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if(embedStyleJSON&&(embedStyleJSON[this.embedURLHash])){if(embedStyleJSON[this.embedURLHash]['inlineStyle']&&embedStyleJSON[this.embedURLHash]['inlineStyle']['embedHeight']){this.defaultHeight='data-frameHeight="'+embedStyleJSON[this.embedURLHash]['inlineStyle']['embedHeight']+'"';}}
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this.setTimer();};this.bindMethod=function(method,scope){return function(){method.apply(scope,arguments);};};this.frameHeight=0;this.getBodyHeight=function(){if(this.formSubmitted===1){return;}
var height;var scrollHeight;var offsetHeight;try{if(this.frame.contentWindow.document.height){height=this.frame.contentWindow.document.height;if(this.frame.contentWindow.document.body.scrollHeight){height=scrollHeight=this.frame.contentWindow.document.body.scrollHeight;}
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if(isChrome){height=scrollHeight=this.frame.contentWindow.document.height;}
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var height=0;try{if(this.frame.contentWindow.window.innerHeight)
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return height;};this.getMD5=function(s){function L(k,d){return(k<<d)|(k>>>(32-d))}function K(G,k){var I,d,F,H,x;F=(G&2147483648);H=(k&2147483648);I=(G&1073741824);d=(k&1073741824);x=(G&1073741823)+(k&1073741823);if(I&d){return(x^2147483648^F^H)}if(I|d){if(x&1073741824){return(x^3221225472^F^H)}else{return(x^1073741824^F^H)}}else{return(x^F^H)}}function r(d,F,k){return(d&F)|((~d)&k)}function q(d,F,k){return(d&k)|(F&(~k))}function p(d,F,k){return(d^F^k)}function n(d,F,k){return(F^(d|(~k)))}function u(G,F,aa,Z,k,H,I){G=K(G,K(K(r(F,aa,Z),k),I));return K(L(G,H),F)}function f(G,F,aa,Z,k,H,I){G=K(G,K(K(q(F,aa,Z),k),I));return K(L(G,H),F)}function D(G,F,aa,Z,k,H,I){G=K(G,K(K(p(F,aa,Z),k),I));return K(L(G,H),F)}function t(G,F,aa,Z,k,H,I){G=K(G,K(K(n(F,aa,Z),k),I));return K(L(G,H),F)}function e(G){var Z;var F=G.length;var x=F+8;var k=(x-(x%64))/64;var I=(k+1)*16;var aa=Array(I-1);var d=0;var H=0;while(H<F){Z=(H-(H%4))/4;d=(H%4)*8;aa[Z]=(aa[Z]|(G.charCodeAt(H)<<d));H++}Z=(H-(H%4))/4;d=(H%4)*8;aa[Z]=aa[Z]|(128<<d);aa[I-2]=F<<3;aa[I-1]=F>>>29;return aa}function B(x){var k="",F="",G,d;for(d=0;d<=3;d++){G=(x>>>(d*8))&255;F="0"+G.toString(16);k=k+F.substr(F.length-2,2)}return k}function J(k){k=k.replace(/rn/g,"n");var d="";for(var F=0;F<k.length;F++){var x=k.charCodeAt(F);if(x<128){d+=String.fromCharCode(x)}else{if((x>127)&&(x<2048)){d+=String.fromCharCode((x>>6)|192);d+=String.fromCharCode((x&63)|128)}else{d+=String.fromCharCode((x>>12)|224);d+=String.fromCharCode(((x>>6)&63)|128);d+=String.fromCharCode((x&63)|128)}}}return d}var C=Array();var P,h,E,v,g,Y,X,W,V;var S=7,Q=12,N=17,M=22;var A=5,z=9,y=14,w=20;var o=4,m=11,l=16,j=23;var U=6,T=10,R=15,O=21;s=J(s);C=e(s);Y=1732584193;X=4023233417;W=2562383102;V=271733878;for(P=0;P<C.length;P+=16){h=Y;E=X;v=W;g=V;Y=u(Y,X,W,V,C[P+0],S,3614090360);V=u(V,Y,X,W,C[P+1],Q,3905402710);W=u(W,V,Y,X,C[P+2],N,606105819);X=u(X,W,V,Y,C[P+3],M,3250441966);Y=u(Y,X,W,V,C[P+4],S,4118548399);V=u(V,Y,X,W,C[P+5],Q,1200080426);W=u(W,V,Y,X,C[P+6],N,2821735955);X=u(X,W,V,Y,C[P+7],M,4249261313);Y=u(Y,X,W,V,C[P+8],S,1770035416);V=u(V,Y,X,W,C[P+9],Q,2336552879);W=u(W,V,Y,X,C[P+10],N,4294925233);X=u(X,W,V,Y,C[P+11],M,2304563134);Y=u(Y,X,W,V,C[P+12],S,1804603682);V=u(V,Y,X,W,C[P+13],Q,4254626195);W=u(W,V,Y,X,C[P+14],N,2792965006);X=u(X,W,V,Y,C[P+15],M,1236535329);Y=f(Y,X,W,V,C[P+1],A,4129170786);V=f(V,Y,X,W,C[P+6],z,3225465664);W=f(W,V,Y,X,C[P+11],y,643717713);X=f(X,W,V,Y,C[P+0],w,3921069994);Y=f(Y,X,W,V,C[P+5],A,3593408605);V=f(V,Y,X,W,C[P+10],z,38016083);W=f(W,V,Y,X,C[P+15],y,3634488961);X=f(X,W,V,Y,C[P+4],w,3889429448);Y=f(Y,X,W,V,C[P+9],A,568446438);V=f(V,Y,X,W,C[P+14],z,3275163606);W=f(W,V,Y,X,C[P+3],y,4107603335);X=f(X,W,V,Y,C[P+8],w,1163531501);Y=f(Y,X,W,V,C[P+13],A,2850285829);V=f(V,Y,X,W,C[P+2],z,4243563512);W=f(W,V,Y,X,C[P+7],y,1735328473);X=f(X,W,V,Y,C[P+12],w,2368359562);Y=D(Y,X,W,V,C[P+5],o,4294588738);V=D(V,Y,X,W,C[P+8],m,2272392833);W=D(W,V,Y,X,C[P+11],l,1839030562);X=D(X,W,V,Y,C[P+14],j,4259657740);Y=D(Y,X,W,V,C[P+1],o,2763975236);V=D(V,Y,X,W,C[P+4],m,1272893353);W=D(W,V,Y,X,C[P+7],l,4139469664);X=D(X,W,V,Y,C[P+10],j,3200236656);Y=D(Y,X,W,V,C[P+13],o,681279174);V=D(V,Y,X,W,C[P+0],m,3936430074);W=D(W,V,Y,X,C[P+3],l,3572445317);X=D(X,W,V,Y,C[P+6],j,76029189);Y=D(Y,X,W,V,C[P+9],o,3654602809);V=D(V,Y,X,W,C[P+12],m,3873151461);W=D(W,V,Y,X,C[P+15],l,530742520);X=D(X,W,V,Y,C[P+2],j,3299628645);Y=t(Y,X,W,V,C[P+0],U,4096336452);V=t(V,Y,X,W,C[P+7],T,1126891415);W=t(W,V,Y,X,C[P+14],R,2878612391);X=t(X,W,V,Y,C[P+5],O,4237533241);Y=t(Y,X,W,V,C[P+12],U,1700485571);V=t(V,Y,X,W,C[P+3],T,2399980690);W=t(W,V,Y,X,C[P+10],R,4293915773);X=t(X,W,V,Y,C[P+1],O,2240044497);Y=t(Y,X,W,V,C[P+8],U,1873313359);V=t(V,Y,X,W,C[P+15],T,4264355552);W=t(W,V,Y,X,C[P+6],R,2734768916);X=t(X,W,V,Y,C[P+13],O,1309151649);Y=t(Y,X,W,V,C[P+4],U,4149444226);V=t(V,Y,X,W,C[P+11],T,3174756917);W=t(W,V,Y,X,C[P+2],R,718787259);X=t(X,W,V,Y,C[P+9],O,3951481745);Y=K(Y,h);X=K(X,E);W=K(W,v);V=K(V,g)}var i=B(Y)+B(X)+B(W)+B(V);return i.toLowerCase()};this.init();}
FrameBuilder.get=qsProxy||[];var i71917229906868=new FrameBuilder("71917229906868",false,"","<!DOCTYPE HTML PUBLIC \"-\/\/W3C\/\/DTD HTML 4.01\/\/EN\" \"http:\/\/www.w3.org\/TR\/html4\/strict.dtd\">\n<html class=\"supernova\"><head>\n<meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n<link rel=\"alternate\" type=\"application\/json+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=json&amp;url=http%3A%2F%2Fwww.jotform.com%2Fform%2F71917229906868\" title=\"oEmbed Form\"><link rel=\"alternate\" type=\"text\/xml+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=xml&amp;url=http%3A%2F%2Fwww.jotform.com%2Fform%2F71917229906868\" title=\"oEmbed Form\">\n<meta property=\"og:title\" content=\"Daycare Form\" >\n<meta property=\"og:url\" content=\"http:\/\/www.jotform.co\/form\/71917229906868\" >\n<meta property=\"og:description\" content=\"Please click the link to complete this form.\">\n<link rel=\"shortcut icon\" href=\"https:\/\/cdn.jotfor.ms\/favicon.ico\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=0\" \/>\n<meta name=\"HandheldFriendly\" content=\"true\" \/>\n<title>Daycare Form<\/title>\n<link href=\"https:\/\/cdn.jotfor.ms\/static\/formCss.css?3.3.4628\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/styles\/nova.css?3.3.4628\" \/>\n<link type=\"text\/css\" media=\"print\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/printForm.css?3.3.4628\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/themes\/CSS\/566a91c2977cdfcd478b4567.css?