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fbRenderedIntegrations.type = "text/javascript";
fbRenderedScripts.type = "text/javascript";
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<p><span style=\'font-size: 24px; color: #752f8b;\'>Referring Provider Information</span></p><div class=\'form-group\'><label for=\'FormField2_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Referring Provider Name<span class=\'fb-required\'>*</span></label><div>\
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<input type=\'text\' name=\'FormField4_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField4_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'City is required.\' data-export-label=\'Referring_Provider_City\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField5_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>State<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField5_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField5_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'State is required.\' data-export-label=\'Referring_Prov_State\' ><option value=\'\' selected>( Please Select )</option><option value=\'MT\'>MT</option><option value=\'ND\'>ND</option><option value=\'SD\'>SD</option><option value=\'WY\'>WY</option></select></div></div><div class=\'form-group\'><label for=\'FormField6_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Phone<span class=\'fb-required\'>*</span></label><div><input type=\'text\' name=\'FormField6_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField6_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Phone is required.\' data-export-label=\'Referring_Prov_Phone\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField7_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Fax</label><div><input type=\'text\' name=\'FormField7_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField7_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\'  data-export-label=\'Referring_Prov_Fax\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField8_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Primary Care Provider Name<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField8_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField8_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Primary Care Provider Name is required.\' data-export-label=\'Primary_Care_Provider_Name\'  placeholder=\'\'  />\
</div></div><p><span style=\'font-size: 24px; color: #752f8b;\'>Patient Information</span></p><div class=\'form-group\'><label for=\'FormField12_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>First Name<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField12_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField12_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'First Name is required.\' data-export-label=\'Pt_First_Name\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField13_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>M.I.</label><div>\
<input type=\'text\' name=\'FormField13_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField13_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'Pt_MI\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField14_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Last Name<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField14_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField14_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Last Name is required.\' data-export-label=\'Pt_Last_Name\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField15_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>City<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField15_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField15_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'City is required.\' data-export-label=\'Pt_City\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField17_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>State<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField17_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField17_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-mini \' value=\'\' data-rule-maxlength=\'2\' data-msg-maxlength=\'You have exceeded the max length of 2 characters.\' required data-msg-required=\'State is required.\' data-export-label=\'Pt_State\'  placeholder=\'\'  />\
<div class=\'formHelp\'>Example: MT</div></div></div><div class=\'form-group\'><label for=\'FormField18_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Birth Date<span class=\'fb-required\'>*</span></label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField18_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField18_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium isDatePicker\' required data-msg-required=\'Birth Date is required.\' data-format=\'mm/dd/yy\' data-export-label=\'Pt_Birth_Date\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField10_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Phone<span class=\'fb-required\'>*</span></label><div><input type=\'text\' name=\'FormField10_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField10_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Phone is required.\' data-export-label=\'Patient_Phone\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField11_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Alternate Phone</label><div><input type=\'text\' name=\'FormField11_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField11_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\'  data-export-label=\'Patient_Alt_Phone\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField19_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Parent&#39;s Name</label><div>\
<input type=\'text\' name=\'FormField19_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField19_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'Parent_Name\'  placeholder=\'\'  />\
