;\r\n document.getElementById('insDate').value = todayISO;\r\n pads.sigPatient.clear(); pads.sigRep.clear(); pads.sigIns.clear();\r\n showToast('Form cleared.');\r\n });\r\n \/\/ Ensure canvases are painted (already are; this is a placeholder for html2canvas compatibility)\r\n async function ensureSignatures(){ return true; }\r\n \/\/ Lightweight signature pad\r\n function setupSignaturePad(canvas){\r\n const ctx = canvas.getContext('2d');\r\n const state = { drawing:false, blank:true, lastX:0, lastY:0 };\r\n function resize(){\r\n const ratio = Math.max(window.devicePixelRatio || 1, 1);\r\n const rect = canvas.getBoundingClientRect();\r\n canvas.width = rect.width * ratio;\r\n canvas.height = rect.height * ratio;\r\n ctx.setTransform(ratio, 0, 0, ratio, 0, 0);\r\n ctx.lineCap = 'round';\r\n ctx.lineJoin = 'round';\r\n ctx.lineWidth = 2.2;\r\n ctx.strokeStyle = '#18223b';\r\n ctx.clearRect(0,0,canvas.width,canvas.height);\r\n state.blank = true;\r\n }\r\n window.addEventListener('resize', resize, { passive:true });\r\n resize();\r\n function getPos(e){\r\n const r = canvas.getBoundingClientRect();\r\n const p = e.touches ? e.touches[0] : e;\r\n return { x: p.clientX - r.left, y: p.clientY - r.top };\r\n }\r\n function start(e){ e.preventDefault(); state.drawing=true; const p=getPos(e); state.lastX=p.x; state.lastY=p.y; }\r\n function move(e){\r\n if(!state.drawing) return;\r\n e.preventDefault();\r\n const p = getPos(e);\r\n ctx.beginPath(); ctx.moveTo(state.lastX, state.lastY); ctx.lineTo(p.x,p.y); ctx.stroke();\r\n state.lastX = p.x; state.lastY = p.y; state.blank = false;\r\n }\r\n function end(){ state.drawing=false; }\r\n canvas.addEventListener('mousedown', start);\r\n canvas.addEventListener('mousemove', move);\r\n window.addEventListener('mouseup', end);\r\n canvas.addEventListener('touchstart', start, { passive:false });\r\n canvas.addEventListener('touchmove', move, { passive:false });\r\n canvas.addEventListener('touchend', end);\r\n function clear(){ ctx.clearRect(0,0,canvas.width,canvas.height); state.blank = true; }\r\n function isBlank(){ return state.blank; }\r\n return { clear, isBlank };\r\n }\r\n})();\r\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 New Patient Intake Form Teledentistry New Patient Intake Form Your Smile Partners PLLC 99 Wall St, New York, NY 10005 Email: talk@yoursmilepartners.com Print Form Save PDF to Device Submit & Upload Clear All Fields Please complete all sections accurately. This information is kept confidential under HIPAA regulations. 1. Patient…<\/p>\n<p><a class=\"btn btn-outline-dark btn-sm anzu-read-more-link\" href=\"https:\/\/stephanie.openteledentistry.com\/?page_id=812\">Continue Reading<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"content-type":"","footnotes":""},"class_list":["post-812","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\/812","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=812"}],"version-history":[{"count":3,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/812\/revisions"}],"predecessor-version":[{"id":815,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/812\/revisions\/815"}],"wp:attachment":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=812"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}