\"\/>\n<style type=\"text\/css\">\n@import '\/\/fonts.googleapis.com\/css?family=Open+Sans:light,lightitalic,normal,italic,bold,bolditalic';\n\n    .form-label-left{\n        width:100px;\n    }\n    .form-line{\n        padding-top:0px;\n        padding-bottom:0px;\n    }\n    .form-label-right{\n        width:100px;\n    }\n    body, html{\n        margin:0;\n        padding:0;\n        background:#ffffff;\n    }\n\n    .form-all{\n        margin:0px auto;\n        padding-top:0px;\n        width:800px;\n        color:#000000 !important;\n        font-family:'Open Sans';\n        font-size:14px;\n    }\n<\/style>\n\n<style type=\"text\/css\" id=\"form-designer-style\">\n    \/* Injected CSS Code *\/\n.form-label.form-label-auto {\n        \n      display: block;\n      float: none;\n      text-align: left;\n      width: 100%;\n    \n      }\/*PREFERENCES STYLE*\/\n    .form-all {\n      font-family: Open Sans, sans-serif;\n    }\n    .form-all .qq-upload-button,\n    .form-all .form-submit-button,\n    .form-all .form-submit-reset,\n    .form-all .form-submit-print {\n      font-family: Open Sans, sans-serif;\n    }\n    .form-all .form-pagebreak-back-container,\n    .form-all .form-pagebreak-next-container {\n      font-family: Open Sans, sans-serif;\n    }\n    .form-header-group {\n      font-family: Open Sans, sans-serif;\n    }\n    .form-label {\n      font-family: Open Sans, sans-serif;\n    }\n  \n    .form-label.form-label-auto {\n      \n    display: block;\n    float: none;\n    text-align: left;\n    width: 100%;\n  \n    }\n  \n    .form-line {\n      margin-top: 0px;\n      margin-bottom: 0px;\n    }\n  \n    .form-all {\n      width: 800px;\n    }\n  \n    .form-label-left,\n    .form-label-right {\n      width: 100px\n    }\n  \n    .form-all {\n      font-size: 14px\n    }\n    .form-all .qq-upload-button,\n    .form-all .qq-upload-button,\n    .form-all .form-submit-button,\n    .form-all .form-submit-reset,\n    .form-all .form-submit-print {\n      font-size: 14px\n    }\n    .form-all .form-pagebreak-back-container,\n    .form-all .form-pagebreak-next-container {\n      font-size: 14px\n    }\n  \n    .supernova {\n      background-color: #ffffff;\n    }\n    .supernova body {\n      background: transparent;\n    }\n  \n    .supernova .form-all, .form-all {\n      background-color: #ffffff;\n      border: 1px solid transparent;\n    }\n  \n    .form-all {\n      color: #000000;\n    }\n    .form-header-group .form-header {\n      color: #000000;\n    }\n    .form-header-group .form-subHeader {\n      color: #000000;\n    }\n    .form-label-top,\n    .form-label-left,\n    .form-label-right,\n    .form-html,\n    .form-checkbox-item label,\n    .form-radio-item label {\n      color: #000000;\n    }\n    .form-sub-label {\n      color: #1a1a1a;\n    }\n  \n    .form-textbox,\n    .form-textarea,\n    .form-radio-other-input,\n    .form-checkbox-other-input,\n    .form-captcha input,\n    .form-spinner input {\n      background-color: #ffffff;\n    }\n  \n    .form-line-error {\n      overflow: hidden;\n      .transition(none; 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class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_dropdown\" id=\"id_7\">\n        <label class=\"form-label form-label-top\" id=\"label_7\" for=\"input_7\">\n          Gender:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_7\" class=\"form-input-wide jf-required\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_7\" name=\"q7_gender\" style=\"width:150px;\" data-component=\"dropdown\" required=\"\">\n            <option value=\"\">  <\/option>\n            <option value=\"Male\"> Male <\/option>\n            <option value=\"Female\"> Female <\/option>\n            <option value=\"N\/A\"> N\/A <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3\" data-type=\"control_textbox\" id=\"id_8\">\n        <label class=\"form-label form-label-top\" id=\"label_8\" for=\"input_8\"> Class\/Grade: <\/label>\n        <div id=\"cid_8\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_8\" name=\"q8_classgrade8\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_4\">\n        <label class=\"form-label form-label-top\" id=\"label_4\" for=\"input_4\">\n          Daycare Centre:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_4\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_4\" name=\"q4_daycareCentre4\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"25\" value=\"\" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1\" data-type=\"control_textbox\" id=\"id_9\">\n        <label class=\"form-label form-label-top\" id=\"label_9\" for=\"input_9\"> Teacher: <\/label>\n        <div id=\"cid_9\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_9\" name=\"q9_teacher9\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_10\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_10\" for=\"input_10\">\n          When did your child last visit a dentist?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_10\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_10\" name=\"q10_whenDid\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"50\" value=\"\" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_21\">\n        <div id=\"cid_21\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:2px;margin-bottom:2px;\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_26\">\n        <div id=\"cid_26\" class=\"form-input-wide\">\n          <div id=\"text_26\" class=\"form-html\" data-component=\"text\">\n            <p><strong><span style=\"font-size: 14pt;\">Medicare Details:<\/span><\/strong><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_number\" id=\"id_12\">\n        <label class=\"form-label form-label-top\" id=\"label_12\" for=\"input_12\">\n          Medicare Card Number:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_12\" class=\"form-input-wide jf-required\">\n          <input type=\"number\" id=\"input_12\" name=\"q12_medicareCard12\" data-type=\"input-number\" class=\" form-number-input form-textbox validate[required]\" style=\"width:140px;\" size=\"15\" value=\"\" placeholder=\"ex: 1234567890\" data-numbermin=\"10\" data-component=\"number\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_number\" id=\"id_13\">\n        <label class=\"form-label form-label-top\" id=\"label_13\" for=\"input_13\">\n          Reference Number:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_13\" class=\"form-input-wide jf-required\">\n          <input type=\"number\" id=\"input_13\" name=\"q13_referenceNumber13\" data-type=\"input-number\" class=\" form-number-input form-textbox validate[required]\" style=\"width:100px;\" size=\"10\" value=\"\" placeholder=\"ex: 2\" data-numbermin=\"1\" data-component=\"number\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3 jf-required\" data-type=\"control_textbox\" id=\"id_15\">\n        <label class=\"form-label form-label-top\" id=\"label_15\" for=\"input_15\">\n          Expiry Date:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_15\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n            <input type=\"text\" id=\"input_15\" name=\"q15_expiryDate\" data-type=\"input-textbox\" class=\"form-textbox validate[required, Fill Mask]\" size=\"10\" data-masked=\"true\" value=\"\" data-component=\"textbox\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_15\" style=\"min-height:13px;\"> eg: 07\/18 <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_16\">\n        <label class=\"form-label form-label-top\" id=\"label_16\" for=\"input_16_0\">\n          Please Tick:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_16\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_16_0\" name=\"q16_pleaseTick[]\" value=\"I give consent to check Medicare CDBS eligibility status for my child\" required=\"\" \/>\n              <label id=\"label_input_16_0\" for=\"input_16_0\"> I give consent to check Medicare CDBS eligibility status for my child <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_16_1\" name=\"q16_pleaseTick[]\" value=\"I give consent to a full oral health assessment which includes examination, cleaning and fluoride treatment. If required fissure sealants and dental fillings to be carried out by Peoples Healthcare dental practitioners (Bulk-Billed; NO GAP payable, if eligible through Medicare Child Dental Benefits Schedule (CDBS)\" required=\"\" \/>\n              <label id=\"label_input_16_1\" for=\"input_16_1\"> I give consent to a full oral health assessment which includes examination, cleaning and fluoride treatment. If required fissure sealants and dental fillings to be carried out by Peoples Healthcare dental practitioners (Bulk-Billed; NO GAP payable, if eligible through Medicare Child Dental Benefits Schedule (CDBS) <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_16_2\" name=\"q16_pleaseTick[]\" value=\"If not eligible, please provide basic oral health assessment for $99. Call us for payment options or pay online\" required=\"\" \/>\n              <label id=\"label_input_16_2\" for=\"input_16_2\"> If not eligible, please provide basic oral health assessment for $99. Call us for payment options or pay online <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_20\">\n        <div id=\"cid_20\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:2px;margin-bottom:2px;\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_27\">\n        <div id=\"cid_27\" class=\"form-input-wide\">\n          <div id=\"text_27\" class=\"form-html\" data-component=\"text\">\n            <p><strong><span style=\"font-size: 14pt;\">Parent\/Guardian Details:<\/span><\/strong><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_fullname\" id=\"id_18\">\n        <label class=\"form-label form-label-top\" id=\"label_18\" for=\"prefix_18\">\n          Parent's Name:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_18\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <select data-component=\"prefix\" name=\"q18_parentsName[prefix]\" id=\"prefix_18\" class=\"dropdown-match-height form-dropdown validate[required]\">\n                <option value=\"Mr.\"> Mr. <\/option>\n                <option value=\"Mrs.\"> Mrs. <\/option>\n                <option value=\"Miss\"> Miss <\/option>\n                <option value=\"Ms\"> Ms <\/option>\n                <option value=\"Dr.\"> Dr. <\/option>\n              <\/select>\n              <label class=\"form-sub-label\" for=\"prefix_18\" id=\"sublabel_prefix\" style=\"min-height:13px;\"> Prefix <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"text\" id=\"first_18\" name=\"q18_parentsName[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_18\" id=\"sublabel_first\" style=\"min-height:13px;\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"text\" id=\"last_18\" name=\"q18_parentsName[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_18\" id=\"sublabel_last\" style=\"min-height:13px;\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_address\" id=\"id_24\">\n        <label class=\"form-label form-label-top\" id=\"label_24\" for=\"input_24_addr_line1\">\n          Residential Address:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_24\" class=\"form-input-wide jf-required\">\n          <table summary=\"\" class=\"form-address-table\" cellpadding=\"0\" cellspacing=\"0\">\n            <tbody>\n              <tr>\n                <td colspan=\"2\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_24_addr_line1\" name=\"q24_address[addr_line1]\" class=\"form-textbox validate[required] form-address-line\" value=\"\" data-component=\"address_line_1\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_24_addr_line1\" id=\"sublabel_24_addr_line1\" style=\"min-height:13px;\"> Street Address <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td colspan=\"2\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_24_addr_line2\" name=\"q24_address[addr_line2]\" class=\"form-textbox form-address-line\" size=\"46\" value=\"\" data-component=\"address_line_2\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_24_addr_line2\" id=\"sublabel_24_addr_line2\" style=\"min-height:13px;\"> Street Address Line 2 <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td width=\"50%\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_24_city\" name=\"q24_address[city]\" class=\"form-textbox validate[required] form-address-city\" size=\"21\" value=\"\" data-component=\"city\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_24_city\" id=\"sublabel_24_city\" style=\"min-height:13px;\"> City <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_24_state\" name=\"q24_address[state]\" class=\"form-textbox validate[required] form-address-state\" size=\"22\" value=\"\" data-component=\"state\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_24_state\" id=\"sublabel_24_state\" style=\"min-height:13px;\"> State <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td width=\"50%\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_24_postal\" name=\"q24_address[postal]\" class=\"form-textbox