{"id":6376,"date":"2020-05-07T22:30:59","date_gmt":"2020-05-07T20:30:59","guid":{"rendered":"https:\/\/excellemd.com\/en\/?page_id=6376"},"modified":"2020-05-07T22:30:59","modified_gmt":"2020-05-07T20:30:59","slug":"form","status":"publish","type":"page","link":"https:\/\/excellemd.com\/en\/form\/","title":{"rendered":"Form"},"content":{"rendered":"<style type=\"text\/css\" id=\"101\" data-form-unique-id=\"14193\" >.ar_main_div_101 .arf_materialize_form label span.arfcheckrequiredfield{color:red!important;margin-left:5px;}<\/style><div class=\"arf_form ar_main_div_101 arf_form_outer_wrapper \" id=\"arffrm_101_container\"><div id=\"arf_message_error\" class=\"frm_error_style\" style=\"display:none;\"><div class=\"msg-detail\"><div class=\"msg-description-success\">Form Submission is restricted<\/div><\/div><\/div><div id=\"arf_message_success_popup\" style=\"display:none;\"><div class=\"msg-detail\"><div class=\"msg-description-success\">Your form has been successfully transmitted.<\/div><\/div><\/div><form enctype=\"multipart\/form-data\" method=\"post\" class=\"arfshowmainform  \" style=\"\" data-form-id=\"form_saofef\"  novalidate=\"\" onsubmit=\"return arf_validate_form_submit()\" arf_form_submit = 0 data-id=\"14193\"  data-random-id=\"101_a1uJm6YiuY\"  data-submission-key=\"mmB4Z0tg\"  data-key-validate=\"false\"  data-popup-id=\"\"><label for='arf_filter_input_101_a1uJm6YiuY' class='arf_hidden_element' style='color:transparent !important;'>Filter<\/label><input id='arf_filter_input_101_a1uJm6YiuY' type='text' name='arf_filter_input' data-jqvalidate='false' data-random-key='101_a1uJm6YiuY' value='' style='opacity:0 !important;display:none !important;visibility:hidden !important;' \/><input type='hidden' id='arf_ajax_url' value='https:\/\/excellemd.com\/wp-admin\/admin-ajax.php' \/><input type=\"hidden\" data-jqvalidate=\"false\" class=\"kpress\" value=\"\" \/><input type=\"hidden\" data-jqvalidate=\"false\" class=\"stime\" value=\"1776779889\" \/><input type=\"hidden\" data-jqvalidate=\"false\" data-id=\"nonce_start_time\" class=\"nonce_start_time\" value=\"form_filter_st\" \/><input type=\"hidden\" data-jqvalidate=\"false\" data-id=\"nonce_keyboard_press\" class=\"nonce_keyboard_press\" value=\"form_filter_kp\" \/><input type=\"hidden\" data-jqvalidate=\"false\" data-id=\"arm_nonce_check\" name=\"arm_nonce_check\" value=\"29a167016d\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_redirect_url_to\" id=\"arf_redirect_url_to\" value=\"same_tab\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_browser_name\" data-id=\"arf_browser_name\" data-version=\"unknown\" value=\"Unknown\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arforms_nonce\" id=\"arforms_nonce\" value=\"37980ff9dc\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arfdecimal_separator\" data-id=\"arfdecimal_separator\" value=\".\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arfform_date_formate_101\" data-id=\"arfform_date_formate_101\" value=\"MMM D, YYYY\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"form_key_101\" data-id=\"form_key_101\" value=\"saofef\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_success_message_show_time_101\" data-id=\"arf_success_message_show_time_101\" value=\"3\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_form_hide_after_submit_101\" data-id=\"arf_form_hide_after_submit_101\" value=\"\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"is_form_preview_101\" data-id=\"is_form_preview_101\" value=\"\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_validate_outside_101\" data-id=\"arf_validate_outside_101\" data-validate=\"0\" value=\"0\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_is_validate_outside_101\" data-id=\"arf_is_validate_outside_101\" data-validate=\"0\" value=\"0\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_is_resetform_aftersubmit_101\" data-id=\"arf_is_resetform_aftersubmit_101\" value=\"1\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_is_resetform_outside_101\" data-id=\"arf_is_resetform_outside_101\" value=\"0\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_form_enable_cookie_101\" data-id=\"arf_form_enable_cookie_101\" value=\"\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_tooltip_settings_101\" data-id=\"arf_tooltip_settings_101\" class=\"arf_front_tooltip_settings\" data-form-id=\"101\" data-color=\"#FFFFFF\" data-position=\"top\" data-width=\"\" data-bg-color=\"#000000\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arfsuccessmsgposition_101\" data-id=\"arfsuccessmsgposition_101\"  value=\"top\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arfpagebreakstyle_101\" data-id=\"arfpagebreakstyle_101\"  value=\"number\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arfpagebreakaddtimer_101\" data-id=\"arfpagebreakaddtimer_101\" value=\"0\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"form_tooltip_error_101\" data-id=\"form_tooltip_error_101\" data-color=\"\" data-position=\"bottom\" value=\"normal\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arfaction\" value=\"create\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"form_id\" data-id=\"form_id\" value=\"101\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"form_data_id\" data-id=\"form_data_id\" value=\"14193\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"form_key\" data-id=\"form_key\" value=\"saofef\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_ajax_url\" value=\"https:\/\/excellemd.com\/wp-admin\/admin-ajax.php\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"form_display_type\" data-id=\"form_display_type\" value=\"0|https:\/\/excellemd.com\/en\/form\/\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"form_submit_type\" data-id=\"form_submit_type\" value=\"1\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_http_referrer_url\" data-id=\"arf_http_referrer_url\" value=\"\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"entry_key\" value=\"\" \/><input