{"id":2561,"date":"2014-07-05T09:56:52","date_gmt":"2014-07-05T16:56:52","guid":{"rendered":"http:\/\/silversagesports.digitalnordic.net\/sssfl\/?page_id=2561"},"modified":"2014-09-14T11:00:12","modified_gmt":"2014-09-14T18:00:12","slug":"silver-sage-center-new-patient-form","status":"publish","type":"page","link":"http:\/\/silversagecenter.com\/staging\/family-medicine\/silver-sage-center-new-patient-form\/","title":{"rendered":"Silver Sage Center New Patient Form"},"content":{"rendered":"<div style='height:50px' class='hr hr-invisible  '><span class='hr-inner ' ><span class='hr-inner-style'><\/span><\/span><\/div>\n<\/div><\/div><\/div><!-- close content main div --><\/div><\/div><div id='av_section_1' class='avia-section main_color avia-section-large avia-no-shadow avia-full-stretch av-parallax-section avia-bg-style-parallax   av-minimum-height av-minimum-height-25 container_wrap sidebar_right'  data-section-bg-repeat='stretch' ><div class='av-parallax' data-avia-parallax-ratio='0.3' ><div class='av-parallax-inner main_color  avia-full-stretch' style = 'background-repeat: no-repeat; background-image: url(http:\/\/silversagecenter.com\/staging\/wp-content\/uploads\/2014\/06\/snowbush-1030x360.jpg);background-attachment: scroll; background-position: top left; ' ><\/div><\/div><div class='container' ><div class='template-page content  av-content-small alpha units'><div class='post-entry post-entry-type-page post-entry-2561'><div class='entry-content-wrapper clearfix'>\n<div style='padding-bottom:10px; color:#ffffff;font-size:40px;' class='av-special-heading av-special-heading-h1 custom-color-heading blockquote modern-quote  av-inherit-size '><h1 class='av-special-heading-tag '  itemprop=\"headline\"  >Silver Sage Center New Patient Form<\/h1><div class='special-heading-border'><div class='special-heading-inner-border' style='border-color:#ffffff'><\/div><\/div><\/div>\n<\/div><\/div><\/div><!-- close content main div --><\/div><\/div><div id='after_section_1' class='main_color av_default_container_wrap container_wrap sidebar_right'   ><div class='container' ><div class='template-page content  av-content-small alpha units'><div class='post-entry post-entry-type-page post-entry-2561'><div class='entry-content-wrapper clearfix'>\n<section class=\"av_textblock_section \"  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock  '   itemprop=\"text\" >\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_4' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/staging\/wp-json\/wp\/v2\/pages\/2561'>\n                        <div class='gform_heading'>\n                            <h3 class='gform_title'>Silver Sage Center Patient Information Sheet<\/h3>\n                            <span class='gform_description'>Silver Sage Center for Family Medicine is currently accepting new patients. To set up an appointment contact us at 775-853-9394 or fill out the SSC forms to pre-register for an appointment. <br \/><br \/><em>In the event of a serious or life-threatening emergency, call 911 or go directly to a Medical Center Emergency Room located nearest you.If you need the Police, an Ambulance or the Fire Department for an Emergency, call 911.<\/em><br \/><br \/><\/span>\n                        <\/div>\n                        <div class='gform_body'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below'><li id='field_4_1'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Patient Information<\/h2><\/li><li id='field_4_6'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_4_6_3' >Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_4_6'>\n                            <span id='input_4_6_3_container' class='name_first' >\n                                                    <input type='text' name='input_6.3' id='input_4_6_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_4_6_3' >First<\/label>\n                                               <\/span>\n                            <span id='input_4_6_6_container' class='name_last' >\n                                                    <input type='text' name='input_6.6' id='input_4_6_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_4_6_6' >Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id='field_4_3'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_3' >Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_4_3' type='text' value='' class='medium'     aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_4'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_4' >Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_4_4' type='text' value='' class='medium'     aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_5'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_5' >Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_4_5' type='text' value='' class='medium'     aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_8'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_8' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_4_8' type='text' value='' class='medium'      aria-invalid=\"false\"\/>\n                        <\/div><\/li><li id='field_4_9'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_9' >Patient Social Security #<\/label><div class='ginput_container ginput_container_number'><input name='input_9' id='input_4_9' type='text'    value='' class='medium'       aria-invalid=\"false\"\/><\/div><\/li><li id='field_4_7'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_7' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_4_7' type='text' value='' class='datepicker medium mdy datepicker_no_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_7' class='gform_hidden' value='http:\/\/silversagecenter.com\/staging\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_4_10'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Gender<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_10'><li class='gchoice_4_10_0'><input name='input_10' type='radio' value='Male'  id='choice_4_10_0'     \/><label for='choice_4_10_0' id='label_4_10_0'>Male<\/label><\/li><li class='gchoice_4_10_1'><input name='input_10' type='radio' value='Female'  id='choice_4_10_1'     \/><label for='choice_4_10_1' id='label_4_10_1'>Female<\/label><\/li><\/ul><\/div><\/li><li id='field_4_54'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_54' >Marital Status<\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_4_54'  class='medium gfield_select'    aria-invalid=\"false\"><option value='Single' >Single<\/option><option value='Married' >Married<\/option><option value='Divorced' >Divorced<\/option><option