{"id":351,"date":"2023-07-14T03:13:52","date_gmt":"2023-07-14T03:13:52","guid":{"rendered":"https:\/\/awacmn.com\/?page_id=351"},"modified":"2023-07-14T03:33:08","modified_gmt":"2023-07-14T03:33:08","slug":"referral","status":"publish","type":"page","link":"https:\/\/awacmn.com\/?page_id=351","title":{"rendered":"Referral"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"351\" class=\"elementor elementor-351\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-64a2aaa e-con-full e-flex e-con e-parent\" data-id=\"64a2aaa\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2f0bef5 ha-has-bg-overlay elementor-widget elementor-widget-heading\" data-id=\"2f0bef5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Rapid Referral Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-e750855 e-flex e-con-boxed e-con e-parent\" data-id=\"e750855\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6b54e60 elementor-widget elementor-widget-shortcode\" data-id=\"6b54e60\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"mf-form-shortcode\">\r\n\t\t<div\r\n\t\t\tid=\"metform-wrap-193-193\"\r\n\t\t\tclass=\"mf-form-wrapper\"\r\n\t\t\tdata-form-id=\"193\"\r\n\t\t\tdata-action=\"https:\/\/awacmn.com\/index.php?rest_route=\/metform\/v1\/entries\/insert\/193\"\r\n\t\t\tdata-wp-nonce=\"7f45a60315\"\r\n\t\t\tdata-form-nonce=\"7da398edfc\"\r\n\t\t\tdata-quiz-summery = \"false\"\r\n\t\t\tdata-save-progress = \"false\"\r\n\t\t\tdata-form-type=\"contact_form\"\r\n\t\t\tdata-stop-vertical-effect=\"\"\r\n\t\t\t><\/div>\r\n\r\n\r\n\t\t<!----------------------------- \r\n\t\t\t* controls_data : find the the props passed indie of data attribute\r\n\t\t\t* props.SubmitResponseMarkup : contains the markup of error or success message\r\n\t\t\t* https:\/\/developer.mozilla.org\/en-US\/docs\/Web\/JavaScript\/Reference\/Template_literals\r\n\t\t--------------------------- -->\r\n\r\n\t\t\t\t<script type=\"text\/mf\" class=\"mf-template\">\r\n\t\t\tfunction controls_data (value){\r\n\t\t\t\tlet currentWrapper = \"mf-response-props-id-193\";\r\n\t\t\t\tlet currentEl = document.getElementById(currentWrapper);\r\n\t\t\t\t\r\n\t\t\t\treturn currentEl ? currentEl.dataset[value] : false\r\n\t\t\t}\r\n\r\n\r\n\t\t\tlet is_edit_mode = '' ? true : false;\r\n\t\t\tlet message_position = controls_data('messageposition') || 'top';\r\n\r\n\t\t\t\r\n\t\t\tlet message_successIcon = controls_data('successicon') || '';\r\n\t\t\tlet message_errorIcon = controls_data('erroricon') || '';\r\n\t\t\tlet message_editSwitch = controls_data('editswitchopen') === 'yes' ? true : false;\r\n\t\t\tlet message_proClass = controls_data('editswitchopen') === 'yes' ? 'mf_pro_activated' : '';\r\n\t\t\t\r\n\t\t\tlet is_dummy_markup = is_edit_mode && message_editSwitch ? true : false;\r\n\r\n\t\t\t\r\n\t\t\treturn html`\r\n\t\t\t\t<form\r\n\t\t\t\t\tclassName=\"metform-form-content\"\r\n\t\t\t\t\tref=${parent.formContainerRef}\r\n\t\t\t\t\tonSubmit=${ validation.handleSubmit( parent.handleFormSubmit ) }\r\n\t\t\t\t\r\n\t\t\t\t\t>\r\n\t\t\t\r\n\t\t\t\r\n\t\t\t\t\t${is_dummy_markup ? message_position === 'top' ?  props.ResponseDummyMarkup(message_successIcon, message_proClass) : '' : ''}\r\n\t\t\t\t\t${is_dummy_markup ? ' ' :  message_position === 'top' ? props.SubmitResponseMarkup`${parent}${state}${message_successIcon}${message_errorIcon}${message_proClass}` : ''}\r\n\r\n\t\t\t\t\t<!--------------------------------------------------------\r\n\t\t\t\t\t*** IMPORTANT \/ DANGEROUS ***\r\n\t\t\t\t\t${html``} must be used as in immediate child of \"metform-form-main-wrapper\"\r\n\t\t\t\t\tclass otherwise multistep form will not run at all\r\n\t\t\t\t\t---------------------------------------------------------->\r\n\r\n\t\t\t\t\t<div className=\"metform-form-main-wrapper\" key=${'hide-form-after-submit'} ref=${parent.formRef}>\r\n\t\t\t\t\t${html`\r\n\t\t\t\t\t\t\t\t<div data-elementor-type=\"wp-post\" key=\"2\" data-elementor-id=\"193\" className=\"elementor elementor-193\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\">\n\t\t\t\t<div className=\"elementor-element elementor-element-006e24d e-flex e-con-boxed e-con e-parent\" data-id=\"006e24d\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div className=\"e-con-inner\">\n\t\t\t\t<div className=\"elementor-element elementor-element-2ce1a29 elementor-widget elementor-widget-heading\" data-id=\"2ce1a29\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<h2 className=\"elementor-heading-title elementor-size-default\">Patient Info\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div className=\"elementor-element elementor-element-b3efd99 e-flex e-con-boxed e-con e-parent\" data-id=\"b3efd99\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div className=\"e-con-inner\">\n\t\t<div className=\"elementor-element elementor-element-2bf4d01 e-flex e-con-boxed e-con e-parent\" data-id=\"2bf4d01\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div className=\"e-con-inner\">\n\t\t\t\t<div className=\"elementor-element elementor-element-29925d7 elementor-widget elementor-widget-mf-text\" data-id=\"29925d7\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Client_Name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-29925d7\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Client Name:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-29925d7\"\r\n\t\t\t\tname=\"Client_Name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Client_Name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Client_Name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-71ae98d elementor-widget elementor-widget-mf-text\" data-id=\"71ae98d\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Client_Address&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-71ae98d\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Client