type=\"hidden\" data-jqvalidate=\"false\" name=\"arf_skip_captcha\" data-id=\"arf_skip_captcha\" value=\"\" \/><input type='hidden' id='arf_pb_field_animation_duration_front_101' name='arf_pb_field_animation_duration_front_101' value='' \/><input type='hidden' id='arf_pb_field_animation_delay_front_101' name='arf_pb_field_animation_delay_front_101' value='' \/><input type='hidden' id='arf_pb_field_animation_inherit_101' name='arf_pb_field_animation_inherit_101' value='0' \/><input type='hidden' id='arf_field_animation_style_front_101' name='arf_field_animation_style_front_101' value='' \/><input type='hidden' id='arf_field_animation_duration_front_101' name='arf_field_animation_duration_front_101' value='' \/><input type='hidden' id='arf_field_animation_delay_front_101' name='arf_field_animation_delay_front_101' value='' \/><input type=\"hidden\" id=\"arf_form_site_wide_101\" value=\"\" \/><div class=\"allfields\" ><div class=\"arf_fieldset arf_materialize_form\" id=\"arf_fieldset_14193\"><div class=\"arftitlecontainer\"><div class=\"formtitle_style\">MEDICAL SERVICE CONTRACT<\/div><\/div><div id=\"page_0\" class=\"page_break\"><input type=\"hidden\" id=\"arf_repeatable_field_counter_171\" data-max_add=\"0\" value=\"1\" \/><div id=\"heading_171\" class=\"arf_heading_div  \"><h2 class='arf_sec_heading_field pos_top  ' style='display:block'; data-field-type='section' >A - PATIENT INFORMATIONS<\/h2><div class=\"arf_field_description arf_heading_description\"><\/div><div id=\"arf_field_159_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_text  top_container top_container arfformfield   arf_field_159\"  style='width: 100%' data-field-type=\"text\" data-parent_field=\"171\" ><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input   type=\"text\" id=\"field_u8b3fa_14193\"  name=\"item_meta[159]\"  class=\" arf_required \" data-validation-required-message=\"This field cannot be blank.\"   \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"text\" for=\"field_u8b3fa_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Full name<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_217_14193_container\" class=\"    arfformfield arf_display_to_confirmation_summary control-group arfmainformfield  arf_field_type_html  top_container  top_container arfformfield  arf_field_217\" data-field-type=\"html\" data-parent_field=\"171\" style='width: 100%'><div class=\"arf_htmlfield_control\">Date of birth<\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_218_14193_container\" class=\"    arfformfield input-field control-group arfmainformfield  arffieldrequired arf_field_type_select  top_container  top_container arfformfield frm_first_third arf_field_218\"  style='width: 30.982%'  data-field-type=\"select\" data-parent_field=\"171\"><div class=\" sltstandard_front controls\"  ><div class=\"arf_material_theme_container arf_material_active_container_open\"><div class=\"arf_selectpicker_wrapper\" style=\"min-width:100px; \"><input type=\"text\" autocomplete=\"off\" class=\"arf-selectpicker-input-control \" id=\"field_t0kzqo_14193\" name=\"item_meta[218]\" value=\"1\"  data-default-val='1'  data-validation-required-message='This field cannot be blank.'  data-field_id='218' ><dl class=\"arf-selectpicker-control  arf_form_field_picker \" data-id=\"field_t0kzqo_14193\" data-name=\"item_meta[218]\"><dt><span>1 <\/span><i class=\"arf-selectpicker-caret\"><\/i><\/dt><dd><ul data-id=\"field_t0kzqo_14193\" id=\"\" class=\"\"><li class=\"\" data-pos=\"0\" aria-label=\"1\"  data-value=\"1\" data-label=\"1\">1<\/li><li class=\"\" data-pos=\"1\" aria-label=\"2\"  data-value=\"2\" data-label=\"2\">2<\/li><li class=\"\" data-pos=\"2\" aria-label=\"3\"  data-value=\"3\" data-label=\"3\">3<\/li><li class=\"\" data-pos=\"3\" aria-label=\"4\"  data-value=\"4\" data-label=\"4\">4<\/li><li class=\"\" data-pos=\"4\" aria-label=\"5\"  data-value=\"5\" data-label=\"5\">5<\/li><li class=\"\" data-pos=\"5\" aria-label=\"6\"  data-value=\"6\" data-label=\"6\">6<\/li><li class=\"\" data-pos=\"6\" aria-label=\"7\"  data-value=\"7\" data-label=\"7\">7<\/li><li class=\"\" data-pos=\"7\" aria-label=\"8\"  data-value=\"8\" data-label=\"8\">8<\/li><li class=\"\" data-pos=\"8\" aria-label=\"9\"  data-value=\"9\" data-label=\"9\">9<\/li><li class=\"\" data-pos=\"9\" aria-label=\"10\"  data-value=\"10\" data-label=\"10\">10<\/li><li class=\"\" data-pos=\"10\" aria-label=\"11\"  data-value=\"11\" data-label=\"11\">11<\/li><li class=\"\" data-pos=\"11\" aria-label=\"12\"  data-value=\"12\" data-label=\"12\">12<\/li><li class=\"\" data-pos=\"12\" aria-label=\"13\"  data-value=\"13\" data-label=\"13\">13<\/li><li class=\"\" data-pos=\"13\" aria-label=\"14\"  data-value=\"14\" data-label=\"14\">14<\/li><li class=\"\" data-pos=\"14\" aria-label=\"15\"  data-value=\"15\" data-label=\"15\">15<\/li><li class=\"\" data-pos=\"15\" aria-label=\"16\"  data-value=\"16\" data-label=\"16\">16<\/li><li class=\"\" data-pos=\"16\" aria-label=\"17\"  data-value=\"17\" data-label=\"17\">17<\/li><li class=\"\" data-pos=\"17\" aria-label=\"18\"  data-value=\"18\" data-label=\"18\">18<\/li><li class=\"\" data-pos=\"18\" aria-label=\"19\"  data-value=\"19\" data-label=\"19\">19<\/li><li class=\"\" data-pos=\"19\" aria-label=\"20\"  data-value=\"20\" data-label=\"20\">20<\/li><li class=\"\" data-pos=\"20\" aria-label=\"21\"  data-value=\"21\" data-label=\"21\">21<\/li><li class=\"\" data-pos=\"21\" aria-label=\"22\"  data-value=\"22\" data-label=\"22\">22<\/li><li class=\"\" data-pos=\"22\" aria-label=\"23\"  