value='Widowed' >Widowed<\/option><option value='Separated' >Separated<\/option><\/select><\/div><\/li><li id='field_4_12'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_4_12_1' >Physical Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gfield_trigger_change' id='input_4_12' >\n                         <span class='ginput_full address_line_1' id='input_4_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_4_12_1' value=''   \/>\n                                        <label for='input_4_12_1' id='input_4_12_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_4_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_4_12_3' value=''   \/>\n                                    <label for='input_4_12_3' id='input_4_12_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_4_12_4_container' >\n                                        <select name='input_12.4' id='input_4_12_4'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' selected='selected'>Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_12_4' id='input_4_12_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_4_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_4_12_5' value=''   \/>\n                                    <label for='input_4_12_5' id='input_4_12_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_12.6' id='input_4_12_6' value='United States'\/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_4_55'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Mailing address is different than physical address.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_55'><li class='gchoice_4_55_0'><input name='input_55' type='radio' value='Yes'  id='choice_4_55_0'   onclick='gf_apply_rules(4,[13]);' onkeypress='gf_apply_rules(4,[13]);'  \/><label for='choice_4_55_0' id='label_4_55_0'>Yes<\/label><\/li><li class='gchoice_4_55_1'><input name='input_55' type='radio' value='No'  id='choice_4_55_1'   onclick='gf_apply_rules(4,[13]);' onkeypress='gf_apply_rules(4,[13]);'  \/><label for='choice_4_55_1' id='label_4_55_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_13'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_4_13_1' >Mailing Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gfield_trigger_change' id='input_4_13' >\n                         <span class='ginput_full address_line_1' id='input_4_13_1_container' >\n                                        <input type='text' name='input_13.1' id='input_4_13_1' value=''   \/>\n                                        <label for='input_4_13_1' id='input_4_13_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_4_13_3_container' >\n                                    <input type='text' name='input_13.3' id='input_4_13_3' value=''   \/>\n                                    <label for='input_4_13_3' id='input_4_13_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_4_13_4_container' >\n                                        <select name='input_13.4' id='input_4_13_4'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' selected='selected'>Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_13_4' id='input_4_13_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_4_13_5_container' >\n                                    <input type='text' name='input_13.5' id='input_4_13_5' value=''   \/>\n                                    <label for='input_4_13_5' id='input_4_13_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_13.6' id='input_4_13_6' value='United States'\/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_4_39'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you require a language translator?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_39'><li class='gchoice_4_39_0'><input name='input_39' type='radio' value='Yes'  id='choice_4_39_0'   onclick='gf_apply_rules(4,[40]);' onkeypress='gf_apply_rules(4,[40]);'  \/><label for='choice_4_39_0' id='label_4_39_0'>Yes<\/label><\/li><li class='gchoice_4_39_1'><input name='input_39' type='radio' value='No'  id='choice_4_39_1'   onclick='gf_apply_rules(4,[40]);' onkeypress='gf_apply_rules(4,[40]);'  \/><label for='choice_4_39_1' id='label_4_39_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_40'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_40' >What language?<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_4_40' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_41'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you visually impaired?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_41'><li class='gchoice_4_41_0'><input name='input_41' type='radio' value='Yes'  id='choice_4_41_0'     \/><label for='choice_4_41_0' id='label_4_41_0'>Yes<\/label><\/li><li class='gchoice_4_41_1'><input name='input_41' type='radio' value='No'  id='choice_4_41_1'     \/><label for='choice_4_41_1' id='label_4_41_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_42'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you hearing impaired and require a sign language translator?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_42'><li class='gchoice_4_42_0'><input name='input_42' type='radio' value='Yes'  id='choice_4_42_0'     \/><label for='choice_4_42_0' id='label_4_42_0'>Yes<\/label><\/li><li class='gchoice_4_42_1'><input name='input_42' type='radio' value='No'  id='choice_4_42_1'     \/><label for='choice_4_42_1' id='label_4_42_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_43'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >If not, can we communicate via paper?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_43'><li class='gchoice_4_43_0'><input name='input_43' type='radio' value='Yes'  id='choice_4_43_0'     \/><label for='choice_4_43_0' id='label_4_43_0'>Yes<\/label><\/li><li class='gchoice_4_43_1'><input name='input_43' type='radio' value='No'  id='choice_4_43_1'     \/><label for='choice_4_43_1' id='label_4_43_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_4_14'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Emergency Contact<\/h2><\/li><li id='field_4_15'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_4_15_3' >Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_4_15'>\n                            <span id='input_4_15_3_container' class='name_first' >\n                                                    <input type='text' name='input_15.3' id='input_4_15_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_4_15_3' >First<\/label>\n                                               <\/span>\n                            <span id='input_4_15_6_container' class='name_last' >\n                                                    <input