form-address-postal\" size=\"10\" value=\"\" data-component=\"zip\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_24_postal\" id=\"sublabel_24_postal\" style=\"min-height:13px;\"> Zip Code <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <select class=\"form-dropdown validate[required] form-address-country\" name=\"q24_address[country]\" id=\"input_24_country\" data-component=\"country\" required=\"\">\n                      <option value=\"\"> Please Select <\/option>\n                      <option value=\"United States\"> United States <\/option>\n                      <option value=\"Afghanistan\"> Afghanistan <\/option>\n                      <option value=\"Albania\"> Albania <\/option>\n                      <option value=\"Algeria\"> Algeria <\/option>\n                      <option value=\"American Samoa\"> American Samoa <\/option>\n                      <option value=\"Andorra\"> Andorra <\/option>\n                      <option value=\"Angola\"> Angola <\/option>\n                      <option value=\"Anguilla\"> Anguilla <\/option>\n                      <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                      <option value=\"Argentina\"> Argentina <\/option>\n                      <option value=\"Armenia\"> Armenia <\/option>\n                      <option value=\"Aruba\"> Aruba <\/option>\n                      <option selected=\"\" value=\"Australia\"> Australia <\/option>\n                      <option value=\"Austria\"> Austria <\/option>\n                      <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                      <option value=\"The Bahamas\"> The Bahamas <\/option>\n                      <option value=\"Bahrain\"> Bahrain <\/option>\n                      <option value=\"Bangladesh\"> Bangladesh <\/option>\n                      <option value=\"Barbados\"> Barbados <\/option>\n                      <option value=\"Belarus\"> Belarus <\/option>\n                      <option value=\"Belgium\"> Belgium <\/option>\n                      <option value=\"Belize\"> Belize <\/option>\n                      <option value=\"Benin\"> Benin <\/option>\n                      <option value=\"Bermuda\"> Bermuda <\/option>\n                      <option value=\"Bhutan\"> Bhutan <\/option>\n                      <option value=\"Bolivia\"> Bolivia <\/option>\n                      <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                      <option value=\"Botswana\"> Botswana <\/option>\n                      <option value=\"Brazil\"> Brazil <\/option>\n                      <option value=\"Brunei\"> Brunei <\/option>\n                      <option value=\"Bulgaria\"> Bulgaria <\/option>\n                      <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                      <option value=\"Burundi\"> Burundi <\/option>\n                      <option value=\"Cambodia\"> Cambodia <\/option>\n                      <option value=\"Cameroon\"> Cameroon <\/option>\n                      <option value=\"Canada\"> Canada <\/option>\n                      <option value=\"Cape Verde\"> Cape Verde <\/option>\n                      <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                      <option value=\"Central African Republic\"> Central African Republic <\/option>\n                      <option value=\"Chad\"> Chad <\/option>\n                      <option value=\"Chile\"> Chile <\/option>\n                      <option value=\"China\"> China <\/option>\n                      <option value=\"Christmas Island\"> Christmas Island <\/option>\n                      <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                      <option value=\"Colombia\"> Colombia <\/option>\n                      <option value=\"Comoros\"> Comoros <\/option>\n                      <option value=\"Congo\"> Congo <\/option>\n                      <option value=\"Cook Islands\"> Cook Islands <\/option>\n                      <option value=\"Costa Rica\"> Costa Rica <\/option>\n                      <option value=\"Cote d&#x27;Ivoire\"> Cote d&#x27;Ivoire <\/option>\n                      <option value=\"Croatia\"> Croatia <\/option>\n                      <option value=\"Cuba\"> Cuba <\/option>\n                      <option value=\"Cyprus\"> Cyprus <\/option>\n                      <option value=\"Czech Republic\"> Czech Republic <\/option>\n                      <option value=\"Democratic Republic of the Congo\"> Democratic Republic of the Congo <\/option>\n                      <option value=\"Denmark\"> Denmark <\/option>\n                      <option value=\"Djibouti\"> Djibouti <\/option>\n                      <option value=\"Dominica\"> Dominica <\/option>\n                      <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                      <option value=\"Ecuador\"> Ecuador <\/option>\n                      <option value=\"Egypt\"> Egypt <\/option>\n                      <option value=\"El Salvador\"> El Salvador <\/option>\n                      <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                      <option value=\"Eritrea\"> Eritrea <\/option>\n                      <option value=\"Estonia\"> Estonia <\/option>\n                      <option value=\"Ethiopia\"> Ethiopia <\/option>\n                      <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                      <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                      <option value=\"Fiji\"> Fiji <\/option>\n                      <option value=\"Finland\"> Finland <\/option>\n                      <option value=\"France\"> France <\/option>\n                      <option value=\"French Polynesia\"> French Polynesia <\/option>\n                      <option value=\"Gabon\"> Gabon <\/option>\n                      <option value=\"The Gambia\"> The Gambia <\/option>\n                      <option value=\"Georgia\"> Georgia <\/option>\n                      <option value=\"Germany\"> Germany <\/option>\n                      <option value=\"Ghana\"> Ghana <\/option>\n                      <option value=\"Gibraltar\"> Gibraltar <\/option>\n                      <option value=\"Greece\"> Greece <\/option>\n                      <option value=\"Greenland\"> Greenland <\/option>\n                      <option value=\"Grenada\"> Grenada <\/option>\n                      <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                      <option value=\"Guam\"> Guam <\/option>\n                      <option