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            function encode(myString) {\
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                /* Fixes issues with single quote and backtick encoding */\
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                for (i = 0; i < entities.length; i++) {\
                    myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
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            function showHideSection(showSection) {\
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                    $(\'#FormField3_93fe6f05-8291-4941-84b5-ebc76d338f7d\').show();\
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                        if (obj.checked) {\
                            $(\'#\' + obj.id).change();\
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                    } else {\
                        $(\'#\' + obj.id).change();\
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fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
    requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
        var fbRequire = fbRequireConfig.fbRequire;\
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        fbRequire([\'jquery\', \'he\'], function ($, he) {\
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            sectionConditions.forEach(function (sectionCondition) {\
                $("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
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                    checkShowHide();\
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                sectionConditions.forEach(function (sectionCondition) {\
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                showHideSection(shouldShowSection);\
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                function checkCheckbox(sectionCondition) {\
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                    return overallResult || newResult;\
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            function isParentVisible(element) {\
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            function encode(myString) {\
                myString = he.encode(he.escape(myString));\
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                /* Fixes issues with single quote and backtick encoding */\
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                for (i = 0; i < entities.length; i++) {\
                    myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
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                return myString;\
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            function showHideSection(showSection) {\
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                    $(\'#FormField22_93fe6f05-8291-4941-84b5-ebc76d338f7d\').show();\
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                $("#FormField22_93fe6f05-8291-4941-84b5-ebc76d338f7d .conditionalSectionListSelection").each(function (i, obj) {\
                    if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
                        if (obj.checked) {\
                            $(\'#\' + obj.id).change();\
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                    } else {\
                        $(\'#\' + obj.id).change();\
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fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
    requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
        var fbRequire = fbRequireConfig.fbRequire;\
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        fbRequire([\'jquery\', \'he\'], function ($, he) {\
            he.encode.options.decimal = true;\
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            var sectionConditions = JSON.parse(\'[{"ElementName":"FormField1_93fe6f05-8291-4941-84b5-ebc76d338f7d","Value":"No"}]\');\
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            sectionConditions.forEach(function (sectionCondition) {\
                $("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
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                $("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
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                var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
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                sectionConditions.forEach(function (sectionCondition) {\
                    checkSelect(sectionCondition);                \
                    checkCheckbox(sectionCondition);                \
                    checkRadio(sectionCondition);                    \
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                showHideSection(shouldShowSection);\
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                function checkSelect(sectionCondition) {\
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                    if (!matchingSelect) {\
                        return;\
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                    if (matchingSelect.type === \'select-multiple\') {\
                        var hasOneMatchingValue = false;\
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                        for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
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                        shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
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                function checkCheckbox(sectionCondition) {\
                    var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
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                    for (var i = 0; i < matchingCheckboxes.length; i++) {\
                        if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
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                function checkRadio(sectionCondition) {\
                    var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
                    \
                    for (var i = 0; i < matchingRadios.length; i++) {\
                        if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
                        }\
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            function mergeCondition(overallResult, newResult, element) {\
