{"id":297,"date":"2025-09-09T17:08:18","date_gmt":"2025-09-09T17:08:18","guid":{"rendered":"https:\/\/projects.thewebworkers.org\/vdli\/?page_id=297"},"modified":"2025-09-16T19:45:04","modified_gmt":"2025-09-16T19:45:04","slug":"rx-form","status":"publish","type":"page","link":"https:\/\/projects.thewebworkers.org\/vdli\/rx-form\/","title":{"rendered":"RX Form"},"content":{"rendered":"<style id=\"wpforms-css-vars-298\">\n\t\t\t\t#wpforms-298 {\n\t\t\t\t--wpforms-field-border-radius: 5px;\n--wpforms-field-border-color: #61cbe4;\n--wpforms-field-border-color-spare: #61cbe4;\n--wpforms-field-text-color: rgba(0, 0, 0, 0.7);\n--wpforms-label-color: rgba(0, 0, 0, 0.85);\n--wpforms-label-sublabel-color: rgba(0, 0, 0, 0.55);\n--wpforms-button-border-style: solid;\n--wpforms-button-border-size: 2px;\n--wpforms-button-border-radius: 8px;\n--wpforms-button-background-color: #ffffff;\n--wpforms-button-border-color: #0077b6;\n--wpforms-button-text-color: #474747;\n--wpforms-background-color: rgba(0, 0, 0, 0);\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 14px;\n--wpforms-label-size-line-height: 17px;\n--wpforms-label-size-sublabel-font-size: 13px;\n--wpforms-label-size-sublabel-line-height: 16px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-298\"><form id=\"wpforms-form-298\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"298\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/vdli\/wp-json\/wp\/v2\/pages\/297\" data-token=\"e141bff6f653ff072241ba996d2aafc8\" data-token-time=\"1776514787\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-298-field_1-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"1\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-298-field_2-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-298-field_2\">Dr. Name: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-298-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-298-field_2-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-298-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-298-field_3\">Practice Location:<\/label><input type=\"text\" id=\"wpforms-298-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-298-field_3-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-298-field_4-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-298-field_4\">Phone: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-298-field_4\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][4]\" aria-label=\"Phone:\" aria-errormessage=\"wpforms-298-field_4-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-298-field_6-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-298-field_6\">Patient Name: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-298-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-298-field_6-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-298-field_5-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"5\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-298-field_10-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-298-field_10\">Date: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-298-field_10\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][10][date]\" aria-errormessage=\"wpforms-298-field_10-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-298-field_11-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-298-field_11\">Due Date: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-298-field_11\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][11][date]\" aria-errormessage=\"wpforms-298-field_11-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-298-field_8-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"8\"><fieldset><legend class=\"wpforms-field-label\">Gender<\/legend><ul id=\"wpforms-298-field_8\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-298-field_8_1\" name=\"wpforms[fields][8]\" value=\"M\" aria-errormessage=\"wpforms-298-field_8_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_8_1\">M<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-298-field_8_2\" name=\"wpforms[fields][8]\" value=\"F\" aria-errormessage=\"wpforms-298-field_8_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_8_2\">F<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-298-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-298-field_9\">Age:<\/label><input type=\"text\" id=\"wpforms-298-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-298-field_9-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-298-field_13-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"13\"><div id=\"wpforms-298-field_13\" aria-errormessage=\"wpforms-298-field_13-error\"><h3>Removable<\/h3><\/div><\/div><div id=\"wpforms-298-field_14-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"14\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Removable<\/legend><ul id=\"wpforms-298-field_14\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_14_1\" name=\"wpforms[fields][14][]\" value=\"Immediate Denture\" aria-errormessage=\"wpforms-298-field_14_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_14_1\">Immediate Denture<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_14_2\" name=\"wpforms[fields][14][]\" value=\"Economy Denture\" aria-errormessage=\"wpforms-298-field_14_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_14_2\">Economy Denture<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_14_3\" name=\"wpforms[fields][14][]\" value=\"Premium Denture\" aria-errormessage=\"wpforms-298-field_14_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_14_3\">Premium Denture<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_14_4\" name=\"wpforms[fields][14][]\" value=\"Partial Denture Vitallium\" aria-errormessage=\"wpforms-298-field_14_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_14_4\">Partial Denture Vitallium<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_14_5\" name=\"wpforms[fields][14][]\" value=\"Partial Denture Standard\" aria-errormessage=\"wpforms-298-field_14_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_14_5\">Partial Denture Standard<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_14_6\" name=\"wpforms[fields][14][]\" value=\"Partial