<div class=\'formHelp\'>If patient is a minor</div></div></div><div class=\'form-group\'><label  class=\'control-label  \'>Does the patient need an interpreter?<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'Yes\' required data-msg-required=\'Does the patient need an interpreter? is required.\' name=\'checkbox20\' id=\'FormField20_cba9876a-53ed-4118-9882-3d7815a5a75f_1\' class=\'right\' data-export-label=\'Pt_Need_Interpreter\' ><label for=\'FormField20_cba9876a-53ed-4118-9882-3d7815a5a75f_1\'>Yes</label></div><div class=\'flow\'><input type=\'radio\' value=\'No\' required data-msg-required=\'Does the patient need an interpreter? is required.\' name=\'checkbox20\' id=\'FormField20_cba9876a-53ed-4118-9882-3d7815a5a75f_2\' class=\'right\' data-export-label=\'Pt_Need_Interpreter\' ><label for=\'FormField20_cba9876a-53ed-4118-9882-3d7815a5a75f_2\'>No</label></div></fieldset></div></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField21_cba9876a-53ed-4118-9882-3d7815a5a75f\'><div class=\'form-group\'><label for=\'FormField22_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>What language?<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField22_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField22_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'What language? is required.\' data-export-label=\'What_language\'  placeholder=\'\'  />\
</div></div></div><div class=\'form-group\'><label for=\'FormField23_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Patient&#39;s Insurance Carrier<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField23_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField23_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Patient&#39;s Insurance Carrier is required.\' data-export-label=\'Patient_Insurance_Carrier\' ><option value=\'\' selected>( Please Select )</option><option value=\'Indian Health Services\'>Indian Health Services</option><option value=\'Medicaid\'>Medicaid</option><option value=\'Mt. Healthy Kids\'>Mt. Healthy Kids</option><option value=\'Other\'>Other</option></select></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField24_cba9876a-53ed-4118-9882-3d7815a5a75f\'><div class=\'form-group\'><label for=\'FormField25_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>If other, please specify:<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField25_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField25_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'If other, please specify: is required.\' data-export-label=\'Other_Pt_Ins_Carrier\'  placeholder=\'\'  />\
</div></div></div><p><span style=\'font-size: 24px; color: #752f8b;\'>Appointment Request</span></p><div class=\'form-group\'><label for=\'FormField28_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Specialty Requested<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField28_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField28_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Specialty Requested is required.\' data-export-label=\'Specialty_Requested\' ><option value=\'\' selected>( Please Select )</option><option value=\'Allergy\'>Allergy</option><option value=\'Cardiology\'>Cardiology</option><option value=\'Cardiovascular Surgery\'>Cardiovascular Surgery</option><option value=\'Dermatology\'>Dermatology</option><option value=\'Diabetes, Endocrinology and Metabolism Center\'>Diabetes, Endocrinology and Metabolism Center</option><option value=\'ENT\'>ENT</option><option value=\'Gastroenterology\'>Gastroenterology</option><option value=\'General/Vascular Surgery\'>General/Vascular Surgery</option><option value=\'Infectious Disease\'>Infectious Disease</option><option value=\'Maternal Fetal Medicine\'>Maternal Fetal Medicine</option><option value=\'Nephrology\'>Nephrology</option><option value=\'Neurology\'>Neurology</option><option value=\'Neurosurgery\'>Neurosurgery</option><option value=\'OB/GYN\'>OB/GYN</option><option value=\'Occupational Medicine\'>Occupational Medicine</option><option value=\'Ophthalmology\'>Ophthalmology</option><option value=\'Orthopedics\'>Orthopedics</option><option value=\'Physical Medicine and Rehab\'>Physical Medicine and Rehab</option><option value=\'Podiatry\'>Podiatry</option><option value=\'Reproductive Endocrinology and Intertility (REI)\'>Reproductive Endocrinology and Intertility (REI)</option><option value=\'Rheumatology\'>Rheumatology</option><option value=\'Spine Clinic\'>Spine Clinic</option><option value=\'Urology\'>Urology</option><option value=\'Other\'>Other</option></select></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField29_cba9876a-53ed-4118-9882-3d7815a5a75f\'><div class=\'form-group\'><label for=\'FormField30_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Other, if not listed above:<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField30_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField30_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Other, if not listed above: is required.\' data-export-label=\'Other_Specialty\'  placeholder=\'\'  />\
</div></div></div><div class=\'form-group\'><label for=\'FormField27_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'control-label  \'>Reason for referral</label><div>\
<textarea rows=\'10\' name=\'FormField27_cba9876a-53ed-4118-9882-3d7815a5a75f\' id=\'FormField27_cba9876a-53ed-4118-9882-3d7815a5a75f\' class=\'form-control textarea-medium\'   data-export-label=\'Reason_for_referral\'  placeholder=\'\'></textarea>\
<div class=\'formHelp\'>(Please be specific - what is the clinical question to be addressed?)</div></div></div>\
\
<div id=\'form-errors\' class=\'alert alert-danger fade in\' role=\'alert\' style=\'display:none\'></div>\
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