                newResult = newResult && isParentVisible(element);\
\
                if (conditionOperator === \'and\') {\
                    return overallResult && newResult;\
                } else {\
                    return overallResult || newResult;\
                }\
            }\
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            function isParentVisible(element) {\
                var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
                return parentSectionDiv && !parentSectionDiv.is(":hidden");\
            }\
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            function encode(myString) {\
                myString = he.encode(he.escape(myString));\
\
                /* Fixes issues with single quote and backtick encoding */\
                var i,\
                    entities = [\
                        [\'&#x27;\', \'&#39;\'],\
                        [\'&#x60;\', \'`\']\
                    ];\
\
                for (i = 0; i < entities.length; i++) {\
                    myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
                }\
\
                return myString;\
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            function showHideSection(showSection) {\
                if (showSection) {\
                    $(\'#FormField24_93fe6f05-8291-4941-84b5-ebc76d338f7d\').show();\
                } else {\
                    $(\'#FormField24_93fe6f05-8291-4941-84b5-ebc76d338f7d\').hide();\
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                $("#FormField24_93fe6f05-8291-4941-84b5-ebc76d338f7d .conditionalSectionListSelection").each(function (i, obj) {\
                    if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
                        if (obj.checked) {\
                            $(\'#\' + obj.id).change();\
                        }\
                    } else {\
                        $(\'#\' + obj.id).change();\
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};\
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fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
    requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
        var fbRequire = fbRequireConfig.fbRequire;\
\
        fbRequire([\'jquery\', \'he\'], function ($, he) {\
            he.encode.options.decimal = true;\
            he.encode.options.allowUnsafeSymbols = true;\
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            sectionConditions.forEach(function (sectionCondition) {\
                $("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
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                $("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
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                    checkShowHide();\
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            function checkShowHide() {\
                var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
                sectionConditions.forEach(function (sectionCondition) {\
                    checkSelect(sectionCondition);                \
                    checkCheckbox(sectionCondition);                \
                    checkRadio(sectionCondition);                    \
                });\
\
                showHideSection(shouldShowSection);\
\
                function checkSelect(sectionCondition) {\
                    var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
                    if (!matchingSelect) {\
                        return;\
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\
                    if (matchingSelect.type === \'select-multiple\') {\
                        var hasOneMatchingValue = false;\
\
                        for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
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\
                        shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
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                        shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
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\
                function checkCheckbox(sectionCondition) {\
                    var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
                    \
                    for (var i = 0; i < matchingCheckboxes.length; i++) {\
                        if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
                        }\
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\
                function checkRadio(sectionCondition) {\
                    var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
                    \
                    for (var i = 0; i < matchingRadios.length; i++) {\
                        if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
                        }\
                    }\
                }\
            }\
\
            function mergeCondition(overallResult, newResult, element) {\
                newResult = newResult && isParentVisible(element);\
\
                if (conditionOperator === \'and\') {\
                    return overallResult && newResult;\
                } else {\
                    return overallResult || newResult;\
                }\
            }\
\
            function isParentVisible(element) {\
                var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
                return parentSectionDiv && !parentSectionDiv.is(":hidden");\
            }\
\
            function encode(myString) {\
                myString = he.encode(he.escape(myString));\
\
                /* Fixes issues with single quote and backtick encoding */\
                var i,\
                    entities = [\
                        [\'&#x27;\', \'&#39;\'],\
                        [\'&#x60;\', \'`\']\
                    ];\
\
                for (i = 0; i < entities.length; i++) {\
                    myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
                }\
\
                return myString;\
            }\
\
            function showHideSection(showSection) {\
                if (showSection) {\
                    $(\'#FormField18_93fe6f05-8291-4941-84b5-ebc76d338f7d\').show();\
                } else {\
                    $(\'#FormField18_93fe6f05-8291-4941-84b5-ebc76d338f7d\').hide();\
                }\
\