type='text' name='input_15.6' id='input_4_15_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_4_15_6' >Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id='field_4_16'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_16' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_4_16' type='text' value='' class='medium'     aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_17'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_17' >Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_4_17' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_18'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Patient or Parent Employment Information<\/h2><\/li><li id='field_4_19'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_19' >Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_4_19' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_20'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_4_20_1' >Employer Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gfield_trigger_change' id='input_4_20' >\n                         <span class='ginput_full address_line_1' id='input_4_20_1_container' >\n                                        <input type='text' name='input_20.1' id='input_4_20_1' value=''   \/>\n                                        <label for='input_4_20_1' id='input_4_20_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_4_20_2_container' >\n                                        <input type='text' name='input_20.2' id='input_4_20_2' value=''   \/>\n                                        <label for='input_4_20_2' id='input_4_20_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_4_20_3_container' >\n                                    <input type='text' name='input_20.3' id='input_4_20_3' value=''   \/>\n                                    <label for='input_4_20_3' id='input_4_20_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_4_20_4_container' >\n                                        <select name='input_20.4' id='input_4_20_4'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' selected='selected'>Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_20_4' id='input_4_20_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_4_20_5_container' >\n                                    <input type='text' name='input_20.5' id='input_4_20_5' value=''   \/>\n                                    <label for='input_4_20_5' id='input_4_20_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_20.6' id='input_4_20_6' value='United States'\/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_4_25'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_4_25_3' >Name of Employee<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_4_25'>\n                            <span id='input_4_25_3_container' class='name_first' >\n                                                    <input type='text' name='input_25.3' id='input_4_25_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_4_25_3' >First<\/label>\n                                               <\/span>\n                            <span id='input_4_25_6_container' class='name_last' >\n                                                    <input type='text' name='input_25.6' id='input_4_25_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_4_25_6' >Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id='field_4_21'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_21' >Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_4_21' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_56'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_56' >Insured Social Security #<\/label><div class='ginput_container ginput_container_number'><input name='input_56' id='input_4_56' type='text'    value='' class='medium'       aria-invalid=\"false\"\/><\/div><\/li><li id='field_4_24'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_24' >Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_4_24' type='text' value='' class='medium'     aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_26'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Insurance Information<\/h2><\/li><li id='field_4_27'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_4_27_3' >Name of Subscriber<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_4_27'>\n                            <span id='input_4_27_3_container' class='name_first' >\n                                                    <input type='text' name='input_27.3' id='input_4_27_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_4_27_3' >First<\/label>\n                                               <\/span>\n                            <span id='input_4_27_6_container' class='name_last' >\n                                                    <input type='text' name='input_27.6' id='input_4_27_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_4_27_6' >Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id='field_4_28'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_28' >Realtionship to Patient<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_4_28' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_29'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_29' >Birthdate of Subscriber<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_29' id='input_4_29' type='text' value='' class='datepicker medium mdy datepicker_no_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_29' class='gform_hidden' value='http:\/\/silversagecenter.com\/staging\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_4_30'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_30' >Social Security #<\/label><div class='ginput_container ginput_container_number'><input name='input_30' id='input_4_30' type='text'    value='' class='medium'       aria-invalid=\"false\"\/><\/div><\/li><li id='field_4_31'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_31' >Name of Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_4_31' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_32'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_32' >Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_32' id='input_4_32' type='text' value='' class='medium'     aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_33'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_33' >Insurance Company<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_4_33' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_34'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_34' >Policy Number<\/label><div class='ginput_container ginput_container_number'><input name='input_34' id='input_4_34' type='text'    