Denture Combo\" aria-errormessage=\"wpforms-298-field_14_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_14_6\">Partial Denture Combo<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_14_7\" name=\"wpforms[fields][14][]\" value=\"Flexible Partial (Valplast)\" aria-errormessage=\"wpforms-298-field_14_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_14_7\">Flexible Partial (Valplast)<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_14_8\" name=\"wpforms[fields][14][]\" value=\"Flexible Partial (TCS)\" aria-errormessage=\"wpforms-298-field_14_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_14_8\">Flexible Partial (TCS)<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_14_9\" name=\"wpforms[fields][14][]\" value=\"Stayplate\" aria-errormessage=\"wpforms-298-field_14_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_14_9\">Stayplate<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-298-field_15-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"15\"><fieldset><legend class=\"wpforms-field-label\">Splint<\/legend><ul id=\"wpforms-298-field_15\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_15_1\" name=\"wpforms[fields][15][]\" value=\"Clear Hard Soft Night Guard\" aria-errormessage=\"wpforms-298-field_15_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_15_1\">Clear Hard Soft Night Guard<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_15_2\" name=\"wpforms[fields][15][]\" value=\"Clear Hard Hard Night Guard\" aria-errormessage=\"wpforms-298-field_15_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_15_2\">Clear Hard Hard Night Guard<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_15_3\" name=\"wpforms[fields][15][]\" value=\"Soft Night Guard\" aria-errormessage=\"wpforms-298-field_15_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_15_3\">Soft Night Guard<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_15_4\" name=\"wpforms[fields][15][]\" value=\"Mouth Guard\" aria-errormessage=\"wpforms-298-field_15_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_15_4\">Mouth Guard<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_15_5\" name=\"wpforms[fields][15][]\" value=\"Study Models\" aria-errormessage=\"wpforms-298-field_15_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_15_5\">Study Models<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_15_6\" name=\"wpforms[fields][15][]\" value=\"Hawley Retainer\" aria-errormessage=\"wpforms-298-field_15_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_15_6\">Hawley Retainer<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_15_7\" name=\"wpforms[fields][15][]\" value=\"Essix Retainer\" aria-errormessage=\"wpforms-298-field_15_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_15_7\">Essix Retainer<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_15_8\" name=\"wpforms[fields][15][]\" value=\"Bleaching Trays\" aria-errormessage=\"wpforms-298-field_15_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_15_8\">Bleaching Trays<\/label><\/li><\/ul><\/fieldset><\/div>\t\t<div id=\"wpforms-298-field_7-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"7\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-298-field_7\" >Number: Layout Design:<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-298-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-298-field_16-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Crown\/ Bridge<\/legend><ul id=\"wpforms-298-field_16\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_16_1\" name=\"wpforms[fields][16][]\" value=\"Full Contour Zirconia\" aria-errormessage=\"wpforms-298-field_16_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_16_1\">Full Contour Zirconia<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_16_2\" name=\"wpforms[fields][16][]\" value=\"Layered Zirconia\" aria-errormessage=\"wpforms-298-field_16_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_16_2\">Layered Zirconia<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_16_3\" name=\"wpforms[fields][16][]\" value=\"E-Max\" aria-errormessage=\"wpforms-298-field_16_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_16_3\">E-Max<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_16_4\" name=\"wpforms[fields][16][]\" value=\"PFM\" aria-errormessage=\"wpforms-298-field_16_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_16_4\">PFM<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_16_5\" name=\"wpforms[fields][16][]\" value=\"PFG\" aria-errormessage=\"wpforms-298-field_16_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_16_5\">PFG<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_16_6\" name=\"wpforms[fields][16][]\" value=\"Semi-Precious\" aria-errormessage=\"wpforms-298-field_16_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_16_6\">Semi-Precious<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_16_7\" name=\"wpforms[fields][16][]\" value=\"Full Gold Crown\" aria-errormessage=\"wpforms-298-field_16_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_16_7\">Full Gold Crown<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_16_8\" name=\"wpforms[fields][16][]\" value=\"Porcelain Margin\" aria-errormessage=\"wpforms-298-field_16_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_16_8\">Porcelain Margin<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_16_9\" name=\"wpforms[fields][16][]\" value=\"Occlusal\" aria-errormessage=\"wpforms-298-field_16_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_16_9\">Occlusal<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_16_10\" name=\"wpforms[fields][16][]\" value=\"Metal Margin\" aria-errormessage=\"wpforms-298-field_16_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_16_10\">Metal Margin<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_16_11\" name=\"wpforms[fields][16][]\" value=\"Lingual\" aria-errormessage=\"wpforms-298-field_16_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_16_11\">Lingual<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-298-field_17-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"17\"><div