Address:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-71ae98d\"\r\n\t\t\t\tname=\"Client_Address\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Client_Address'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Client_Address\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-e6e604f elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-mf-text\" data-id=\"e6e604f\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Gender&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-e6e604f\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Gender:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-e6e604f\"\r\n\t\t\t\tname=\"Gender\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Gender'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Gender\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-f048b65 elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-mf-number\" data-id=\"f048b65\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Emergency_Contact&quot;}\" data-widget_type=\"mf-number.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-number-f048b65\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Emergency Contact:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"number\"\r\n\t\t\t\tstep=\"any\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-mobile-f048b65\"\r\n\t\t\t\tname=\"Emergency_Contact\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Number`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Emergency_Contact'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Emergency_Contact\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div className=\"elementor-element elementor-element-a3b5a94 e-con-full e-flex e-con e-parent\" data-id=\"a3b5a94\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t<div className=\"elementor-element elementor-element-e8953db elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-mf-date\" data-id=\"e8953db\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Date_of_Birth&quot;}\" data-widget_type=\"mf-date.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-date-e8953db\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Date of Birth:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<${props.Flatpickr}\r\n\t\t\t\t\tname=\"Date_of_Birth\"\r\n\t\t\t\t\tclassName=\"mf-input mf-date-input mf-left-parent  \"\r\n\t\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Date`) } \"\r\n\t\t\t\t\toptions=${{\"minDate\":\"\",\"maxDate\":\"\",\"dateFormat\":\"m-d-Y\",\"enableTime\":\"\",\"disable\":[],\"mode\":\"single\",\"static\":true,\"disableMobile\":true,\"time_24hr\":false}}\r\n\t\t\t\t\tvalue=${parent.getValue('Date_of_Birth')}\r\n\t\t\t\t\tonInput=${parent.handleDateTime}\r\n\t\t\t\t\taria-invalid=${validation.errors['Date_of_Birth'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el => props.DateWidget(\r\n\t\t\t\t\t\t\tel, \r\n\t\t\t\t\t\t\t'', \r\n\t\t\t\t\t\t\t{\"message\":\"This field is required.\",\"required\":false},  \r\n\t\t\t\t\t\t\tregister, \r\n\t\t\t\t\t\t\tparent \r\n\t\t\t\t\t\t)}\r\n\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Date_of_Birth\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\r\n\t\t\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div className=\"elementor-element elementor-element-f3f3997 e-flex e-con-boxed e-con e-parent\" data-id=\"f3f3997\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div className=\"e-con-inner\">\n\t\t\t\t<div className=\"elementor-element elementor-element-c254f84 elementor-widget__width-initial elementor-widget elementor-widget-mf-text\" data-id=\"c254f84\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;City&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-c254f84\">\r\n\t\t\t\t\t${ parent.decodeEntities(`City:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-c254f84\"\r\n\t\t\t\tname=\"City\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['City'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"City\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-7e2af87 elementor-widget__width-initial elementor-widget elementor-widget-mf-text\" data-id=\"7e2af87\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Zip_Code&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-7e2af87\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Zip Code:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-7e2af87\"\r\n\t\t\t\tname=\"Zip_Code\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Zip_Code'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Zip_Code\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-3ca27e9 elementor-widget elementor-widget-mf-number\" data-id=\"3ca27e9\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Client_Phone&quot;}\" data-widget_type=\"mf-number.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-number-3ca27e9\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Client Phone:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"number\"\r\n\t\t\t\tstep=\"any\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-mobile-3ca27e9\"\r\n\t\t\t\tname=\"Client_Phone\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Number`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Client_Phone'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Client_Phone\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-c4b9b4f elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-mf-number\" data-id=\"c4b9b4f\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Emergency_Contact_Phone&quot;}\" data-widget_type=\"mf-number.