value=\"Guatemala\"> Guatemala <\/option>\n                      <option value=\"Guernsey\"> Guernsey <\/option>\n                      <option value=\"Guinea\"> Guinea <\/option>\n                      <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                      <option value=\"Guyana\"> Guyana <\/option>\n                      <option value=\"Haiti\"> Haiti <\/option>\n                      <option value=\"Honduras\"> Honduras <\/option>\n                      <option value=\"Hong Kong\"> Hong Kong <\/option>\n                      <option value=\"Hungary\"> Hungary <\/option>\n                      <option value=\"Iceland\"> Iceland <\/option>\n                      <option value=\"India\"> India <\/option>\n                      <option value=\"Indonesia\"> Indonesia <\/option>\n                      <option value=\"Iran\"> Iran <\/option>\n                      <option value=\"Iraq\"> Iraq <\/option>\n                      <option value=\"Ireland\"> Ireland <\/option>\n                      <option value=\"Israel\"> Israel <\/option>\n                      <option value=\"Italy\"> Italy <\/option>\n                      <option value=\"Jamaica\"> Jamaica <\/option>\n                      <option value=\"Japan\"> Japan <\/option>\n                      <option value=\"Jersey\"> Jersey <\/option>\n                      <option value=\"Jordan\"> Jordan <\/option>\n                      <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                      <option value=\"Kenya\"> Kenya <\/option>\n                      <option value=\"Kiribati\"> Kiribati <\/option>\n                      <option value=\"North Korea\"> North Korea <\/option>\n                      <option value=\"South Korea\"> South Korea <\/option>\n                      <option value=\"Kosovo\"> Kosovo <\/option>\n                      <option value=\"Kuwait\"> Kuwait <\/option>\n                      <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                      <option value=\"Laos\"> Laos <\/option>\n                      <option value=\"Latvia\"> Latvia <\/option>\n                      <option value=\"Lebanon\"> Lebanon <\/option>\n                      <option value=\"Lesotho\"> Lesotho <\/option>\n                      <option value=\"Liberia\"> Liberia <\/option>\n                      <option value=\"Libya\"> Libya <\/option>\n                      <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                      <option value=\"Lithuania\"> Lithuania <\/option>\n                      <option value=\"Luxembourg\"> Luxembourg <\/option>\n                      <option value=\"Macau\"> Macau <\/option>\n                      <option value=\"Macedonia\"> Macedonia <\/option>\n                      <option value=\"Madagascar\"> Madagascar <\/option>\n                      <option value=\"Malawi\"> Malawi <\/option>\n                      <option value=\"Malaysia\"> Malaysia <\/option>\n                      <option value=\"Maldives\"> Maldives <\/option>\n                      <option value=\"Mali\"> Mali <\/option>\n                      <option value=\"Malta\"> Malta <\/option>\n                      <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                      <option value=\"Martinique\"> Martinique <\/option>\n                      <option value=\"Mauritania\"> Mauritania <\/option>\n                      <option value=\"Mauritius\"> Mauritius <\/option>\n                      <option value=\"Mayotte\"> Mayotte <\/option>\n                      <option value=\"Mexico\"> Mexico <\/option>\n                      <option value=\"Micronesia\"> Micronesia <\/option>\n                      <option value=\"Moldova\"> Moldova <\/option>\n                      <option value=\"Monaco\"> Monaco <\/option>\n                      <option value=\"Mongolia\"> Mongolia <\/option>\n                      <option value=\"Montenegro\"> Montenegro <\/option>\n                      <option value=\"Montserrat\"> Montserrat <\/option>\n                      <option value=\"Morocco\"> Morocco <\/option>\n                      <option value=\"Mozambique\"> Mozambique <\/option>\n                      <option value=\"Myanmar\"> Myanmar <\/option>\n                      <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                      <option value=\"Namibia\"> Namibia <\/option>\n                      <option value=\"Nauru\"> Nauru <\/option>\n                      <option value=\"Nepal\"> Nepal <\/option>\n                      <option value=\"Netherlands\"> Netherlands <\/option>\n                      <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                      <option value=\"New Caledonia\"> New Caledonia <\/option>\n                      <option value=\"New Zealand\"> New Zealand <\/option>\n                      <option value=\"Nicaragua\"> Nicaragua <\/option>\n                      <option value=\"Niger\"> Niger <\/option>\n                      <option value=\"Nigeria\"> Nigeria <\/option>\n                      <option value=\"Niue\"> Niue <\/option>\n                      <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                      <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                      <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                      <option value=\"Norway\"> Norway <\/option>\n                      <option value=\"Oman\"> Oman <\/option>\n                      <option value=\"Pakistan\"> Pakistan <\/option>\n                      <option value=\"Palau\"> Palau <\/option>\n                      <option value=\"Palestine\"> Palestine <\/option>\n                      <option value=\"Panama\"> Panama <\/option>\n                      <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                      <option value=\"Paraguay\"> Paraguay <\/option>\n                      <option value=\"Peru\"> Peru <\/option>\n                      <option value=\"Philippines\"> Philippines <\/option>\n                      <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                      <option value=\"Poland\"> Poland <\/option>\n                      <option value=\"Portugal\"> Portugal <\/option>\n                      <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                      <option value=\"Qatar\"> Qatar <\/option>\n                      <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n                      <option value=\"Romania\"> Romania <\/option>\n                      <option value=\"Russia\"> Russia <\/option>\n                      <option value=\"Rwanda\"> Rwanda <\/option>\n                      <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                      <option value=\"Saint Helena\"> Saint Helena <\/option>\n                      <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                      <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                      <option value=\"Saint Martin\"> Saint Martin <\/option>\n                      <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                      <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                      <option value=\"Samoa\"> Samoa <\/option>\n                      <option value=\"San Marino\"> San Marino <\/option>\n                      <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                      <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                      <option value=\"Senegal\"> Senegal <\/option>\n                      <option value=\"Serbia\"> Serbia <\/option>\n                      <option value=\"Seychelles\"> Seychelles <\/option>\n                      <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                      <option value=\"Singapore\"> Singapore <\/option>\n                      <option value=\"Slovakia\"> Slovakia <\/option>\n                      <option value=\"Slovenia\"> Slovenia <\/option>\n                      <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                      <option value=\"Somalia\"> Somalia <\/option>\n                      <option value=\"Somaliland\"> Somaliland <\/option>\n                      <option value=\"South Africa\"> South Africa <\/option>\n                      <option value=\"South Ossetia\"> South Ossetia <\/option>\n                      <option value=\"South Sudan\"> South Sudan <\/option>\n                      <option value=\"Spain\"> Spain <\/option>\n                      <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                      <option value=\"Sudan\"> Sudan <\/option>\n                      <option value=\"Suriname\"> Suriname <\/option>\n                      <option value=\"Svalbard\"> Svalbard <\/option>\n                      <option value=\"Swaziland\"> Swaziland <\/option>\n                      <option value=\"Sweden\"> Sweden <\/option>\n                      <option value=\"Switzerland\"> Switzerland <\/option>\n                      <option value=\"Syria\"> Syria <\/option>\n                      <option value=\"Taiwan\"> Taiwan <\/option>\n                      <option value=\"Tajikistan\"> Tajikistan <\/option>\n                      <option value=\"Tanzania\"> Tanzania <\/option>\n                      <option value=\"Thailand\"> Thailand <\/option>\n                      <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                      <option value=\"Togo\"> Togo <\/option>\n                      <option value=\"Tokelau\"> Tokelau <\/option>\n                      <option value=\"Tonga\"> Tonga <\/option>\n                      <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                      <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                      <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                      <option value=\"Tunisia\"> Tunisia <\/option>\n                      <option value=\"Turkey\"> Turkey <\/option>\n                      <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                      <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                      <option value=\"Tuvalu\"> Tuvalu <\/option>\n                      <option value=\"Uganda\"> Uganda <\/option>\n                      <option value=\"Ukraine\"> Ukraine <\/option>\n                      <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                      <option value=\"United Kingdom\"> United Kingdom <\/option>\n                      <option value=\"Uruguay\"> Uruguay <\/option>\n                      <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                      <option value=\"Vanuatu\"> Vanuatu <\/option>\n                      <option value=\"Vatican City\"> Vatican City <\/option>\n                      <option value=\"Venezuela\"> Venezuela <\/option>\n                      <option value=\"Vietnam\"> Vietnam <\/option>\n                      <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                      <option value=\"Isle of Man\"> Isle of Man <\/option>\n                      <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                      <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                      <option value=\"Western Sahara\"> Western Sahara <\/option>\n                      <option value=\"Yemen\"> Yemen <\/option>\n                      <option value=\"Zambia\"> Zambia <\/option>\n                      <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                      <option value=\"other\"> Other <\/option>\n                    <\/select>\n                    <label class=\"form-sub-label\" for=\"input_24_country\" id=\"sublabel_24_country\" style=\"min-height:13px;\"> Country <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n            <\/tbody>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_number\" id=\"id_22\">\n        <label class=\"form-label form-label-top\" id=\"label_22\" for=\"input_22\">\n          Contact Number:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_22\" class=\"form-input-wide jf-required\">\n          <input type=\"number\" id=\"input_22\" name=\"q22_number\" data-type=\"input-number\" class=\" form-number-input form-textbox validate[required]\" style=\"width:180px;\" size=\"20\" value=\"\" placeholder=\"ex: 0412 345 678\" data-numbermin=\"10\" data-component=\"number\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_email\" id=\"id_40\">\n        <label class=\"form-label form-label-top\" id=\"label_40\" for=\"input_40\">\n          Email Address:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_40\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n            <input type=\"email\" id=\"input_40\" name=\"q40_emailAddress\" class=\"form-textbox validate[required, Email]\" size=\"30\" value=\"\" data-component=\"email\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_40\" style=\"min-height:13px;\"> example@example.com <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_25\">\n        <div id=\"cid_25\" class=\"form-input-wide\">\n          <div data-component=\"divider\" style=\"border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:2px;margin-bottom:2px;\">\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_28\">\n        <div id=\"cid_28\" class=\"form-input-wide\">\n          <div id=\"text_28\" class=\"form-html\" data-component=\"text\">\n            <p>Please complete the following. Information about Medical History is for Dentist's Use only. <\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_radio\" id=\"id_29\">\n        <label class=\"form-label form-label-top\" id=\"label_29\" for=\"input_29\">\n          Is your child receiving any medical treatment at present?