                $("#FormField18_93fe6f05-8291-4941-84b5-ebc76d338f7d .conditionalSectionListSelection").each(function (i, obj) {\
                    if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
                        if (obj.checked) {\
                            $(\'#\' + obj.id).change();\
                        }\
                    } else {\
                        $(\'#\' + obj.id).change();\
                    }\
                });\
            }\
        });\
    });\
};\
\
fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
    requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
        var fbRequire = fbRequireConfig.fbRequire;\
\
        fbRequire([\'jquery\', \'he\'], function ($, he) {\
            he.encode.options.decimal = true;\
            he.encode.options.allowUnsafeSymbols = true;\
\
            var sectionConditions = JSON.parse(\'[{"ElementName":"FormField15_93fe6f05-8291-4941-84b5-ebc76d338f7d","Value":"Treating cancer or discussing treatment options"},{"ElementName":"FormField19_93fe6f05-8291-4941-84b5-ebc76d338f7d","Value":"Yes"}]\');\
            var conditionOperator = \'or\';\
\
            sectionConditions.forEach(function (sectionCondition) {\
                $("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
                \
                $("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
                \
                $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\
                    checkShowHide();\
                });\
            });\
            \
            function checkShowHide() {\
                var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
                sectionConditions.forEach(function (sectionCondition) {\
                    checkSelect(sectionCondition);                \
                    checkCheckbox(sectionCondition);                \
                    checkRadio(sectionCondition);                    \
                });\
\
                showHideSection(shouldShowSection);\
\
                function checkSelect(sectionCondition) {\
                    var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
                    if (!matchingSelect) {\
                        return;\
                    }\
\
                    if (matchingSelect.type === \'select-multiple\') {\
                        var hasOneMatchingValue = false;\
\
                        for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
                            if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\
                                hasOneMatchingValue = true;\
                            }\
                        }\
\
                        shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
                    } else {\
                        shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
                    }\
                }\
\
                function checkCheckbox(sectionCondition) {\
                    var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
                    \
                    for (var i = 0; i < matchingCheckboxes.length; i++) {\
                        if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
                            shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
                        }\
                    }\
                }\
\
                function checkRadio(sectionCondition) {\
                    var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
                    \
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<h2>Cancer Care Appointment Request</h2><p>Thank you for your interest in the FirstHealth Cancer Center. We understand you may have a lot of questions and we are here to help. If you are a new patient, please fill out this form to request an appointment for cancer care at FirstHealth.</p><p>This form should take less than 5 minutes to complete. Once you complete this form, we will call you within two business days and connect you to the right team of experts.</p><p>&nbsp;We appreciate you trusting your care to us.</p><div class=\'form-group\'><label for=\'FormField1_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>Are you the patient?<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField1_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField1_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Are you the patient? is required.\' data-export-label=\'Are_you_the_patient\' ><option value=\'\' selected>( Please Select )</option><option value=\'Yes\'>Yes</option><option value=\'No\'>No</option></select></div></div><div class=\'form-group\'><label for=\'FormField2_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>Is the patient a US citizen or a lawful permanent resident of the US?<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField2_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField2_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Is the patient a US citizen or a lawful permanent resident of the US? is required.\' data-export-label=\'US_Citizen\' ><option value=\'\' selected>( Please Select )</option><option value=\'Yes\'>Yes</option><option value=\'No\'>No</option></select></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField3_93fe6f05-8291-4941-84b5-ebc76d338f7d\'><div class=\'form-group\'><label for=\'FormField4_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>Has the patient had an appointment with FirstHealth Cancer Services within the last 3 years?<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField4_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField4_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Has the patient had an appointment with FirstHealth Cancer Services within the last 3 years? is required.\' data-export-label=\'Appt_Last_Three_Years\' ><option value=\'\' selected>( Please Select )</option><option value=\'Yes\'>Yes</option><option value=\'No\'>No</option></select></div></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField22_93fe6f05-8291-4941-84b5-ebc76d338f7d\'><h2>Please Use MyChart</h2><p>Returning Patients: Please log in to <a href=\'https://www.firsthealthmychart.org/mychartprd/Authentication/Login\'>MyChart</a> to request a new appointment. If you haven&apos;t registered for MyChart yet, please visit <a href=\'https://www.firsthealthmychart.org/mychartprd/signup\'>the MyChart sign up page</a> to get your account activated.</p></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField24_93fe6f05-8291-4941-84b5-ebc76d338f7d\'><h2>Your Contact Information</h2>\
