{"id":450,"date":"2020-06-15T20:17:47","date_gmt":"2020-06-15T20:17:47","guid":{"rendered":"https:\/\/orange-shrew-941945.hostingersite.com\/blog\/?page_id=450"},"modified":"2020-06-15T17:04:45","modified_gmt":"2020-06-15T21:04:45","slug":"patient-screening-form","status":"publish","type":"page","link":"https:\/\/indianhillsdentistry.com\/blog\/patient-screening-form\/","title":{"rendered":"Patient Screening Form"},"content":{"rendered":"\n<h3 class=\"has-text-align-center wp-block-heading\"><strong>Please complete our COVID-Prescreening\u00a0Form before your visit<\/strong>:<\/h3>\n\n\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' ><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/blog\/wp-json\/wp\/v2\/pages\/450' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Patient Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_12' id='input_1_12' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_11' id='input_1_11' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you\/they have fever or have you\/they felt hot or feverish recently  (14-21 days)?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_2'>\n\t\t\t<li class='gchoice gchoice_1_2_0'>\n\t\t\t\t<input name='input_2' type='radio' value='Yes'  id='choice_1_2_0'    \/>\n\t\t\t\t<label for='choice_1_2_0' id='label_1_2_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_2_1'>\n\t\t\t\t<input name='input_2' type='radio' value='No'  id='choice_1_2_1'    \/>\n\t\t\t\t<label for='choice_1_2_1' id='label_1_2_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you\/they having shortness of breath or other difficulties breathing?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_3'>\n\t\t\t<li class='gchoice gchoice_1_3_0'>\n\t\t\t\t<input name='input_3' type='radio' value='Yes'  id='choice_1_3_0'    \/>\n\t\t\t\t<label for='choice_1_3_0' id='label_1_3_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_3_1'>\n\t\t\t\t<input name='input_3' type='radio' value='No'  id='choice_1_3_1'    \/>\n\t\t\t\t<label for='choice_1_3_1' id='label_1_3_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you\/they have a cough?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_4'>\n\t\t\t<li class='gchoice gchoice_1_4_0'>\n\t\t\t\t<input name='input_4' type='radio' value='Yes'  id='choice_1_4_0'    \/>\n\t\t\t\t<label for='choice_1_4_0' id='label_1_4_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_4_1'>\n\t\t\t\t<input name='input_4' type='radio' value='No'  id='choice_1_4_1'    \/>\n\t\t\t\t<label for='choice_1_4_1' id='label_1_4_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Any other flu-like symptoms, such as gastrointestinal upset, headache  or fatigue?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_5'>\n\t\t\t<li class='gchoice gchoice_1_5_0'>\n\t\t\t\t<input name='input_5' type='radio' value='Yes'  id='choice_1_5_0'    \/>\n\t\t\t\t<label for='choice_1_5_0' id='label_1_5_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_5_1'>\n\t\t\t\t<input name='input_5' type='radio' value='No'  id='choice_1_5_1'    \/>\n\t\t\t\t<label for='choice_1_5_1' id='label_1_5_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you\/they experienced recent loss of taste or smell?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_6'>\n\t\t\t<li class='gchoice gchoice_1_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Yes'  id='choice_1_6_0'    \/>\n\t\t\t\t<label for='choice_1_6_0' id='label_1_6_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='No'  id='choice_1_6_1'    \/>\n\t\t\t\t<label for='choice_1_6_1' id='label_1_6_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you\/they in contact with any confirmed COVID-19 positive patients?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_7'>Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_7'>\n\t\t\t<li class='gchoice gchoice_1_7_0'>\n\t\t\t\t<input name='input_7' type='radio' value='Yes'  id='choice_1_7_0'    \/>\n\t\t\t\t<label for='choice_1_7_0' id='label_1_7_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_7_1'>\n\t\t\t\t<input name='input_7' type='radio' value='No'  id='choice_1_7_1'    \/>\n\t\t\t\t<label for='choice_1_7_1' id='label_1_7_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Is your\/their age over 60?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_8'>\n\t\t\t<li class='gchoice gchoice_1_8_0'>\n\t\t\t\t<input name='input_8' type='radio' value='Yes'  id='choice_1_8_0'    \/>\n\t\t\t\t<label for='choice_1_8_0' id='label_1_8_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_8_1'>\n\t\t\t\t<input name='input_8' type='radio' value='No'  id='choice_1_8_1'    \/>\n\t\t\t\t<label for='choice_1_8_1' id='label_1_8_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you\/they have heart disease, lung disease, kidney disease,  diabetes or any auto-immune disorders?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_9'>\n\t\t\t<li class='gchoice gchoice_1_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='Yes'  id='choice_1_9_0'    \/>\n\t\t\t\t<label for='choice_1_9_0' id='label_1_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='No'  id='choice_1_9_1'    \/>\n\t\t\t\t<label for='choice_1_9_1' id='label_1_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you\/they traveled in the past 14 days to any regions affected  by COVID-19? 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