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-number-c4b9b4f\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Emergency Contact Phone`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"number\"\r\n\t\t\t\tstep=\"any\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-mobile-c4b9b4f\"\r\n\t\t\t\tname=\"Emergency_Contact_Phone\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Number`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Emergency_Contact_Phone'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Emergency_Contact_Phone\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-3ea02af elementor-widget elementor-widget-heading\" data-id=\"3ea02af\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<h2 className=\"elementor-heading-title elementor-size-default\">Referral Source<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div className=\"elementor-element elementor-element-6b871f8 e-flex e-con-boxed e-con e-parent\" data-id=\"6b871f8\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div className=\"e-con-inner\">\n\t\t<div className=\"elementor-element elementor-element-4bed2c9 e-flex e-con-boxed e-con e-parent\" data-id=\"4bed2c9\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div className=\"e-con-inner\">\n\t\t\t\t<div className=\"elementor-element elementor-element-6fcffa9 elementor-widget elementor-widget-mf-text\" data-id=\"6fcffa9\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Name_&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-6fcffa9\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Name:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-6fcffa9\"\r\n\t\t\t\tname=\"Name_\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Name_'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Name_\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-83bc28c elementor-widget elementor-widget-mf-number\" data-id=\"83bc28c\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Phone_&quot;}\" data-widget_type=\"mf-number.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-number-83bc28c\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Phone:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"number\"\r\n\t\t\t\tstep=\"any\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-mobile-83bc28c\"\r\n\t\t\t\tname=\"Phone_\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Number`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Phone_'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Phone_\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-65d7335 elementor-widget elementor-widget-mf-email\" data-id=\"65d7335\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Email&quot;}\" data-widget_type=\"mf-email.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-email-65d7335\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Email:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input \r\n\t\t\t\ttype=\"email\" \r\n\t\t\t\t \r\n\t\t\t\tdefaultValue=\"\" \r\n\t\t\t\tclassName=\"mf-input \" \r\n\t\t\t\tid=\"mf-input-email-65d7335\" \r\n\t\t\t\tname=\"Email\" \r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Email`) } \" \r\n\t\t\t\t \r\n\t\t\t\tonBlur=${parent.handleChange} onFocus=${parent.handleChange} aria-invalid=${validation.errors['Email'] ? 'true' : 'false' } \r\n\t\t\t\tref=${el=> parent.activateValidation({\"message\":\"This field is required.\",\"emailMessage\":\"Please enter a valid Email address\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t<${validation.ErrorMessage} \r\n\t\t\t\terrors=${validation.errors} \r\n\t\t\t\tname=\"Email\" \r\n\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div className=\"elementor-element elementor-element-f9e31be e-con-full e-flex e-con e-parent\" data-id=\"f9e31be\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t<div className=\"elementor-element elementor-element-6fd2681 elementor-widget elementor-widget-mf-checkbox\" data-id=\"6fd2681\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Case_Manager&quot;,&quot;mf_input_list&quot;:[{&quot;mf_input_option_text&quot;:&quot;Social Worker&quot;,&quot;mf_input_option_value&quot;:&quot;Social Worker&quot;,&quot;_id&quot;:&quot;00c559a&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Read Care Coordinator&quot;,&quot;mf_input_option_value&quot;:&quot;Care Coordination Clinic&quot;,&quot;_id&quot;:&quot;c704635&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;}]}\" data-widget_type=\"mf-checkbox.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\r\n\t\t\t<div \r\n\t\t\t\t\t\t\t\t\tref=${el => parent.handleCheckbox(el, 'onLoad')}\r\n\t\t\t\t\t\t\t\t\tclassName=\"mf-checkbox multi-option-input-type\"\r\n\t\t\t\t\tid=\"mf-input-checkbox-6fd2681\">\r\n\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"Case_Manager\"\r\n\t\t\t\t\t\t\t\tvalue=\"Social Worker\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['Case_Manager'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Social Worker`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"Case_Manager\"\r\n\t\t\t\t\t\t\t\tvalue=\"Care Coordination Clinic\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['Case_Manager'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Read Care Coordinator`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\t\t\t<input type=\"hidden\" name=\"Case_Manager\" value=\"\" \/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Case_Manager\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-d87dee3 elementor-widget elementor-widget-mf-text\" data-id=\"d87dee3\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Title&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-d87dee3\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Title:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-d87dee3\"\r\n\t\t\t\tname=\"Title\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Title'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Title\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-54a8406 elementor-widget elementor-widget-mf-text\" data-id=\"54a8406\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Fax&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-54a8406\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Fax:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-54a8406\"\r\n\t\t\t\tname=\"Fax\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Fax'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Fax\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-cbcbe91 elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-heading\" data-id=\"cbcbe91\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<h2 className=\"elementor-heading-title elementor-size-default\">Primary Care Provider &amp; Medical Info<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div className=\"elementor-element elementor-element-39b517e elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile e-flex e-con-boxed e-con e-parent\" data-id=\"39b517e\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div className=\"e-con-inner\">\n\t\t<div className=\"elementor-element elementor-element-7e77688 e-flex e-con-boxed e-con e-parent\" data-id=\"7e77688\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div className=\"e-con-inner\">\n\t\t\t\t<div className=\"elementor-element elementor-element-6e736c5 elementor-widget elementor-widget-mf-text\" data-id=\"6e736c5\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Physician_Name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-6e736c5\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Physician Name:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-6e736c5\"\r\n\t\t\t\tname=\"Physician_Name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Physician_Name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Physician_Name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-4a240eb elementor-widget elementor-widget-mf-number\" data-id=\"4a240eb\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Phone_&quot;}\" data-widget_type=\"mf-number.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-number-4a240eb\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Phone:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"number\"\r\n\t\t\t\tstep=\"any\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-mobile-4a240eb\"\r\n\t\t\t\tname=\"Phone_\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Number`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Phone_'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Phone_\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-50d5412 elementor-widget elementor-widget-mf-text\" data-id=\"50d5412\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Primary_DX&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-50d5412\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Primary DX:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-50d5412\"\r\n\t\t\t\tname=\"Primary_DX\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Primary_DX'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Primary_DX\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-e4e1fcb elementor-widget elementor-widget-mf-text\" data-id=\"e4e1fcb\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Psychiatrist_Name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-e4e1fcb\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Psychiatrist Name:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-e4e1fcb\"\r\n\t\t\t\tname=\"Psychiatrist_Name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Psychiatrist_Name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Psychiatrist_Name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div className=\"elementor-element elementor-element-e55c532 e-con-full e-flex e-con e-parent\" data-id=\"e55c532\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t<div className=\"elementor-element elementor-element-703935a elementor-widget elementor-widget-mf-text\" data-id=\"703935a\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Clinic_Name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-703935a\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Clinic Name:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-703935a\"\r\n\t\t\t\tname=\"Clinic_Name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Clinic_Name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Clinic_Name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-aea3073 elementor-widget elementor-widget-mf-text\" data-id=\"aea3073\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Fax&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-aea3073\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Fax:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-aea3073\"\r\n\t\t\t\tname=\"Fax\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Fax'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Fax\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-d08ff33 elementor-widget elementor-widget-mf-text\" data-id=\"d08ff33\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Secondary_DX&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-d08ff33\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Secondary DX:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-text-d08ff33\"\r\n\t\t\t\tname=\"Secondary_DX\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Secondary_DX'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Secondary_DX\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-efd92eb elementor-widget elementor-widget-mf-number\" data-id=\"efd92eb\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Phone_&quot;}\" data-widget_type=\"mf-number.