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</div></div><div class=\'form-group\'><label for=\'FormField28_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>Phone Type</label><div><select  name=\'FormField28_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField28_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control \' style=\'width: auto\'  data-export-label=\'Phone_Type_contact\' ><option value=\'\' selected>( Please Select )</option><option value=\'Mobile\'>Mobile</option><option value=\'Home\'>Home</option><option value=\'Work \'>Work </option><option value=\'Other\'>Other</option></select></div></div><div class=\'form-group\'><label for=\'FormField29_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>Contact Email<span class=\'fb-required\'>*</span></label><div><input type=\'email\' name=\'FormField29_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField29_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Contact Email is required.\' data-export-label=\'Contact_Email\'  data-msg-email=\'Please specify a valid email.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField31_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>Relationship to Patient<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField31_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField31_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Relationship to Patient is required.\' data-export-label=\'Relationship_to_Patient\' ><option value=\'\' selected>( Please Select )</option><option value=\'Family Member\'>Family Member</option><option value=\'Friend\'>Friend</option><option value=\'Caregiver\'>Caregiver</option><option value=\'Other\'>Other</option></select></div></div></div><div class=\'fb-section\'><h2>Patient Information</h2>\
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</div></div><div class=\'form-group\'><label for=\'FormField9_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>Phone Type<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField9_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField9_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Phone Type is required.\' data-export-label=\'Phone_Type\' ><option value=\'\' selected>( Please Select )</option><option value=\'Mobile\'>Mobile</option><option value=\'Home\'>Home</option><option value=\'Work \'>Work </option><option value=\'Other\'>Other</option></select></div></div><div class=\'form-group\'><label for=\'FormField10_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>Email<span class=\'fb-required\'>*</span></label><div><input type=\'email\' name=\'FormField10_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField10_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Email is required.\' data-export-label=\'Email\'  data-msg-email=\'Please specify a valid email.\' />\
</div></div>\
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                        <input class=\'form-control\' id=\'FormField11_93fe6f05-8291-4941-84b5-ebc76d338f7d_Line2\' name=\'FormField11_93fe6f05-8291-4941-84b5-ebc76d338f7d_Line2\' type=\'text\' data-export-label=\'Patient_Address_Line2\'     />\
                    </div>\
                </div>\
                    <div class=\'row\'>\
                        <div class=\'col-sm-4\'>\
                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField11_93fe6f05-8291-4941-84b5-ebc76d338f7d_City\'>City<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'form-control\' id=\'FormField11_93fe6f05-8291-4941-84b5-ebc76d338f7d_City\' name=\'FormField11_93fe6f05-8291-4941-84b5-ebc76d338f7d_City\' type=\'text\' data-export-label=\'Patient_Address_City\'  required data-msg-required=\'Patient Address City is required.\' autocomplete=\'locality\'  />\
                    </div>\
                </div>\
                        </div>\
                        <div class=\'col-sm-4\'>\
                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField11_93fe6f05-8291-4941-84b5-ebc76d338f7d_State\'>State<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <select class=\'form-control\' name=\'FormField11_93fe6f05-8291-4941-84b5-ebc76d338f7d_State\' id=\'FormField11_93fe6f05-8291-4941-84b5-ebc76d338f7d_State\' autocomplete=\'region\' required=\'required\' data-msg-required=\'Patient Address State is required.\' data-export-label=\'Patient_Address_State\' >\
                            <option value=\'\'>( Please Select )</option>\
                            <option value=\'AL\'>Alabama</option>\
                            <option value=\'AK\'>Alaska</option>\
                            <option value=\'AZ\'>Arizona</option>\
                            <option value=\'AR\'>Arkansas</option>\
                            <option value=\'CA\'>California</option>\
                            <option value=\'CO\'>Colorado</option>\
                            <option value=\'CT\'>Connecticut</option>\
                            <option value=\'DE\'>Delaware</option>\
                            <option value=\'DC\'>District Of Columbia</option>\
                            <option value=\'FL\'>Florida</option>\
                            <option value=\'GA\'>Georgia</option>\
                            <option value=\'HI\'>Hawaii</option>\
                            <option value=\'ID\'>Idaho</option>\
                            <option value=\'IL\'>Illinois</option>\
                            <option value=\'IN\'>Indiana</option>\
                            <option value=\'IA\'>Iowa</option>\
                            <option value=\'KS\'>Kansas</option>\
                            <option value=\'KY\'>Kentucky</option>\
                            <option value=\'LA\'>Louisiana</option>\
                            <option value=\'ME\'>Maine</option>\
                            <option value=\'MD\'>Maryland</option>\
                            <option value=\'MA\'>Massachusetts</option>\
                            <option value=\'MI\'>Michigan</option>\
                            <option value=\'MN\'>Minnesota</option>\
                            <option value=\'MS\'>Mississippi</option>\
                            <option value=\'MO\'>Missouri</option>\
                            <option value=\'MT\'>Montana</option>\
                            <option value=\'NE\'>Nebraska</option>\