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_29\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_29_0\" name=\"q29_isYour\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_29_0\" for=\"input_29_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_29_1\" name=\"q29_isYour\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_29_1\" for=\"input_29_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2\" data-type=\"control_textbox\" id=\"id_30\">\n        <label class=\"form-label form-label-top\" id=\"label_30\" for=\"input_30\"> If yes please provide details: <\/label>\n        <div id=\"cid_30\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_30\" name=\"q30_ifYes30\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"25\" value=\"\" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3 jf-required\" data-type=\"control_radio\" id=\"id_31\">\n        <label class=\"form-label form-label-top\" id=\"label_31\" for=\"input_31\">\n          Does your child have any serious or long standing illness?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_31\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_31_0\" name=\"q31_doesYour\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_31_0\" for=\"input_31_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_31_1\" name=\"q31_doesYour\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_31_1\" for=\"input_31_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-4\" data-type=\"control_textbox\" id=\"id_32\">\n        <label class=\"form-label form-label-top\" id=\"label_32\" for=\"input_32\"> If yes please provide details: <\/label>\n        <div id=\"cid_32\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_32\" name=\"q32_ifYes\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"24\" value=\"\" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-5 jf-required\" data-type=\"control_radio\" id=\"id_35\">\n        <label class=\"form-label form-label-top\" id=\"label_35\" for=\"input_35\">\n          Medications (eg. Epilim):\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_35\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_35_0\" name=\"q35_medicationseg35\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_35_0\" for=\"input_35_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_35_1\" name=\"q35_medicationseg35\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_35_1\" for=\"input_35_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-6 jf-required\" data-type=\"control_radio\" id=\"id_33\">\n        <label class=\"form-label form-label-top\" id=\"label_33\" for=\"input_33\">\n          Allergies (eg. Penicillin):\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_33\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_33_0\" name=\"q33_allergieseg\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_33_0\" for=\"input_33_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_33_1\" name=\"q33_allergieseg\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_33_1\" for=\"input_33_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-7\" data-type=\"control_textbox\" id=\"id_34\">\n        <label class=\"form-label form-label-top\" id=\"label_34\" for=\"input_34\"> If yes please provide details: <\/label>\n        <div id=\"cid_34\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_34\" name=\"q34_ifYes34\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"30\" value=\"\" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-8\" data-type=\"control_textbox\" id=\"id_36\">\n        <label class=\"form-label form-label-top\" id=\"label_36\" for=\"input_36\"> If yes please provide details: <\/label>\n        <div id=\"cid_36\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_36\" name=\"q36_ifYes36\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"30\" value=\"\" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_43\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_43\" for=\"input_43_0\">\n          Child Dental Benefits Schedule - Bulk Billing Consent:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_43\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_43_0\" name=\"q43_childDental[]\" value=\"I, parent\/legal guardian, certify, that I have been informed of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule. The likely cost of this treatment; and that I will be bulk billed for services under the Child Dental Benefits Schedule and that I will not pay out-of-pocket costs, subject to sufficient funds being available under the benefit cap.\" required=\"\" \/>\n              <label id=\"label_input_43_0\" for=\"input_43_0\"> I, parent\/legal guardian, certify, that I have been informed of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule. The likely cost of this treatment; and that I will be bulk billed for services under the Child Dental Benefits Schedule and that I will not pay out-of-pocket costs, subject to sufficient funds being available under the benefit cap. <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_43_1\" name=\"q43_childDental[]\" value=\"I understand that I \/ the patient will only have access to dental benefits of up to the benefit cap and that the benefits for some services may have restrictions and that Child Dental Benefits Schedule covers a limited range of services. I understand I will need to personally meet the costs of any services not covered by the Child Dental Benefits Schedule.I understand that the cost of services will reduce the available benefit cap and that I will need to personally meet the costs of any additional services once benefits are exhausted.