data-value=\"23\" data-label=\"23\">23<\/li><li class=\"\" data-pos=\"23\" aria-label=\"24\"  data-value=\"24\" data-label=\"24\">24<\/li><li class=\"\" data-pos=\"24\" aria-label=\"25\"  data-value=\"25\" data-label=\"25\">25<\/li><li class=\"\" data-pos=\"25\" aria-label=\"26\"  data-value=\"26\" data-label=\"26\">26<\/li><li class=\"\" data-pos=\"26\" aria-label=\"27\"  data-value=\"27\" data-label=\"27\">27<\/li><li class=\"\" data-pos=\"27\" aria-label=\"28\"  data-value=\"28\" data-label=\"28\">28<\/li><li class=\"\" data-pos=\"28\" aria-label=\"29\"  data-value=\"29\" data-label=\"29\">29<\/li><li class=\"\" data-pos=\"29\" aria-label=\"30\"  data-value=\"30\" data-label=\"30\">30<\/li><li class=\"\" data-pos=\"30\" aria-label=\"31\"  data-value=\"31\" data-label=\"31\">31<\/li><\/ul><\/dd><\/dl><\/div><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch\"><label data-type=\"select\" for=\"field_t0kzqo_14193\" class=\"arf_main_label arf_main_label_16px active \" aria-label = >Day<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div class=\"arf_half_middle\"><\/div><div id=\"arf_field_219_14193_container\" class=\"    arfformfield input-field control-group arfmainformfield  arffieldrequired arf_field_type_select  top_container  top_container arfformfield frm_third arf_field_219\"  style='width: 31.113%'  data-field-type=\"select\" data-parent_field=\"171\"><div class=\" sltstandard_front controls\"  ><div class=\"arf_material_theme_container arf_material_active_container_open\"><div class=\"arf_selectpicker_wrapper\" style=\"min-width:100px; \"><input type=\"text\" autocomplete=\"off\" class=\"arf-selectpicker-input-control \" id=\"field_m2nh3m_14193\" name=\"item_meta[219]\" value=\"January\"  data-default-val='January'  data-validation-required-message='This field cannot be blank.'  data-field_id='219' ><dl class=\"arf-selectpicker-control  arf_form_field_picker \" data-id=\"field_m2nh3m_14193\" data-name=\"item_meta[219]\"><dt><span>January <\/span><i class=\"arf-selectpicker-caret\"><\/i><\/dt><dd><ul data-id=\"field_m2nh3m_14193\" id=\"\" class=\"\"><li class=\"\" data-pos=\"0\" aria-label=\"January\"  data-value=\"January\" data-label=\"January\">January<\/li><li class=\"\" data-pos=\"1\" aria-label=\"February\"  data-value=\"February\" data-label=\"February\">February<\/li><li class=\"\" data-pos=\"2\" aria-label=\"March\"  data-value=\"March\" data-label=\"March\">March<\/li><li class=\"\" data-pos=\"3\" aria-label=\"April\"  data-value=\"April\" data-label=\"April\">April<\/li><li class=\"\" data-pos=\"4\" aria-label=\"May\"  data-value=\"May\" data-label=\"May\">May<\/li><li class=\"\" data-pos=\"5\" aria-label=\"June\"  data-value=\"June\" data-label=\"June\">June<\/li><li class=\"\" data-pos=\"6\" aria-label=\"July\"  data-value=\"July\" data-label=\"July\">July<\/li><li class=\"\" data-pos=\"7\" aria-label=\"August\"  data-value=\"August\" data-label=\"August\">August<\/li><li class=\"\" data-pos=\"8\" aria-label=\"September\"  data-value=\"September\" data-label=\"September\">September<\/li><li class=\"\" data-pos=\"9\" aria-label=\"October\"  data-value=\"October\" data-label=\"October\">October<\/li><li class=\"\" data-pos=\"10\" aria-label=\"November\"  data-value=\"November\" data-label=\"November\">November<\/li><li class=\"\" data-pos=\"11\" aria-label=\"December\"  data-value=\"December\" data-label=\"December\">December<\/li><\/ul><\/dd><\/dl><\/div><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch\"><label data-type=\"select\" for=\"field_m2nh3m_14193\" class=\"arf_main_label arf_main_label_16px active \" aria-label = >Month<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div class=\"arf_third_middle\"><\/div><div id=\"arf_field_220_14193_container\" class=\"    arfformfield control-group arfmainformfield input-field  arffieldrequired arf_field_type_number  top_container   top_container arfformfield frm_last_third arf_field_220\"  style='width: 30.982%'  data-field-type=\"number\" data-parent_field=\"171\"><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input type=\"text\" class=\"arf_number_field\" id=\"field_l4hsd3_14193\" dir=\" ltr\"name=\"item_meta[220]\"  class=\" arf_required \"data-validation-required-message=\"This field cannot be blank.\" onkeydown=\"arfvalidatenumber(this,event);\" \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"number\" for=\"field_l4hsd3_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Year<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_161_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_text  top_container top_container arfformfield   arf_field_161\"  style='width: 100%' data-field-type=\"text\" data-parent_field=\"171\" ><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input   type=\"text\" id=\"field_ykyaw3_14193\"  name=\"item_meta[161]\"  class=\" arf_required \" data-validation-required-message=\"This field cannot be blank.\"   \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"text\" for=\"field_ykyaw3_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >RAMQ (Health Insurance)<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_162_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_date  top_container  top_container arfformfield  arf_field_162\"  style='width: 100%'  data-field-type=\"date\" data-parent_field=\"171\"><div class=\"controls arf_date_main_controls \"   ><div class=\"arf_material_theme_container  \"><input type=\"text\" data-date-format=\"MMM D, YYYY\" data-start-date=\"01\/01\/1876 00:00 AM\" data-cl-format=\"YYYY-MM-DD\" data-date-new-format=\"MM\/DD\/YYYY\" data-end-date=\"12\/31\/2076 11:59 PM\" data-default-date=\"\" id=\"field_of18wp_14193\"    class=\" arf_required frm_date arforms_datepicker_control\" data-name='item_meta[162]' data-format='MMM D, YYYY' data-field-options=\"{&quot;required&quot;:&quot;1&quot;,&quot;required_indicator&quot;:&quot;*&quot;,&quot;blank&quot;:&quot;This field cannot be blank.