                            <option value=\'NV\'>Nevada</option>\
                            <option value=\'NH\'>New Hampshire</option>\
                            <option value=\'NJ\'>New Jersey</option>\
                            <option value=\'NM\'>New Mexico</option>\
                            <option value=\'NY\'>New York</option>\
                            <option value=\'NC\'>North Carolina</option>\
                            <option value=\'ND\'>North Dakota</option>\
                            <option value=\'OH\'>Ohio</option>\
                            <option value=\'OK\'>Oklahoma</option>\
                            <option value=\'OR\'>Oregon</option>\
                            <option value=\'PA\'>Pennsylvania</option>\
                            <option value=\'RI\'>Rhode Island</option>\
                            <option value=\'SC\'>South Carolina</option>\
                            <option value=\'SD\'>South Dakota</option>\
                            <option value=\'TN\'>Tennessee</option>\
                            <option value=\'TX\'>Texas</option>\
                            <option value=\'UT\'>Utah</option>\
                            <option value=\'VT\'>Vermont</option>\
                            <option value=\'VA\'>Virginia</option>\
                            <option value=\'WA\'>Washington</option>\
                            <option value=\'WV\'>West Virginia</option>\
                            <option value=\'WI\'>Wisconsin</option>\
                            <option value=\'WY\'>Wyoming</option>\
                        </select>\
                    </div>\
                </div>\
                \
                        </div>\
                        <div class=\'col-sm-4\'>\
                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField11_93fe6f05-8291-4941-84b5-ebc76d338f7d_Zip\'>Zip<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'form-control\' id=\'FormField11_93fe6f05-8291-4941-84b5-ebc76d338f7d_Zip\' name=\'FormField11_93fe6f05-8291-4941-84b5-ebc76d338f7d_Zip\' type=\'text\' data-export-label=\'Patient_Address_Zip\'  required data-msg-required=\'Patient Address Zip is required.\' autocomplete=\'postal-code\' data-rule-zipCode=\'true\' />\
                    </div>\
                </div>\
                        </div>\
                    </div>\
                </fieldset><div class=\'form-group\'><label for=\'FormField12_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>Date of Birth<span class=\'fb-required\'>*</span></label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField12_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField12_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control input-medium isDatePicker\' required data-msg-required=\'Date of Birth is required.\' data-format=\'mm/dd/yy\' data-export-label=\'Date_of_Birth\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField13_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>Gender<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField13_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField13_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Gender is required.\' data-export-label=\'Gender\' ><option value=\'\' selected>( Please Select )</option><option value=\'Male\'>Male</option><option value=\'Female\'>Female</option><option value=\'Another\'>Another</option></select></div></div></div><div class=\'fb-section\'><div class=\'form-group\'><label for=\'FormField15_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>What type of appointment are you interested in?<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField15_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField15_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'What are you interested in? is required.\' data-export-label=\'What_are_you_interested_in\' ><option value=\'\' selected>( Please Select )</option><option value=\'Treating cancer or discussing treatment options\'>Treating cancer or discussing treatment options</option><option value=\'Finding out if I have cancer\'>Finding out if I have cancer</option></select></div></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField18_93fe6f05-8291-4941-84b5-ebc76d338f7d\'><div class=\'form-group\'><label for=\'FormField19_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>Have you been told you have a possible cancer diagnosis?<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField19_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField19_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Have you been told you have a possible cancer diagnosis? is required.\' data-export-label=\'Possible_Diagnosis\' ><option value=\'\' selected>( Please Select )</option><option value=\'Yes\'>Yes</option><option value=\'No\'>No</option></select></div></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField16_93fe6f05-8291-4941-84b5-ebc76d338f7d\'><div class=\'form-group\'><label for=\'FormField17_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'control-label  \'>What is your diagnosis?<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField17_93fe6f05-8291-4941-84b5-ebc76d338f7d\' id=\'FormField17_93fe6f05-8291-4941-84b5-ebc76d338f7d\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'What is your diagnosis? is required.\' data-export-label=\'What_is_your_diagnosis\' ><option value=\'\' selected>( Please Select )</option><option value=\'Anal Cancer\'>Anal Cancer</option><option value=\'Brain Tumor\'>Brain Tumor</option><option value=\'Breast Cancer\'>Breast Cancer</option><option value=\'Colon Cancer\'>Colon Cancer</option><option value=\'Gynecologic Cancer\'>Gynecologic Cancer</option><option value=\'Head and Neck Cancer\'>Head and Neck Cancer</option><option value=\'Hematology\'>Hematology</option><option value=\'Lung Cancer\'>Lung Cancer</option><option value=\'Prostate Cancer\'>Prostate Cancer</option><option value=\'Renal Cancer\'>Renal Cancer</option></select></div></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField20_93fe6f05-8291-4941-84b5-ebc76d338f7d\'><p>Please contact our Patient Referral Center to establish a primary care provider for screening tests. [REVISIT TEXT]</p></div><p>Please contact our Patient Referral Center to establish a primary care provider for screening tests. [REVISIT TEXT]</p>\
\
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