value='' class='medium'       aria-invalid=\"false\"\/><\/div><\/li><li id='field_4_35'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_35' >Group Number<\/label><div class='ginput_container ginput_container_number'><input name='input_35' id='input_4_35' type='text'    value='' class='medium'       aria-invalid=\"false\"\/><\/div><\/li><li id='field_4_44'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_44' >Secondary Insurance<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_4_44' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_45'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_4_45_3' >Subscriber Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_4_45'>\n                            <span id='input_4_45_3_container' class='name_first' >\n                                                    <input type='text' name='input_45.3' id='input_4_45_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_4_45_3' >First<\/label>\n                                               <\/span>\n                            <span id='input_4_45_6_container' class='name_last' >\n                                                    <input type='text' name='input_45.6' id='input_4_45_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_4_45_6' >Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id='field_4_48'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_48' >Birthdate of Subscriber<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_48' id='input_4_48' type='text' value='' class='datepicker medium mdy datepicker_no_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_48' class='gform_hidden' value='http:\/\/silversagecenter.com\/staging\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_4_47'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_47' >Relationship to Patient<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_4_47' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_46'  class='gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_46' >Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_4_46' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_60'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_60'><li class='gchoice_4_60_1'>\n\t\t\t\t\t\t\t\t<input name='input_60.1' type='checkbox'  value='I understand that co-payments are due at time of visit. I authorize payment of medical benefits from my insurance company to Silver Sage Center for Family Medicine. I also authorize the release of any medical information necessary to process any medical claim. I realize that I am responsible for any balance my insurance company does not cover\/pay. I acknowledge receipt of the privacy policies and practices notice.'  id='choice_4_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_60_1' id='label_4_60_1'>I understand that co-payments are due at time of visit. I authorize payment of medical benefits from my insurance company to Silver Sage Center for Family Medicine. I also authorize the release of any medical information necessary to process any medical claim. I realize that I am responsible for any balance my insurance company does not cover\/pay. I acknowledge receipt of the privacy policies and practices notice.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_4_61'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Disclosure<\/h2><div class='gsection_description'>We can not release ANY information to any one else but the patient without written permission from the patients.<\/div><\/li><li id='field_4_49'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_4_49_3' >Is there a friend or family member whom we may disclose your medical information?<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_4_49'>\n                            <span id='input_4_49_3_container' class='name_first' >\n                                                    <input type='text' name='input_49.3' id='input_4_49_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_4_49_3' >First<\/label>\n                                               <\/span>\n                            <span id='input_4_49_6_container' class='name_last' >\n                                                    <input type='text' name='input_49.6' id='input_4_49_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_4_49_6' >Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id='field_4_50'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_50' >What is there relationship to you?<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_4_50' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_59'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Signature<\/h2><div class='gsection_description'>We do not discriminate against anyone regardless of color, race or creed or physical ability.<\/div><\/li><li id='field_4_57'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_57' >What is the best means to contact you?<\/label><div class='ginput_container ginput_container_select'><select name='input_57' id='input_4_57'  class='medium gfield_select'    aria-invalid=\"false\"><option value='Home' selected='selected'>Home<\/option><option value='Cell' >Cell<\/option><option value='Work' >Work<\/option><option value='Email' >Email<\/option><option value='Mail' >Mail<\/option><\/select><\/div><\/li><li id='field_4_58'  class='gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_4_58' >Signature<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_name'>\n                                    <input name='input_58' id='input_4_58' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                <\/div><\/li><li id='field_4_2'  class='gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_2' >Date<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_4_2' type='text' value='' class='datepicker medium mdy datepicker_with_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_2' class='gform_hidden' value='http:\/\/silversagecenter.com\/staging\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_4_37'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Signature<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_37'><li class='gchoice_4_37_1'>\n\t\t\t\t\t\t\t\t<input name='input_37.1' type='checkbox'  value='By checking this box, I am agreeing that this information is being submitted digitally via the web, and will serve as an acceptance in place for my signature.'  id='choice_4_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_37_1' id='label_4_37_1'>By checking this box, I am agreeing that this information 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