&quot;,&quot;field_width&quot;:&quot;&quot;,&quot;locale&quot;:&quot;en&quot;,&quot;currentdefaultdate&quot;:&quot;&quot;,&quot;name&quot;:&quot;Expiration date&quot;,&quot;default_value&quot;:&quot;&quot;,&quot;description&quot;:&quot;&quot;,&quot;placeholdertext&quot;:&quot;&quot;,&quot;show_time_calendar&quot;:&quot;&quot;,&quot;frm_show_time_calendar_field_indicator&quot;:&quot;&quot;,&quot;clock&quot;:&quot;12&quot;,&quot;step&quot;:&quot;30&quot;,&quot;off_days&quot;:&quot;&quot;,&quot;start_date&quot;:&quot;&quot;,&quot;end_date&quot;:&quot;&quot;,&quot;arf_show_min_current_date&quot;:&quot;0&quot;,&quot;arf_show_max_current_date&quot;:&quot;0&quot;,&quot;arf_tooltip&quot;:&quot;&quot;,&quot;frm_arf_tooltip_field_indicator&quot;:&quot;&quot;,&quot;tooltip_text&quot;:&quot;&quot;,&quot;enable_arf_prefix&quot;:&quot;&quot;,&quot;arf_prefix_icon&quot;:&quot;&quot;,&quot;enable_arf_suffix&quot;:&quot;&quot;,&quot;arf_suffix_icon&quot;:&quot;&quot;,&quot;classes&quot;:&quot;arf_1&quot;,&quot;inner_class&quot;:&quot;arf_1col&quot;,&quot;key&quot;:&quot;of18wp&quot;,&quot;selectdefaultdate&quot;:&quot;&quot;,&quot;arfnewdateformat&quot;:&quot;&quot;,&quot;css_outer_wrapper&quot;:&quot;&quot;,&quot;css_label&quot;:&quot;&quot;,&quot;css_input_element&quot;:&quot;&quot;,&quot;css_description&quot;:&quot;&quot;,&quot;css_add_icon&quot;:&quot;&quot;,&quot;type&quot;:&quot;date&quot;,&quot;arf_enable_readonly&quot;:&quot;0&quot;,&quot;has_parent&quot;:&quot;1&quot;,&quot;parent_field&quot;:&quot;171&quot;,&quot;parent_field_type&quot;:&quot;section&quot;,&quot;image_position_from&quot;:&quot;top_left&quot;,&quot;clear_on_focus&quot;:0,&quot;default_blank&quot;:0}\" data-validation-required-message=\"This field cannot be blank.\" \/><input type=\"hidden\" name=\"item_meta[162]\" id=\"field_of18wp_14193_formatted\" \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"date\" for=\"field_of18wp_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Expiration date<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_163_14193_container\" class=\"    arfformfield control-group arfmainformfield  arf_field_type_text  top_container top_container arfformfield   arf_field_163\"  style='width: 100%' data-field-type=\"text\" data-parent_field=\"171\" ><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input   type=\"text\" id=\"field_sgz2sp_14193\"  name=\"item_meta[163]\"   \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"text\" for=\"field_sgz2sp_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Full name of the representative (if under 14 years old)<\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_164_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_text  top_container top_container arfformfield   arf_field_164\"  style='width: 100%' data-field-type=\"text\" data-parent_field=\"171\" ><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input   type=\"text\" id=\"field_m6k1lk_14193\"  name=\"item_meta[164]\"  class=\" arf_required \" data-validation-required-message=\"This field cannot be blank.\"   \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"text\" for=\"field_m6k1lk_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Address<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_165_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_text  top_container top_container arfformfield   arf_field_165\"  style='width: 100%' data-field-type=\"text\" data-parent_field=\"171\" ><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input   type=\"text\" id=\"field_k54y9c_14193\"  name=\"item_meta[165]\"  class=\" arf_required \" data-validation-required-message=\"This field cannot be blank.\"   \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"text\" for=\"field_k54y9c_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Street<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_166_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_text  top_container top_container arfformfield   arf_field_166\"  style='width: 100%' data-field-type=\"text\" data-parent_field=\"171\" ><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input   type=\"text\" id=\"field_97uu85_14193\"  name=\"item_meta[166]\"  class=\" arf_required \" data-validation-required-message=\"This field cannot be blank.\"   \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"text\" for=\"field_97uu85_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Town<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_167_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_text  top_container top_container arfformfield   arf_field_167\"  style='width: 100%' data-field-type=\"text\" data-parent_field=\"171\" ><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input   type=\"text\" id=\"field_wg8h1g_14193\"  name=\"item_meta[167]\"  class=\" arf_required \" data-validation-required-message=\"This field cannot be blank.\"   \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"text\" for=\"field_wg8h1g_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Postal code<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_168_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_phone  top_container  top_container arfformfield   arf_field_168\"  style='width: 100%'  data-field-type=\"phone\" data-parent_field=\"171\"><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input type=\"text\" data-type=\"phone\"  id=\"field_aa9ejq_14193\"name=\"item_meta[168]\" class=\" arf_required \"data-validation-required-message=\"This field cannot be blank.