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window.location.href = "https:" + window.location.href.substring(window.location.protocol.length);
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var fbScriptTag = document.getElementsByClassName("b9060325-6262-487a-b018-81c9fe1c35b8"),
fbBodyTag = document.body,
fbHeadTag = document.head,
fbIsTestResponse = 'False',
fbEnableInstaMedScript = 'False',
fbRenderContainer = document.createElement("div"),
fbRenderedCssContainer = document.createElement("div"),
fbConfigScript = document.createElement("script"),
fbRequireJSScript = document.createElement("script"),
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fbGeoCaptchaCallback = document.createElement("script"),
fbGeoReCaptchaCallback = document.createElement("script"),
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renderedScripts = '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":"FormField121_b9060325-6262-487a-b018-81c9fe1c35b8","Value":"Other"}]\');\
var conditionOperator = \'and\';\
\
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();\
});\
\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
checkShowHide();\
});\
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$("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\']");\
\
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 = [\
[\''\', \''\'],\
[\'`\', \'`\']\
];\
\
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) {\
$(\'#FormField122_b9060325-6262-487a-b018-81c9fe1c35b8\').show();\
} else {\
$(\'#FormField122_b9060325-6262-487a-b018-81c9fe1c35b8\').hide();\
}\
\
$("#FormField122_b9060325-6262-487a-b018-81c9fe1c35b8 .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":"FormField17_b9060325-6262-487a-b018-81c9fe1c35b8","Value":"Yes "}]\');\
var conditionOperator = \'and\';\
\
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\']");\
\
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 = [\
[\''\', \''\'],\
[\'`\', \'`\']\
];\
\
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) {\
$(\'#FormField110_b9060325-6262-487a-b018-81c9fe1c35b8\').show();\
} else {\
$(\'#FormField110_b9060325-6262-487a-b018-81c9fe1c35b8\').hide();\
}\
\
$("#FormField110_b9060325-6262-487a-b018-81c9fe1c35b8 .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":"FormField32_b9060325-6262-487a-b018-81c9fe1c35b8","Value":"Yes "}]\');\
var conditionOperator = \'and\';\
\
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\']");\
\
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 = [\
[\''\', \''\'],\
[\'`\', \'`\']\
];\
\
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) {\
$(\'#FormField34_b9060325-6262-487a-b018-81c9fe1c35b8\').show();\
} else {\
$(\'#FormField34_b9060325-6262-487a-b018-81c9fe1c35b8\').hide();\
}\
\
$("#FormField34_b9060325-6262-487a-b018-81c9fe1c35b8 .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":"FormField70_b9060325-6262-487a-b018-81c9fe1c35b8","Value":"Yes "}]\');\
var conditionOperator = \'and\';\
\
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\']");\
\
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 = [\
[\''\', \''\'],\
[\'`\', \'`\']\
];\
\
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) {\
$(\'#FormField71_b9060325-6262-487a-b018-81c9fe1c35b8\').show();\
} else {\
$(\'#FormField71_b9060325-6262-487a-b018-81c9fe1c35b8\').hide();\
}\
\
$("#FormField71_b9060325-6262-487a-b018-81c9fe1c35b8 .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":"FormField50_b9060325-6262-487a-b018-81c9fe1c35b8","Value":"Yes"}]\');\
var conditionOperator = \'and\';\
\
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\']");\
\
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 = [\
[\''\', \''\'],\
[\'`\', \'`\']\
];\
\
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) {\
$(\'#FormField51_b9060325-6262-487a-b018-81c9fe1c35b8\').show();\
} else {\
$(\'#FormField51_b9060325-6262-487a-b018-81c9fe1c35b8\').hide();\
}\
\
$("#FormField51_b9060325-6262-487a-b018-81c9fe1c35b8 .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) {\
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Required fields are marked with *
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Please complete ALL sections of this form so we can properly care for your child. You must complete a separate form for each child. This information will be kept confidential.
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Enter School Name
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Has the child experienced the following medical problems?
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I GIVE CONSENT to the dental staff of St. Christopher’s Hospital for Children to provide dental services including x-rays, cleaning, sealants, topical fluoride, injection of a numbing agent (local anesthesia), nerve therapy, tooth root therapy, crown placement, tooth extraction, and/or dental fillings as needed by my child following an examination by a licensed dentist on the Ronald McDonald Care Mobile. If additional services are needed by my child, I must agree to those services before they are provided.
I understand that the risks of dental treatment are uncommon but could occur. These risks are a possible allergic reaction or tissue irritation to local anesthetic, soreness, pain and swelling. I understand that it is my responsibility to notify the dental staff of any changes in my child’s health or medications. I understand that if I have questions or concerns, I should call the dental program coordinator at 215-427-8877 before signing this consent.
If the child is attending school, I give permission for my child to be taken out of the classroom and escorted to the Ronald McDonald Care Mobile which will be parked next to my child’s school. Some treatment may be provided inside the school building. I may or may not wish to be present at the time of the dental visit. I understand I can ask for a dental treatment plan for my child at any time.
I acknowledge that I have received the Notice of Privacy Practices of St. Christopher’s Hospital for Children and will keep a copy for my records.
I authorize St. Christopher’s Hospital for Children to provide my child’s school with a copy of the report of the dental examination and services performed. I understand that St. Christopher will provide a copy of the report to the school to allow the school to maintain complete health records for my child. This consent is valid for one year from the date signed.
I give permission to bill my insurance for all qualifying charges and understand that I will not be balance billed for charges not covered by Medicaid. For dental services provided to Medicaid recipients, the payment and satisfaction of the claim submitted by the provider of the services will be from Federal and State funds, and any false claims, statements of documents or concealment of material facts may be prosecuted under applicable Federal and State Laws.
The undersigned has the right to revoke consent at any time by oral or written request.
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A Notice of Privacy Practices (NPP) is provided to all patients. This Notice of Privacy Practices identifies: 1) how medical information about you may be used or disclosed; 2) your rights to access your medical information, amend your medical information, request an accounting of disclosures of your medical information, and request additional restrictions on our uses and disclosures of that information; 3) your rights to complain if you believe your privacy rights have been violated; and 4) our responsibilities for maintaining the privacy of your medical information.