\" required=\"\" \/>\n              <label id=\"label_input_43_1\" for=\"input_43_1\"> I understand that I \/ the patient will only have access to dental benefits of up to the benefit cap and that the benefits for some services may have restrictions and that Child Dental Benefits Schedule covers a limited range of services. I understand I will need to personally meet the costs of any services not covered by the Child Dental Benefits Schedule.I understand that the cost of services will reduce the available benefit cap and that I will need to personally meet the costs of any additional services once benefits are exhausted. <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_37\">\n        <div id=\"cid_37\" class=\"form-input-wide\">\n          <div id=\"text_37\" class=\"form-html\" data-component=\"text\">\n            <p><em><span style=\"font-size: 10pt;\">The information provided above may be shared with appropriate governmental health care authority, and or\/with Medicare to check or assess the oral health service your child has received and how these services were provided. We won't use your child's personal details in any publication however we may use your child's photograph on our print and\/or electronic media platforms for marketing purposes only.<\/span><\/em><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_44\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_44\" for=\"input_44_0\">\n          Please Tick &amp; Sign:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_44\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_44_0\" name=\"q44_pleaseTick44[]\" value=\"By signing below, you give consent for us to provide the services mentioned above:\" required=\"\" \/>\n              <label id=\"label_input_44_0\" for=\"input_44_0\"> By signing below, you give consent for us to provide the services mentioned above: <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_signature\" id=\"id_38\">\n        <label class=\"form-label form-label-top\" id=\"label_38\" for=\"input_38\">\n          Parent \/ Legal Guardian Signature\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_38\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <div id=\"signature_pad_38\" class=\"signature-pad-wrapper\" style=\"width:302px;height:102px;\">\n              <div data-wrapper-react=\"true\">\n                <!--[if IE 7]>\n                  <script type=\"text\/javascript\" src=\"\/js\/vendor\/json2.js\"><\/script>\n                <![endif]-->\n              <\/div>\n              <div class=\"signature-line signature-wrapper\" data-component=\"signature\" style=\"width:302px;height:102px;\">\n                <div id=\"sig_pad_38\" data-width=\"300\" data-height=\"100\" data-id=\"38\" data-required=\"true\" class=\"pad\">\n                <\/div>\n                <input type=\"hidden\" name=\"q38_parent\" class=\"output4\" id=\"input_38\" \/>\n              <\/div>\n              <span class=\"clear-pad-btn clear-pad\">\n                Clear\n              <\/span>\n            <\/div>\n            <div data-wrapper-react=\"true\">\n              <script type=\"text\/javascript\">\n              window.signatureForm = true\n              <\/script>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2\" data-type=\"control_datetime\" id=\"id_39\">\n        <label class=\"form-label form-label-top\" id=\"label_39\" for=\"lite_mode_39\"> Date <\/label>\n        <div id=\"cid_39\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <div style=\"display:none;\">\n              <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                <input class=\"currentDate form-textbox validate[limitDate]\" id=\"day_39\" name=\"q39_date[day]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" value=\"12\" \/>\n                <span class=\"date-separate\">\n                  \u00a0.\n                <\/span>\n                <label class=\"form-sub-label\" for=\"day_39\" id=\"sublabel_day\" style=\"min-height:13px;\"> Day <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                <input class=\"form-textbox validate[limitDate]\" id=\"month_39\" name=\"q39_date[month]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" value=\"02\" \/>\n                <span class=\"date-separate\">\n                  \u00a0.\n                <\/span>\n                <label class=\"form-sub-label\" for=\"month_39\" id=\"sublabel_month\" style=\"min-height:13px;\"> Month <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                <input class=\"form-textbox validate[limitDate]\" id=\"year_39\" name=\"q39_date[year]\" type=\"tel\" size=\"4\" data-maxlength=\"4\" value=\"2018\" \/>\n                <label class=\"form-sub-label\" for=\"year_39\" id=\"sublabel_year\" style=\"min-height:13px;\"> Year <\/label>\n              <\/span>\n            <\/div>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input class=\"form-textbox validate[limitDate, validateLiteDate]\" id=\"lite_mode_39\" type=\"text\" size=\"12\" data-maxlength=\"12\" value=\"12.02.2018\" data-format=\"ddmmyyyy\" data-seperator=\".\" placeholder=\"dd.mm.yyyy\" \/>\n              <label class=\"form-sub-label\" for=\"lite_mode_39\" id=\"sublabel_litemode\" style=\"min-height:13px;\"> Date <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <img class=\"showAutoCalendar\" alt=\"Pick a Date\" id=\"input_39_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" style=\"vertical-align:middle;\" data-component=\"datetime\" \/>\n              <label class=\"form-sub-label\" for=\"input_39_pick\" style=\"min-height:13px;\">  <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_2\">\n        <div id=\"cid_2\" class=\"form-input-wide\">\n          <div style=\"margin-left:156px;\" class=\"form-buttons-wrapper\">\n            <button id=\"input_2\" type=\"submit\" class=\"form-submit-button form-submit-button-simple_green_apple\" data-component=\"button\">\n              Submit\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li style=\"display:none\">\n        Should be Empty:\n        <input type=\"text\" name=\"website\" value=\"\" \/>\n      <\/li>\n    <\/ul>\n  <\/div>\n  <script>\n  JotForm.showJotFormPowered = \"0\";\n  <\/script>\n  <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"71917229906868\" \/>\n  <script type=\"text\/javascript\">\n  document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"71917229906868-71917229906868\";\n  <\/script>\n<\/form><\/body>\n<\/html>\n","Dental Consent Form - Daycare",Array,0);(function(){window.handleIFrameMessage=function(e){if(!e.data||!e.data.split)return;var args=e.data.split(":");var iframe=document.getElementById("71917229906868");if(!iframe){return};switch(args[0]){case"scrollIntoView":if(!("nojump"in FrameBuilder.get)){iframe.scrollIntoView();}
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