{"id":3702,"date":"2023-11-01T17:18:32","date_gmt":"2023-11-01T17:18:32","guid":{"rendered":"https:\/\/rambunctiousfy.wpengine.com\/?page_id=3702"},"modified":"2023-12-18T17:42:35","modified_gmt":"2023-12-18T17:42:35","slug":"book","status":"publish","type":"page","link":"https:\/\/familyeyephysicians.com\/es\/book\/","title":{"rendered":"Book"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3702\" class=\"elementor elementor-3702\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7742a78 elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile e-flex e-con-boxed e-con e-parent\" data-id=\"7742a78\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-486d5cc elementor-widget elementor-widget-heading\" data-id=\"486d5cc\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Book<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-e1a01fa hs_form elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile e-flex e-con-boxed e-con e-parent\" data-id=\"e1a01fa\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-738de2a e-con-full e-flex e-con e-child\" data-id=\"738de2a\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0c37421 elementor-widget elementor-widget-image\" data-id=\"0c37421\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" width=\"500\" height=\"500\" src=\"https:\/\/familyeyephysicians.com\/wp-content\/uploads\/2023\/10\/Bassel.webp\" class=\"attachment-full size-full wp-image-2257\" alt=\"Bassel\" srcset=\"https:\/\/familyeyephysicians.com\/wp-content\/uploads\/2023\/10\/Bassel.webp 500w, https:\/\/familyeyephysicians.com\/wp-content\/uploads\/2023\/10\/Bassel-300x300.webp 300w, https:\/\/familyeyephysicians.com\/wp-content\/uploads\/2023\/10\/Bassel-150x150.webp 150w\" sizes=\"(max-width: 500px) 100vw, 500px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c0b7793 elementor-widget elementor-widget-heading\" data-id=\"c0b7793\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Dr. Al Khudari<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-98c589d elementor-align-center elementor-widget elementor-widget-button\" data-id=\"98c589d\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-size-sm\" role=\"button\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Select Below<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-74fffdc e-con-full e-flex e-con e-child\" data-id=\"74fffdc\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0964b9b elementor-widget elementor-widget-image\" data-id=\"0964b9b\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img width=\"470\" height=\"504\" src=\"https:\/\/familyeyephysicians.com\/wp-content\/uploads\/2023\/10\/Cosmetic-Eye-Procedures-2.png\" class=\"attachment-full size-full wp-image-2906\" alt=\"Cosmetic Eye Procedures (2)\" srcset=\"https:\/\/familyeyephysicians.com\/wp-content\/uploads\/2023\/10\/Cosmetic-Eye-Procedures-2.png 470w, https:\/\/familyeyephysicians.com\/wp-content\/uploads\/2023\/10\/Cosmetic-Eye-Procedures-2-280x300.png 280w\" sizes=\"(max-width: 470px) 100vw, 470px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e3a10f9 elementor-widget elementor-widget-heading\" data-id=\"e3a10f9\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Family Eye Physicians<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2674a9e elementor-widget elementor-widget-text-editor\" data-id=\"2674a9e\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>4459 N Kedzie<br data-v-d91b852c=\"\" \/>Chicago, IL 60625<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-dd69b7d elementor-list-item-link-inline elementor-icon-list--layout-traditional elementor-widget elementor-widget-icon-list\" data-id=\"dd69b7d\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.google.com\/maps\/place\/4459+N+Kedzie+Chicago%2C+IL+60625\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-map-marker-alt\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">View Map<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-ee19418 hs_form elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile e-flex e-con-boxed e-con e-parent\" data-id=\"ee19418\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-82bb9e5 e-flex e-con-boxed e-con e-child\" data-id=\"82bb9e5\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-f9f2f44 e-flex e-con-boxed e-con e-child\" data-id=\"f9f2f44\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-431d7a7 elementor-position-left elementor-vertical-align-top elementor-widget elementor-widget-image-box\" data-id=\"431d7a7\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-image-box-wrapper\"><figure class=\"elementor-image-box-img\"><img fetchpriority=\"high\" width=\"500\" height=\"500\" src=\"https:\/\/familyeyephysicians.com\/wp-content\/uploads\/2023\/10\/Bassel.webp\" class=\"attachment-full size-full wp-image-2257\" alt=\"Bassel\" srcset=\"https:\/\/familyeyephysicians.com\/wp-content\/uploads\/2023\/10\/Bassel.webp 500w, https:\/\/familyeyephysicians.com\/wp-content\/uploads\/2023\/10\/Bassel-300x300.webp 300w, https:\/\/familyeyephysicians.com\/wp-content\/uploads\/2023\/10\/Bassel-150x150.webp 150w\" sizes=\"(max-width: 500px) 