\"data-validation-number-message=\"Phone is invalid\"\/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"phone\" for=\"field_aa9ejq_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Main phone number<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_169_14193_container\" class=\"    arfformfield control-group arfmainformfield  arf_field_type_phone  top_container  top_container arfformfield   arf_field_169\"  style='width: 100%'  data-field-type=\"phone\" data-parent_field=\"171\"><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input type=\"text\" data-type=\"phone\"  id=\"field_n1gg29_14193\"name=\"item_meta[169]\"data-validation-number-message=\"Phone is invalid\"\/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"phone\" for=\"field_n1gg29_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Secondary phone number<\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_170_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_email  top_container   top_container arfformfield  arf_field_170\"  style='width: 100%'  data-field-type=\"email\" data-parent_field=\"171\"><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input type=\"text\" id=\"field_p3f1up_14193\" name=\"item_meta[170]\"  class=\" arf_required \" data-validation-required-message=\"This field cannot be blank.\"  data-validation-regex-regex=\"[\\p{L}0-9._-]+@[\\p{L}0-9.-]+\\.[\\p{L}]+\" data-validation-regex-message=\"Email is invalid\"  \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"email\" for=\"field_p3f1up_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Email<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><\/div><div style=\"clear:both;\"><\/div><input type=\"hidden\" id=\"arf_repeatable_field_counter_177\" data-max_add=\"0\" value=\"1\" \/><div id=\"heading_177\" class=\"arf_heading_div  \"><h2 class='arf_sec_heading_field pos_top  ' style='display:block'; data-field-type='section' >B - EMERGENCY CONTACT<\/h2><div class=\"arf_field_description arf_heading_description\"><\/div><div id=\"arf_field_172_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_text  top_container top_container arfformfield   arf_field_172\"  style='width: 100%' data-field-type=\"text\" data-parent_field=\"177\" ><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input   type=\"text\" id=\"field_8crnk4_14193\"  name=\"item_meta[172]\"  class=\" arf_required \" data-validation-required-message=\"This field cannot be blank.\"   \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"text\" for=\"field_8crnk4_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Full name<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_173_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_phone  top_container  top_container arfformfield   arf_field_173\"  style='width: 100%'  data-field-type=\"phone\" data-parent_field=\"177\"><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input type=\"text\" data-type=\"phone\"  id=\"field_6ecrdg_14193\"name=\"item_meta[173]\" class=\" arf_required \"data-validation-required-message=\"This field cannot be blank.\"data-validation-number-message=\"Phone is invalid\"\/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"phone\" for=\"field_6ecrdg_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Main phone number<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_174_14193_container\" class=\"    arfformfield control-group arfmainformfield  arf_field_type_phone  top_container  top_container arfformfield   arf_field_174\"  style='width: 100%'  data-field-type=\"phone\" data-parent_field=\"177\"><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input type=\"text\" data-type=\"phone\"  id=\"field_toqgdr_14193\"name=\"item_meta[174]\"data-validation-number-message=\"Phone is invalid\"\/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"phone\" for=\"field_toqgdr_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Secondary phone number<\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_175_14193_container\" class=\"    arfformfield control-group arfmainformfield  arf_horizontal_radio  arffieldrequired arf_field_type_radio   top_container arfformfield  top_container arf_field_175\"  style='width: 100%'  data-field-type=\"radio\" data-parent_field=\"177\"><label data-type=\"radio\" for=\"field_m8l2sp_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Relation<span class=\"arfcheckrequiredfield\">*<\/span><\/label><div class=\"setting_radio controls  arf_material_radio arf_default_material \" style=\"padding-top:5px;\" ><div class=\"arf_radiobutton \"><div class='arf_radio_input_wrapper'><input type=\"radio\" name=\"item_meta[175]\" data-type=\"radio\" id=\"field_175-0-14193\" data-unique-id=\"14193\" value=\"Spouse\"   class=\" arf_required \" data-validation-minchecked-minchecked=\"1\" data-validation-minchecked-message=\"This field cannot be blank.\" style=\" \" \/><span><\/span><\/div><label data-type=\"radio\" for=\"field_175-0-14193\" class=\"\" aria-label=\"Spouse\">Spouse<\/label><\/div><div class=\"arf_radiobutton \"><div class='arf_radio_input_wrapper'><input type=\"radio\" name=\"item_meta[175]\" data-type=\"radio\" id=\"field_175-1-14193\" data-unique-id=\"14193\" value=\"Mother\"   class=\" arf_required \" style=\" \" \/><span><\/span><\/div><label data-type=\"radio\" for=\"field_175-1-14193\" class=\"\" aria-label=\"Mother\">Mother<\/label><\/div><div class=\"arf_radiobutton \"><div class='arf_radio_input_wrapper'><input type=\"radio\" name=\"item_meta[175]\" data-type=\"radio\" id=\"field_175-2-14193\" data-unique-id=\"14193\" value=\"Father\"   class=\" arf_required \" style=\" \" \/><span><\/span><\/div><label data-type=\"radio\" for=\"field_175-2-14193\" class=\"\" aria-label=\"Father\">Father<\/label><\/div><div class=\"arf_radiobutton \"><div class='arf_radio_input_wrapper'><input type=\"radio\" name=\"item_meta[175]\" data-type=\"radio\" id=\"field_175-3-14193\" data-unique-id=\"14193\" value=\"Child\"   class=\" arf_required \" style=\" \" \/><span><\/span><\/div><label data-type=\"radio\" for=\"field_175-3-14193\" class=\"\" aria-label=\"Child\">Child<\/label><\/div><div class=\"arf_radiobutton \"><div class='arf_radio_input_wrapper'><input type=\"radio\" name=\"item_meta[175]\" data-type=\"radio\" id=\"field_175-4-14193\" data-unique-id=\"14193\" value=\"Family member\"   class=\" arf_required \" style=\" \" \/><span><\/span><\/div><label data-type=\"radio\" for=\"field_175-4-14193\" class=\"\" aria-label=\"Family member\">Family member<\/label><\/div><div class=\"arf_radiobutton \"><div class='arf_radio_input_wrapper'><input type=\"radio\" name=\"item_meta[175]\" data-type=\"radio\" id=\"field_175-5-14193\" data-unique-id=\"14193\" value=\"Other\"   class=\" arf_required \" style=\" \" \/><span><\/span><\/div><label data-type=\"radio\" for=\"field_175-5-14193\" class=\"\" aria-label=\"Other\">Other<\/label><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_176_14193_container\" class=\"    arfformfield control-group arfmainformfield  arf_field_type_text  top_container top_container arfformfield   arf_field_176\"  style='width: 100%' data-field-type=\"text\" data-parent_field=\"177\" ><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input   type=\"text\" id=\"field_bfatwf_14193\"  name=\"item_meta[176]\"   \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"text\" for=\"field_bfatwf_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Relation (if other)<\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><\/div><div style=\"clear:both;\"><\/div><input type=\"hidden\" id=\"arf_repeatable_field_counter_180\" data-max_add=\"0\" value=\"1\" \/><div id=\"heading_180\" class=\"arf_heading_div  \"><h2 class='arf_sec_heading_field pos_top  ' style='display:block'; data-field-type='section' >C - TO BE COMPLETED IF THE PATIENT IS BETWEEN 14 AND 18 YEARS OLD<\/h2><div class=\"arf_field_description arf_heading_description\"><\/div><div id=\"arf_field_178_14193_container\" class=\"    arfformfield control-group arfmainformfield  arf_horizontal_radio  arf_field_type_radio   top_container arfformfield  top_container arf_field_178\"  style='width: 100%'  data-field-type=\"radio\" data-parent_field=\"180\"><label data-type=\"radio\" for=\"field_sarza1_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Do you authorize the representative named in the Patient Information section above to receive the results on your behalf? NoYes I authorize the representative to receive my results.<\/label><div class=\"setting_radio controls  arf_material_radio arf_default_material \" style=\"padding-top:5px;\" ><div class=\"arf_radiobutton \"><div class='arf_radio_input_wrapper'><input type=\"radio\" name=\"item_meta[178]\" data-type=\"radio\" id=\"field_178-0-14193\" data-unique-id=\"14193\" value=\"Yes\"   style=\" \" \/><span><\/span><\/div><label data-type=\"radio\" for=\"field_178-0-14193\" class=\"\" aria-label=\"Yes\">Yes<\/label><\/div><div class=\"arf_radiobutton \"><div class='arf_radio_input_wrapper'><input type=\"radio\" name=\"item_meta[178]\" data-type=\"radio\" id=\"field_178-1-14193\" data-unique-id=\"14193\" value=\"No\"   style=\" \" \/><span><\/span><\/div><label data-type=\"radio\" for=\"field_178-1-14193\" class=\"\" aria-label=\"No\">No<\/label><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_179_14193_container\" class=\"     arfformfield control-group arfmainformfield input-field  arf_field_type_signature  top_container  top_container arfformfield  arf_field_179\"  style='width: 100%' data-field-type=\"signature\" data-parent_field=\"180\"><\/div><div style=\"clear:both;\"><\/div><\/div><div style=\"clear:both;\"><\/div><input type=\"hidden\" id=\"arf_repeatable_field_counter_184\" data-max_add=\"0\" value=\"1\" \/><div id=\"heading_184\" class=\"arf_heading_div  \"><h2 class='arf_sec_heading_field pos_top  ' style='display:block'; data-field-type='section' >D - TO BE COMPLETED IF LANGUAGE IS A BARRIER BETWEEN THE PATIENT AND EXCELLEMD<\/h2><div class=\"arf_field_description arf_heading_description\"><\/div><div id=\"arf_field_181_14193_container\" class=\"    arfformfield arf_display_to_confirmation_summary control-group arfmainformfield  arf_field_type_html  top_container  top_container arfformfield  arf_field_181\" data-field-type=\"html\" data-parent_field=\"184\" style='width: 100%'><div class=\"arf_htmlfield_control\">The person mentioned below will serve as a translator and is also authorized to obtain results on my behalf.<\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_182_14193_container\" class=\"    arfformfield control-group arfmainformfield  arf_field_type_text  top_container top_container arfformfield   arf_field_182\"  style='width: 100%' data-field-type=\"text\" data-parent_field=\"184\" ><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input   type=\"text\" id=\"field_jhbd5w_14193\"  name=\"item_meta[182]\"   \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"text\" for=\"field_jhbd5w_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Full name<\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_183_14193_container\" class=\"     arfformfield control-group arfmainformfield input-field  arf_field_type_signature  top_container  top_container arfformfield  arf_field_183\"  style='width: 100%' data-field-type=\"signature\" data-parent_field=\"184\"><\/div><div style=\"clear:both;\"><\/div><\/div><div style=\"clear:both;\"><\/div><input type=\"hidden\" id=\"arf_repeatable_field_counter_189\" data-max_add=\"0\" value=\"1\" \/><div