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-number-efd92eb\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Phone:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"number\"\r\n\t\t\t\tstep=\"any\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-mobile-efd92eb\"\r\n\t\t\t\tname=\"Phone_\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Number`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['Phone_'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Phone_\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-fef5e31 elementor-widget elementor-widget-heading\" data-id=\"fef5e31\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<h2 className=\"elementor-heading-title elementor-size-default\">Insurance Coverage<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div className=\"elementor-element elementor-element-8dabcd5 e-flex e-con-boxed e-con e-parent\" data-id=\"8dabcd5\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div className=\"e-con-inner\">\n\t\t\t\t<div className=\"elementor-element elementor-element-7aafbb1 elementor-widget__width-inherit elementor-widget elementor-widget-mf-checkbox\" data-id=\"7aafbb1\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Payer Source:&quot;,&quot;mf_input_list&quot;:[{&quot;mf_input_option_text&quot;:&quot;Private Pay&quot;,&quot;mf_input_option_value&quot;:&quot;Private Pay&quot;,&quot;_id&quot;:&quot;00c559a&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Cadi Waiver&quot;,&quot;mf_input_option_value&quot;:&quot;Cadi Waiver&quot;,&quot;_id&quot;:&quot;c704635&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;DD Waiver&quot;,&quot;mf_input_option_value&quot;:&quot;DD Waiver&quot;,&quot;_id&quot;:&quot;4a02a85&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Elderly Waiver&quot;,&quot;mf_input_option_value&quot;:&quot;Elderly Waiver&quot;,&quot;_id&quot;:&quot;ef4fa5f&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Medical Assistant&quot;,&quot;mf_input_option_value&quot;:&quot;Medical Assistant&quot;,&quot;_id&quot;:&quot;a11db40&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Other&quot;,&quot;mf_input_option_value&quot;:&quot;Other&quot;,&quot;_id&quot;:&quot;cb1b250&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;}]}\" data-widget_type=\"mf-checkbox.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-checkbox-7aafbb1\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Payer Source:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<div \r\n\t\t\t\t\t\t\t\t\tref=${el => parent.handleCheckbox(el, 'onLoad')}\r\n\t\t\t\t\t\t\t\t\tclassName=\"mf-checkbox multi-option-input-type\"\r\n\t\t\t\t\tid=\"mf-input-checkbox-7aafbb1\">\r\n\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"Payer Source:\"\r\n\t\t\t\t\t\t\t\tvalue=\"Private Pay\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['Payer Source:'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Private Pay`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"Payer Source:\"\r\n\t\t\t\t\t\t\t\tvalue=\"Cadi Waiver\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['Payer Source:'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Cadi Waiver`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"Payer Source:\"\r\n\t\t\t\t\t\t\t\tvalue=\"DD Waiver\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['Payer Source:'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`DD Waiver`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"Payer Source:\"\r\n\t\t\t\t\t\t\t\tvalue=\"Elderly Waiver\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['Payer Source:'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Elderly Waiver`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"Payer Source:\"\r\n\t\t\t\t\t\t\t\tvalue=\"Medical Assistant\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['Payer Source:'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Medical Assistant`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"Payer Source:\"\r\n\t\t\t\t\t\t\t\tvalue=\"Other\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['Payer Source:'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Other`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\t\t\t<input type=\"hidden\" name=\"Payer Source:\" value=\"\" \/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Payer Source:\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-9330a2e mf-btn--justify mf-btn--tablet-justify mf-btn--mobile-justify elementor-widget elementor-widget-mf-button\" data-id=\"9330a2e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"mf-button.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div className=\"mf-btn-wraper \" data-mf-form-conditional-logic-requirement=\"\">\r\n\t\t\t\t\t\t\t<button type=\"submit\" className=\"metform-btn metform-submit-btn \" id=\"\">\r\n\t\t\t\t\t<span>${ parent.decodeEntities(`Submit`) } <\/span>\r\n\t\t\t\t<\/button>\r\n\t\t\t        <\/div>\r\n        \t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t`}\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t${is_dummy_markup ? message_position === 'bottom' ? props.ResponseDummyMarkup(message_successIcon, message_proClass) : '' : ''}\r\n\t\t\t\t\t${is_dummy_markup ? ' ' : message_position === 'bottom' ? props.SubmitResponseMarkup`${parent}${state}${message_successIcon}${message_errorIcon}${message_proClass}` : ''}\r\n\t\t\t\t\r\n\t\t\t\t<\/form>\r\n\t\t\t`\r\n\t\t<\/script>\r\n\r\n\t\t<\/div><\/div>\n\t\t\t\t\t\t<\/div>\n\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>Rapid Referral Form<\/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":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"_uf_show_specific_survey":0,"_uf_disable_surveys":false,"footnotes":""},"class_list":["post-351","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/awacmn.com\/index.php?rest_route=\/wp\/v2\/pages\/351","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/awacmn.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/awacmn.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/awacmn.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/awacmn.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=351"}],"version-history":[{"count":14,"href":"https:\/\/awacmn.com\/index.php?rest_route=\/wp\/v2\/pages\/351\/revisions"}],"predecessor-version":[{"id":403,"href":"https:\/\/awacmn.com\/index.php?rest_route=\/wp\/v2\/pages\/351\/revisions\/403"}],"wp:attachment":[{"href":"https:\/\/awacmn.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=351"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}