100vw, 500px\" \/><\/figure><div class=\"elementor-image-box-content\"><h3 class=\"elementor-image-box-title\">Dr. Al Khudari<\/h3><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-1d7fc57 e-flex e-con-boxed e-con e-child\" data-id=\"1d7fc57\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6ccc734 elementor-align-right elementor-widget elementor-widget-button\" data-id=\"6ccc734\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-size-sm\" role=\"button\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Select Below<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-297fc22 cs_step_form e-flex e-con-boxed e-con e-parent\" data-id=\"297fc22\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ae9d194 elementor-widget elementor-widget-heading\" data-id=\"ae9d194\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Request an Appointment<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6d13ac5 elementor-widget__width-inherit elementor-widget elementor-widget-shortcode\" data-id=\"6d13ac5\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Step Form<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/es\/wp-json\/wp\/v2\/pages\/3702#gf_5' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_5_42\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_42'><span class='gform-field-label__text'>Instagram<\/span><\/label><div class='gfield_description' id='gfield_description_5_42'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><div class='ginput_container'><input name='input_42' id='input_5_42' type='text' value='' autocomplete='new-password'\/><\/div><\/div><fieldset id=\"field_5_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full hs_radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Main Button<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_36'>\n\t\t\t<div class='gchoice gchoice_5_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='I&#039;m a Returning Patient'  id='choice_5_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_36_0' id='label_5_36_0' class='gform-field-label gform-field-label--type-inline'>I'm a Returning Patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='I&#039;m a New Patient'  id='choice_5_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_36_1' id='label_5_36_1' class='gform-field-label gform-field-label--type-inline'>I'm a New Patient<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_37\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><a href=\"javascript:void(0)\" class=\"hs-radio-button\" data-radio=\"choice_5_36_0\">I'm a Returning Patient<\/a>\n\t\t\t<a href=\"javascript:void(0)\" class=\"hs-radio-button\" data-radio=\"choice_5_36_1\">I'm a New Patient<\/a><\/div><fieldset id=\"field_5_5\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_5'>\n                            \n                            <span id='input_5_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_5_5_3' class='gform-field-label gform-field-label--type-sub '>First Name *<\/label>\n                                                    <input type='text' name='input_5.3' id='input_5_5_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                <\/span>\n                            \n                            <span id='input_5_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_5_5_6' class='gform-field-label gform-field-label--type-sub '>Last Name *<\/label>\n                                                            <input type='text' name='input_5.6' id='input_5_5_6' value=''   aria-required='true'   placeholder='Last Name'  \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_7\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_7'><span class='gform-field-label__text'>Email Address *<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_5_7' type='email' value='' class='large'   placeholder='Email Address' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_8\" class=\"gfield gfield--type-phone gfield--phone-format-international gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_8'><span class='gform-field-label__text'>Phone Number *<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_5_8' type='tel' value='' class='large'  placeholder='(123) 456-7890' aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_5_38\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_38'><span class='gform-field-label__text'>Select Location<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_5_38' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select Location' >Select Location<\/option><option value='Albany Park' >Albany Park<\/option><option value='Buffalo Grove' >Buffalo Grove<\/option><option value='Oakbrook Terrace' >Oakbrook Terrace<\/option><option value='Oak Lawn' >Oak Lawn<\/option><option value='Orland Park' >Orland Park<\/option><option value='Schaumburg' >Schaumburg<\/option><\/select><\/div><\/div><fieldset id=\"field_5_9\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Patient Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_5_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_5_9_1' value=''   placeholder='Address' aria-required='false'    \/>\n                                        <label for='input_5_9_1' id='input_5_9_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_9_2_container' >\n                                        <input type='text' name='input_9.2' id='input_5_9_2' value=''   placeholder='Appartment, Suite, Unit, Building, Floor, etc.'  aria-required='false'   \/>\n                                        <label for='input_5_9_2' id='input_5_9_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_9_3_container' >\n                                    <input type='text' name='input_9.3' id='input_5_9_3' value=''   placeholder='City' aria-required='false'    \/>\n                                    <label for='input_5_9_3' id='input_5_9_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_9_4_container' >\n                                        <input type='text' name='input_9.4' id='input_5_9_4' value=''     placeholder='State\/Province' aria-required='false'    \/>\n                                        <label for='input_5_9_4' id='input_5_9_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_9_5_container' >\n                                    <input type='text' name='input_9.5' id='input_5_9_5' value=''   placeholder='Zip\/Postal' aria-required='false'    \/>\n                                    <label for='input_5_9_5' id='input_5_9_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_5_9_6_container' >\n                                        <select name='input_9.6' id='input_5_9_6'   aria-required='false'    ><option value='' >Country<\/option><option value='AF' >Afghanist\u00e1n<\/option><option value='AL' >Albania<\/option><option value='DE' >Alemania<\/option><option value='AD' selected='selected'>Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Ant\u00e1rtida<\/option><option value='AG' >Antigua y Barbuda<\/option><option value='SA' >Arabia Saudita<\/option><option value='DZ' >Argelia<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaiy\u00e1n<\/option><option value='BS' >Bahamas<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BH' >Bar\u00e9in<\/option><option value='BE' >B\u00e9lgica<\/option><option value='BZ' >Belice<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhut\u00e1n<\/option><option value='BY' >Bielorusia<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, San Eustaquio y Saba<\/option><option value='BA' >Bosnia y Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BR' >Brasil<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='CV' >Cabo Verde<\/option><option value='KH' >Camboya<\/option><option value='CM' >Camer\u00fan<\/option><option value='CA' >Canada<\/option><option value='TD' >Chad<\/option><option value='CZ' >Chequia<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CY' >Chipre<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoras<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='KR' >Corea, Rep\u00fablica de<\/option><option value='KP' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='CI' >Costa de Marfil<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croacia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Curazao<\/option><option value='DK' >Dinamarca<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egipto<\/option><option value='SV' >El Salvador<\/option><option value='AE' >Emiratos \u00c1rabes Unidos<\/option><option value='ER' >Eritrea<\/option><option value='SK' >Eslovaquia<\/option><option value='SI' >Eslovenia<\/option><option value='ES' >Espa\u00f1a<\/option><option value='US' >Estados Unidos<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Esuatini<\/option><option value='ET' >Etiop\u00eda<\/option><option value='RU' >Federaci\u00f3n Rusa<\/option><option value='FJ' >Fiji<\/option><option value='PH' >Filipinas<\/option><option value='FI' >Finlandia<\/option><option value='FR' >Francia<\/option><option value='GA' >Gab\u00f3n<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GD' >Granada<\/option><option value='GR' >Grecia<\/option><option value='GL' >Groenlandia<\/option><option value='GP' >Guadalupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GY' >Guayana<\/option><option value='GF' >Guayana Francesa<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea Bissau<\/option><option value='GQ' >Guinea Ecuatorial<\/option><option value='HT' >Hait\u00ed<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungr\u00eda<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Ir\u00e1n<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlanda<\/option><option value='BV' >Isla Bouvet<\/option><option value='IM' >Isla de Man<\/option><option value='CX' >Isla de Navidad<\/option><option value='NF' >Isla Norfolk<\/option><option value='IS' >Islandia<\/option><option value='AX' >Islas \u00c5land<\/option><option value='KY' >Islas Caim\u00e1n<\/option><option value='CC' >Islas Cocos<\/option><option value='CK' >Islas Cook<\/option><option value='FO' >Islas Faroe<\/option><option value='HM' >Islas Heard y McDonald<\/option><option value='FK' >Islas Malvinas<\/option><option value='MP' >Islas Marianas del Norte<\/option><option