id=\"wpforms-298-field_17\" aria-errormessage=\"wpforms-298-field_17-error\"><h3>Implant<\/h3><\/div><\/div><div id=\"wpforms-298-field_18-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"18\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-298-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-298-field_20\">Implant Brand:<\/label><input type=\"text\" id=\"wpforms-298-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" aria-errormessage=\"wpforms-298-field_20-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-298-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-298-field_21\">Implant Size:<\/label><input type=\"text\" id=\"wpforms-298-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-298-field_21-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-298-field_19-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"19\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Implant<\/legend><ul id=\"wpforms-298-field_19\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_19_1\" name=\"wpforms[fields][19][]\" value=\"Screw Retained\" aria-errormessage=\"wpforms-298-field_19_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_19_1\">Screw Retained<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_19_2\" name=\"wpforms[fields][19][]\" value=\"Cement Retained\" aria-errormessage=\"wpforms-298-field_19_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_19_2\">Cement Retained<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_19_3\" name=\"wpforms[fields][19][]\" value=\"Custom Titanium\" aria-errormessage=\"wpforms-298-field_19_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_19_3\">Custom Titanium<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_19_4\" name=\"wpforms[fields][19][]\" value=\"Other\" aria-errormessage=\"wpforms-298-field_19_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_19_4\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-298-field_22-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"22\"><fieldset><legend class=\"wpforms-field-label\">Hybrid-Fixed Implant Restoration<\/legend><ul id=\"wpforms-298-field_22\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_22_1\" name=\"wpforms[fields][22][]\" value=\"All-on-4\" aria-errormessage=\"wpforms-298-field_22_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_22_1\">All-on-4<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_22_2\" name=\"wpforms[fields][22][]\" value=\"Solid Zirconia\" aria-errormessage=\"wpforms-298-field_22_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_22_2\">Solid Zirconia<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_22_3\" name=\"wpforms[fields][22][]\" value=\"Denture- Titanium Bar\" aria-errormessage=\"wpforms-298-field_22_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_22_3\">Denture- Titanium Bar<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_22_4\" name=\"wpforms[fields][22][]\" value=\"Overdenture Hybrid Restoration\" aria-errormessage=\"wpforms-298-field_22_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_22_4\">Overdenture Hybrid Restoration<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-298-field_23-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"23\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-298-field_24-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">Framework Design<\/legend><ul id=\"wpforms-298-field_24\" class=\"wpforms-image-choices wpforms-image-choices-modern\"><li class=\"choice-1 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_24_1\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/FD_1.png\" alt=\"1\" title=\"1\"><\/span><input type=\"checkbox\" id=\"wpforms-298-field_24_1\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][24][]\" value=\"1\" aria-errormessage=\"wpforms-298-field_24_1-error\" tabindex=\"-1\"  ><span class=\"wpforms-image-choices-label\">1<\/span><\/label><\/li><li class=\"choice-2 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_24_2\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/FD_2.png\" alt=\"2\" title=\"2\"><\/span><input type=\"checkbox\" id=\"wpforms-298-field_24_2\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][24][]\" value=\"2\" aria-errormessage=\"wpforms-298-field_24_2-error\" tabindex=\"-1\"  ><span class=\"wpforms-image-choices-label\">2<\/span><\/label><\/li><li class=\"choice-3 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_24_3\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/FD_3.png\" alt=\"3\" title=\"3\"><\/span><input type=\"checkbox\" id=\"wpforms-298-field_24_3\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][24][]\" value=\"3\" aria-errormessage=\"wpforms-298-field_24_3-error\" tabindex=\"-1\"  ><span class=\"wpforms-image-choices-label\">3<\/span><\/label><\/li><li class=\"choice-4 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_24_4\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/FD_4.png\" alt=\"4\" title=\"4\"><\/span><input type=\"checkbox\" id=\"wpforms-298-field_24_4\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][24][]\" value=\"4\" aria-errormessage=\"wpforms-298-field_24_4-error\" tabindex=\"-1\"  ><span class=\"wpforms-image-choices-label\">4<\/span><\/label><\/li><li class=\"choice-5 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_24_5\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/FD_5.png\" alt=\"5\" title=\"5\"><\/span><input type=\"checkbox\" id=\"wpforms-298-field_24_5\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][24][]\" value=\"5\" aria-errormessage=\"wpforms-298-field_24_5-error\" tabindex=\"-1\"  ><span class=\"wpforms-image-choices-label\">5<\/span><\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-298-field_25-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"25\"><fieldset><legend class=\"wpforms-field-label\">Pontic Design:<\/legend><ul id=\"wpforms-298-field_25\" class=\"wpforms-image-choices wpforms-image-choices-modern\"><li class=\"choice-1 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_25_1\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/PD_1.png\" alt=\"1\" title=\"1\"><\/span><input