id=\"heading_189\" class=\"arf_heading_div  \"><h2 class='arf_sec_heading_field pos_top  ' style='display:block'; data-field-type='section' >E - OTHER INFORMATIONS<\/h2><div class=\"arf_field_description arf_heading_description\"><\/div><div id=\"arf_field_185_14193_container\" class=\"    arfformfield control-group arfmainformfield  arf_field_type_text  top_container top_container arfformfield   arf_field_185\"  style='width: 100%' data-field-type=\"text\" data-parent_field=\"189\" ><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input   type=\"text\" id=\"field_3mozaq_14193\"  name=\"item_meta[185]\"   \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"text\" for=\"field_3mozaq_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Name of your pharmacy<\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_186_14193_container\" class=\"    arfformfield control-group arfmainformfield  arf_field_type_text  top_container top_container arfformfield   arf_field_186\"  style='width: 100%' data-field-type=\"text\" data-parent_field=\"189\" ><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input   type=\"text\" id=\"field_826wod_14193\"  name=\"item_meta[186]\"   \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"text\" for=\"field_826wod_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Address of your pharmacy<\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_187_14193_container\" class=\"    arfformfield control-group arfmainformfield  arf_field_type_phone  top_container  top_container arfformfield   arf_field_187\"  style='width: 100%'  data-field-type=\"phone\" data-parent_field=\"189\"><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input type=\"text\" data-type=\"phone\"  id=\"field_ynk61e_14193\"name=\"item_meta[187]\"data-validation-number-message=\"Phone is invalid\"\/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"phone\" for=\"field_ynk61e_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Phone number<\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_188_14193_container\" class=\"    arfformfield control-group arfmainformfield  arf_field_type_phone  top_container  top_container arfformfield   arf_field_188\"  style='width: 100%'  data-field-type=\"phone\" data-parent_field=\"189\"><div class=\"controls\"   ><div class=\"arf_material_theme_container  \"><input type=\"text\" data-type=\"phone\"  id=\"field_iltkud_14193\"name=\"item_meta[188]\"data-validation-number-message=\"Phone is invalid\"\/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"phone\" for=\"field_iltkud_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Fax<\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><\/div><div style=\"clear:both;\"><\/div><input type=\"hidden\" id=\"arf_repeatable_field_counter_193\" data-max_add=\"0\" value=\"1\" \/><div id=\"heading_193\" class=\"arf_heading_div  \"><h2 class='arf_sec_heading_field pos_top  ' style='display:block'; data-field-type='section' >TERMS AND CONDITIONS OF THE MEDICAL SERVICE CONTRACT<\/h2><div class=\"arf_field_description arf_heading_description\"><\/div><div id=\"arf_field_190_14193_container\" class=\"    arfformfield arf_display_to_confirmation_summary control-group arfmainformfield  arf_field_type_html  top_container  top_container arfformfield  arf_field_190\" data-field-type=\"html\" data-parent_field=\"193\" style='width: 100%'><div class=\"arf_htmlfield_control\"><b>1. PURPOSE OF THE CONTRACT<\/b>\n<p>In accordance with this Contract, ExcelleMD is a provider of private medical services. The Patient accepts the private medical care services offered by ExcelleMD in accordance with the terms and conditions of this Contract. <\/p>\n\n<b>2. LEGAL DISCLOSURE<\/b>\n<p>ExcelleMD regroups non-participating physicians and to this effect, the health care providers do not participate in the Qu\u00e9bec Health Insurance Plan as governed by the Health Insurance Act. The Patient acknowledges that he\/she cannot claim the reimbursement of any consultation fees nor any other charges to the R\u00e9gie de l\u2019assurance maladie du Qu\u00e9bec (RAMQ). As such, the Patient must pay the health care received from ExcelleMD and he\/she is ineligible for a RAMQ refund.<\/p>\n\n<b>3. PATIENT OBLIGATION<\/b>\n<p>The Patient must call ExcelleMD to make an appointment to see a doctor. The Patient agrees to pay all fees in accordance with the ExcelleMD fee rate in effect. In addition, the Patient agrees to pay, as applicable, additional consult costs, including without limitation, the surgical instruments, medication, medical equipment and\/or nursing services. <\/p>\n\n<b>4. FEES<\/b>\n<p>The complete list of applicable fees is posted at the clinic and is subject to change without notice. The Patient accepts to pay the cancellation or no-show fees in accordance with the ExcelleMD policy in effect. The service fees are charge to the Patient. Please note the following fees: <\/p>\n<ul><li>Cancelled appointment without 24-hour notice or no-show: $45.00<\/li>\n<li>No-show or cancelled annual exam appointment without 24-hour notice: $90.00<\/li>\n<li>An administrative fee of 20$ will be charged annually.<\/li>\n<li>NB: Clauses not applicable for company consultations. <\/li>\n<\/ul>\n<p>Prices are subject to change without notice.