value='MH' >Islas Marshall<\/option><option value='SB' >Islas Salom\u00f3n<\/option><option value='TC' >Islas Turcas y Caicos<\/option><option value='UM' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='VG' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='VI' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='IL' >Israel<\/option><option value='IT' >Italia<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Jap\u00f3n<\/option><option value='JE' >Jersey<\/option><option value='GS' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='JO' >Jord\u00e1n<\/option><option value='KZ' >Kazajist\u00e1n<\/option><option value='KE' >Kenia<\/option><option value='KG' >Kirguist\u00e1n<\/option><option value='KI' >Kiribati<\/option><option value='KW' >Kuwait<\/option><option value='LS' >Lesoto<\/option><option value='LB' >L\u00edbano<\/option><option value='LR' >Liberia<\/option><option value='LY' >LIbia<\/option><option value='LI' >Liechtenstein<\/option><option value='LV' >Lituania<\/option><option value='LT' >Lituania<\/option><option value='LU' >Luxemburgo<\/option><option value='MO' >Macau<\/option><option value='MK' >Macedonia del Norte<\/option><option value='MG' >Madagascar<\/option><option value='MY' >Malasia<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldivas<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MA' >Marruecos<\/option><option value='MQ' >Martinica<\/option><option value='MU' >Mauricio<\/option><option value='MR' >Mauritania<\/option><option value='YT' >Mayotte<\/option><option value='MX' >M\u00e9xico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldavia<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >N\u00edger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NO' >Noruega<\/option><option value='NC' >Nueva Caledonia<\/option><option value='NZ' >Nueva Zelanda<\/option><option value='OM' >Om\u00e1n<\/option><option value='NL' >Paises Bajos<\/option><option value='PK' >Pakist\u00e1n<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestina, Estado de<\/option><option value='PA' >Panam\u00e1<\/option><option value='PG' >Pap\u00faa Nueva Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Per\u00fa<\/option><option value='PN' >Pitcairn<\/option><option value='PF' >Polinesia Francesa<\/option><option value='PL' >Polonia<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='GB' >Reino Unido<\/option><option value='SY' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='CF' >Rep\u00fablica Centroafricana<\/option><option value='LA' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='DO' >Rep\u00fablica Dominicana<\/option><option value='RE' >Reuni\u00f3n<\/option><option value='RW' >Ruanda<\/option><option value='RO' >Ruman\u00eda<\/option><option value='EH' >Sahara Occidental<\/option><option value='WS' >Samoa<\/option><option value='AS' >Samoa Americana<\/option><option value='BL' >San Bartolom\u00e9<\/option><option value='KN' >San Crist\u00f3bal y Nieves<\/option><option value='SM' >San Marino<\/option><option value='MF' >San Mart\u00edn<\/option><option value='PM' >San Pedro y Miquel\u00f3n<\/option><option value='VC' >San Vicente y las Granadinas<\/option><option value='SH' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='LC' >Santa Luc\u00eda<\/option><option value='VA' >Santa Sede<\/option><option value='ST' >Santo Tom\u00e9 y Principe<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leona<\/option><option value='SG' >Singapur<\/option><option value='SX' >Sint Maarten<\/option><option value='SO' >Somalia<\/option><option value='LK' >Sri Lanka<\/option><option value='ZA' >Sud\u00e1frica<\/option><option value='SD' >Sud\u00e1n<\/option><option value='SS' >Sud\u00e1n del Sur<\/option><option value='SE' >Suecia<\/option><option value='CH' >Suiza<\/option><option value='SR' >Surinam<\/option><option value='SJ' >Svalbard y Jan Mayen<\/option><option value='TH' >Tailandia<\/option><option value='TW' >Taiwan<\/option><option value='TZ' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='TJ' >Tayikist\u00e1n<\/option><option value='IO' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='TF' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='TL' >Timor Oriental<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad y Tobago<\/option><option value='TN' >T\u00fanez<\/option><option value='TM' >Turkmenist\u00e1n<\/option><option value='TR' >Turqu\u00eda<\/option><option value='TV' >Tuvalu<\/option><option value='UA' >Ucrania<\/option><option value='UG' >Uganda<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekist\u00e1n<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis y Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbaue<\/option><\/select>\n                                        <label for='input_5_9_6' id='input_5_9_6_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_14\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_14'><span class='gform-field-label__text'>Gender<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_5_14' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select Gender' >Select Gender<\/option><option