type=\"checkbox\" id=\"wpforms-298-field_25_1\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][25][]\" value=\"1\" aria-errormessage=\"wpforms-298-field_25_1-error\" tabindex=\"-1\"  ><span class=\"wpforms-image-choices-label\">1<\/span><\/label><\/li><li class=\"choice-2 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_25_2\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/PD_2.png\" alt=\"2\" title=\"2\"><\/span><input type=\"checkbox\" id=\"wpforms-298-field_25_2\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][25][]\" value=\"2\" aria-errormessage=\"wpforms-298-field_25_2-error\" tabindex=\"-1\"  ><span class=\"wpforms-image-choices-label\">2<\/span><\/label><\/li><li class=\"choice-3 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_25_3\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/PD_3.png\" alt=\"3\" title=\"3\"><\/span><input type=\"checkbox\" id=\"wpforms-298-field_25_3\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][25][]\" value=\"3\" aria-errormessage=\"wpforms-298-field_25_3-error\" tabindex=\"-1\"  ><span class=\"wpforms-image-choices-label\">3<\/span><\/label><\/li><li class=\"choice-4 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_25_4\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/PD_4.png\" alt=\"4\" title=\"4\"><\/span><input type=\"checkbox\" id=\"wpforms-298-field_25_4\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][25][]\" value=\"4\" aria-errormessage=\"wpforms-298-field_25_4-error\" tabindex=\"-1\"  ><span class=\"wpforms-image-choices-label\">4<\/span><\/label><\/li><li class=\"choice-5 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_25_5\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/PD_5.png\" alt=\"5\" title=\"5\"><\/span><input type=\"checkbox\" id=\"wpforms-298-field_25_5\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][25][]\" value=\"5\" aria-errormessage=\"wpforms-298-field_25_5-error\" tabindex=\"-1\"  ><span class=\"wpforms-image-choices-label\">5<\/span><\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-298-field_36-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"36\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-298-field_26-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"26\"><div id=\"wpforms-298-field_26\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-298-field_26-error\"><p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-328 aligncenter\" src=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/tooth-shade.png\" alt=\"\" width=\"200\" height=\"73\" \/><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-298-field_28-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"28\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Shade Option<\/legend><ul id=\"wpforms-298-field_28\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-298-field_28_1\" name=\"wpforms[fields][28]\" value=\"Call to Discuss Case\" aria-errormessage=\"wpforms-298-field_28_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_28_1\">Call to Discuss Case<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-298-field_28_2\" name=\"wpforms[fields][28]\" value=\"Custom Shade\" aria-errormessage=\"wpforms-298-field_28_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_28_2\">Custom Shade<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-298-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-298-field_29\" aria-hidden=\"false\">Shade:<\/label><input type=\"text\" id=\"wpforms-298-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" placeholder=\"Shade:\" aria-errormessage=\"wpforms-298-field_29-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-298-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-298-field_30\" aria-hidden=\"false\">Stump Shade:<\/label><input type=\"text\" id=\"wpforms-298-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" placeholder=\"Stump Shade:\" aria-errormessage=\"wpforms-298-field_30-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-298-field_38-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"38\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-298-field_31-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"31\"><div id=\"wpforms-298-field_31\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-298-field_31-error\"><p><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-342 aligncenter\" src=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/Partial-tooth-number-300x135.webp\" alt=\"\" width=\"300\" height=\"135\" srcset=\"https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/Partial-tooth-number-300x135.webp 300w, https:\/\/projects.thewebworkers.org\/vdli\/wp-content\/uploads\/2025\/09\/Partial-tooth-number.webp 500w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-67\"><div id=\"wpforms-298-field_32-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"32\"><fieldset><legend class=\"wpforms-field-label\">Tooth Number:<\/legend><ul id=\"wpforms-298-field_32\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_1\" name=\"wpforms[fields][32][]\" value=\"1\" aria-errormessage=\"wpforms-298-field_32_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_1\">1<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_2\" name=\"wpforms[fields][32][]\" value=\"2\" aria-errormessage=\"wpforms-298-field_32_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_2\">2<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_3\" name=\"wpforms[fields][32][]\" value=\"3\" aria-errormessage=\"wpforms-298-field_32_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_3\">3<\/label><\/li><li class=\"choice-32 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_32\" name=\"wpforms[fields][32][]\" value=\"4\" aria-errormessage=\"wpforms-298-field_32_32-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_32\">4<\/label><\/li><li class=\"choice-31 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_31\" name=\"wpforms[fields][32][]\" value=\"5\" aria-errormessage=\"wpforms-298-field_32_31-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_31\">5<\/label><\/li><li class=\"choice-30 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_30\" name=\"wpforms[fields][32][]\" value=\"6\" aria-errormessage=\"wpforms-298-field_32_30-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_30\">6<\/label><\/li><li