<\/p>\n\n<b>5. DECLARATION<\/b>\n<p>Prior to the execution of this Contract, the Patient declares having received the explanations required to make a decision to retain the private medical services of ExcelleMD. <\/p><\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_191_14193_container\" class=\"     arfformfield control-group arfmainformfield input-field  arffieldrequired arf_field_type_signature  top_container  top_container arfformfield  arf_field_191\"  style='width: 100%' data-field-type=\"signature\" data-parent_field=\"193\"><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_192_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_date  top_container  top_container arfformfield  arf_field_192\"  style='width: 100%'  data-field-type=\"date\" data-parent_field=\"193\"><div class=\"controls arf_date_main_controls \"   ><div class=\"arf_material_theme_container  \"><input type=\"text\" data-date-format=\"MMM D, YYYY\" data-start-date=\"01\/01\/1876 00:00 AM\" data-cl-format=\"YYYY-MM-DD\" data-date-new-format=\"MM\/DD\/YYYY\" data-end-date=\"12\/31\/2076 11:59 PM\" data-default-date=\"\" id=\"field_yxtmxu_14193\"    class=\" arf_required frm_date arforms_datepicker_control\" data-name='item_meta[192]' data-format='MMM D, YYYY' data-field-options=\"{&quot;required&quot;:&quot;1&quot;,&quot;required_indicator&quot;:&quot;*&quot;,&quot;blank&quot;:&quot;This field cannot be blank.&quot;,&quot;field_width&quot;:&quot;&quot;,&quot;locale&quot;:&quot;en&quot;,&quot;currentdefaultdate&quot;:&quot;&quot;,&quot;name&quot;:&quot;Date&quot;,&quot;default_value&quot;:&quot;&quot;,&quot;description&quot;:&quot;&quot;,&quot;placeholdertext&quot;:&quot;&quot;,&quot;show_time_calendar&quot;:&quot;&quot;,&quot;frm_show_time_calendar_field_indicator&quot;:&quot;&quot;,&quot;clock&quot;:&quot;12&quot;,&quot;step&quot;:&quot;30&quot;,&quot;off_days&quot;:&quot;&quot;,&quot;start_date&quot;:&quot;&quot;,&quot;end_date&quot;:&quot;&quot;,&quot;arf_show_min_current_date&quot;:&quot;0&quot;,&quot;arf_show_max_current_date&quot;:&quot;0&quot;,&quot;arf_tooltip&quot;:&quot;&quot;,&quot;frm_arf_tooltip_field_indicator&quot;:&quot;&quot;,&quot;tooltip_text&quot;:&quot;&quot;,&quot;enable_arf_prefix&quot;:&quot;&quot;,&quot;arf_prefix_icon&quot;:&quot;&quot;,&quot;enable_arf_suffix&quot;:&quot;&quot;,&quot;arf_suffix_icon&quot;:&quot;&quot;,&quot;classes&quot;:&quot;arf_1&quot;,&quot;inner_class&quot;:&quot;arf_1col&quot;,&quot;key&quot;:&quot;yxtmxu&quot;,&quot;selectdefaultdate&quot;:&quot;&quot;,&quot;arfnewdateformat&quot;:&quot;&quot;,&quot;css_outer_wrapper&quot;:&quot;&quot;,&quot;css_label&quot;:&quot;&quot;,&quot;css_input_element&quot;:&quot;&quot;,&quot;css_description&quot;:&quot;&quot;,&quot;css_add_icon&quot;:&quot;&quot;,&quot;type&quot;:&quot;date&quot;,&quot;arf_enable_readonly&quot;:&quot;0&quot;,&quot;has_parent&quot;:&quot;1&quot;,&quot;parent_field&quot;:&quot;193&quot;,&quot;parent_field_type&quot;:&quot;section&quot;,&quot;image_position_from&quot;:&quot;top_left&quot;,&quot;clear_on_focus&quot;:0,&quot;default_blank&quot;:0}\" data-validation-required-message=\"This field cannot be blank.\" \/><input type=\"hidden\" name=\"item_meta[192]\" id=\"field_yxtmxu_14193_formatted\" \/><div class=\"arf_material_standard\"><div class=\"arf_material_theme_prefix\"><\/div><div class=\"arf_material_theme_notch \"><label data-type=\"date\" for=\"field_yxtmxu_14193\" class=\"arf_main_label arf_main_label_16px\" aria-label = >Date<span class=\"arfcheckrequiredfield\">*<\/span><\/label><\/div><div class=\"arf_material_theme_suffix\"><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><\/div><div style=\"clear:both;\"><\/div><input type=\"hidden\" id=\"arf_repeatable_field_counter_197\" data-max_add=\"0\" value=\"1\" \/><div id=\"heading_197\" class=\"arf_heading_div  \"><h2 class='arf_sec_heading_field pos_top  ' style='display:block'; data-field-type='section' >CONSENT TO ACCESS TO PERSONAL INFORMATION AND TRANSMISSION<\/h2><div class=\"arf_field_description arf_heading_description\"><\/div><div id=\"arf_field_194_14193_container\" class=\"    arfformfield arf_display_to_confirmation_summary control-group arfmainformfield  arf_field_type_html  top_container  top_container arfformfield  arf_field_194\" data-field-type=\"html\" data-parent_field=\"197\" style='width: 100%'><div class=\"arf_htmlfield_control\">I give the doctors of clinic ExcelleMD permission to access the information necessary to the delivery of care or social services required by my health. 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This consent ceases to have effect upon ExcelleMD receipt of a written notice.<\/div><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_195_14193_container\" class=\"     arfformfield control-group arfmainformfield input-field  arffieldrequired arf_field_type_signature  top_container  top_container arfformfield  arf_field_195\"  style='width: 100%' data-field-type=\"signature\" data-parent_field=\"197\"><\/div><div style=\"clear:both;\"><\/div><div id=\"arf_field_196_14193_container\" class=\"    arfformfield control-group arfmainformfield  arffieldrequired arf_field_type_date  top_container  top_container arfformfield  arf_field_196\"  style='width: 100%'  data-field-type=\"date\" data-parent_field=\"197\"><div class=\"controls arf_date_main_controls \"   ><div class=\"arf_material_theme_container  \"><input type=\"text\" data-date-format=\"MMM D, YYYY\" data-start-date=\"01\/01\/1876 00:00 AM\" data-cl-format=\"YYYY-MM-DD\" data-date-new-format=\"MM\/DD\/YYYY\" 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[...]","protected":false},"author":8,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_kad_blocks_custom_css":"","_kad_blocks_head_custom_js":"","_kad_blocks_body_custom_js":"","_kad_blocks_footer_custom_js":"","footnotes":""},"class_list":["post-6376","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Form - Excelle MD<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/excellemd.com\/formulaire\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Form - Excelle MD\" \/>\n<meta property=\"og:url\" content=\"https:\/\/excellemd.com\/formulaire\/\" 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