class=\"choice-29 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_29\" name=\"wpforms[fields][32][]\" value=\"7\" aria-errormessage=\"wpforms-298-field_32_29-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_29\">7<\/label><\/li><li class=\"choice-28 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_28\" name=\"wpforms[fields][32][]\" value=\"8\" aria-errormessage=\"wpforms-298-field_32_28-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_28\">8<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_27\" name=\"wpforms[fields][32][]\" value=\"9\" aria-errormessage=\"wpforms-298-field_32_27-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_27\">9<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_26\" name=\"wpforms[fields][32][]\" value=\"10\" aria-errormessage=\"wpforms-298-field_32_26-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_26\">10<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_25\" name=\"wpforms[fields][32][]\" value=\"11\" aria-errormessage=\"wpforms-298-field_32_25-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_25\">11<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_24\" name=\"wpforms[fields][32][]\" value=\"12\" aria-errormessage=\"wpforms-298-field_32_24-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_24\">12<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_23\" name=\"wpforms[fields][32][]\" value=\"13\" aria-errormessage=\"wpforms-298-field_32_23-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_23\">13<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_22\" name=\"wpforms[fields][32][]\" value=\"14\" aria-errormessage=\"wpforms-298-field_32_22-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_22\">14<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_21\" name=\"wpforms[fields][32][]\" value=\"15\" aria-errormessage=\"wpforms-298-field_32_21-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_21\">15<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_20\" name=\"wpforms[fields][32][]\" value=\"16\" aria-errormessage=\"wpforms-298-field_32_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_20\">16<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_19\" name=\"wpforms[fields][32][]\" value=\"17\" aria-errormessage=\"wpforms-298-field_32_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_19\">17<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_18\" name=\"wpforms[fields][32][]\" value=\"18\" aria-errormessage=\"wpforms-298-field_32_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_18\">18<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_17\" name=\"wpforms[fields][32][]\" value=\"19\" aria-errormessage=\"wpforms-298-field_32_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_17\">19<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_16\" name=\"wpforms[fields][32][]\" value=\"20\" aria-errormessage=\"wpforms-298-field_32_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_16\">20<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_15\" name=\"wpforms[fields][32][]\" value=\"21\" aria-errormessage=\"wpforms-298-field_32_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_15\">21<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_14\" name=\"wpforms[fields][32][]\" value=\"22\" aria-errormessage=\"wpforms-298-field_32_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_14\">22<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_13\" name=\"wpforms[fields][32][]\" value=\"23\" aria-errormessage=\"wpforms-298-field_32_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_13\">23<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_12\" name=\"wpforms[fields][32][]\" value=\"24\" aria-errormessage=\"wpforms-298-field_32_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_12\">24<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_11\" name=\"wpforms[fields][32][]\" value=\"25\" aria-errormessage=\"wpforms-298-field_32_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_11\">25<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_10\" name=\"wpforms[fields][32][]\" value=\"26\" aria-errormessage=\"wpforms-298-field_32_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_10\">26<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_9\" name=\"wpforms[fields][32][]\" value=\"27\" aria-errormessage=\"wpforms-298-field_32_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_9\">27<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_8\" name=\"wpforms[fields][32][]\" value=\"28\" aria-errormessage=\"wpforms-298-field_32_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_8\">28<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_7\" name=\"wpforms[fields][32][]\" value=\"29\" aria-errormessage=\"wpforms-298-field_32_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_7\">29<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_6\" name=\"wpforms[fields][32][]\" value=\"30\" aria-errormessage=\"wpforms-298-field_32_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_6\">30<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_5\" name=\"wpforms[fields][32][]\" value=\"31\" aria-errormessage=\"wpforms-298-field_32_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_5\">31<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-298-field_32_4\" name=\"wpforms[fields][32][]\" value=\"32\" aria-errormessage=\"wpforms-298-field_32_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-298-field_32_4\">32<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-298-field_37-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"37\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-298-field_33-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-298-field_33\">Doctor&#039;s Signature:<\/label><input type=\"text\" id=\"wpforms-298-field_33\" class=\"wpforms-signature-input wpforms-screen-reader-element\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][33]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-298-field_33-error\" ><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" 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