value='Female' >Female<\/option><option value='Male' >Male<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_5_16\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_16'><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/aaaa'\n\t\t\t\t\tid='input_5_16'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_16'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_16' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_16' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_16' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Supplementary Information<\/h3><\/div><div id=\"field_5_19\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_19'><span class='gform-field-label__text'>What Dates\/ Times are best for you? *<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_5_19' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_18\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_18'><span class='gform-field-label__text'>Purpose of Visit *<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_5_18' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_39\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_39'><span class='gform-field-label__text'>If Your Insurance<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_5_39' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select Option' >Select Option<\/option><option value='Insurance has Changed' >Insurance has Changed<\/option><option value='Insurance had not Changed' >Insurance had not Changed<\/option><\/select><\/div><\/div><div id=\"field_5_20\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_20'><span class='gform-field-label__text'>Vision Insurance Provider<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_5_20' type='text' value='' class='large'    placeholder='Insurance Provider Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_21\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_21'><span class='gform-field-label__text'>Group ID<\/span><\/label><div class='ginput_container ginput_container_text' data-text-counter-max='25' data-text-counter-template='{current} of {max} max characters'><input name='input_21' id='input_5_21' type='text' value='' class='large' maxlength='25'   placeholder='Group ID'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_22\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_22'><span class='gform-field-label__text'>Member ID<\/span><\/label><div class='ginput_container ginput_container_text' data-text-counter-max='25' data-text-counter-template='{current} of {max} max characters'><input name='input_22' id='input_5_22' type='text' value='' class='large' maxlength='25'   placeholder='Member ID'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_23\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_23'><span class='gform-field-label__text'>Insurance Card Photo Upload<\/span><\/label><div class='gfield_description' id='gfield_description_5_23'>Front Image<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='268435456' \/><input name='input_23' id='input_5_23' type='file' class='large' aria-describedby=\"gfield_upload_rules_5_23 gfield_description_5_23\" onchange='javascript:gformValidateFileSize( this, 268435456 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_23'>Tipos de archivos aceptados: jpg, gif, png, pdf, Tama\u00f1o m\u00e1ximo de archivo: 256 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_23'><\/div> <\/div><\/div><div id=\"field_5_24\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_above gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_24'><span class='gform-field-label__text'>Insurance Card Photo Upload<\/span><\/label><div class='gfield_description' id='gfield_description_5_24'>Back Image<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='268435456' \/><input name='input_24' id='input_5_24' type='file' class='large' aria-describedby=\"gfield_upload_rules_5_24 gfield_description_5_24\" onchange='javascript:gformValidateFileSize( this, 268435456 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_24'>Tipos de archivos aceptados: jpg, gif, png, pdf, Tama\u00f1o m\u00e1ximo de archivo: 256 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_24'><\/div> <\/div><\/div><div id=\"field_5_25\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Primary Policy Holder Information<\/h3><div class='gsection_description' id='gfield_description_5_25'>Are you the primary policy holder? *<\/div><\/div><div id=\"field_5_35\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><a href=\"javascript:void(0)\" class=\"hs-radio-button\" data-radio=\"choice_5_26_0\">yes<\/a>\n<a href=\"javascript:void(0)\" class=\"hs-radio-button\" data-radio=\"choice_5_26_1\">no<\/a>\n<script>\n\tjQuery(document).ready(function () {\n\t\tjQuery(\".hs-radio-button\").click(function () {\n\t\t\tjQuery(this).parent().find(\"a\").removeClass(\"hs_active\");\n\t\t\tjQuery(this).addClass(\"hs_active\");\n\t\t\tlet radio_val = jQuery(this).data('radio');\n\t\t\tjQuery(\".hs_radio input[id='\" + radio_val + \"']\").prop(\"checked\", true);\n\t\t\tjQuery(\".hs_radio input\").trigger(\"change\");\n\t\t});\n\t\tjQuery('div[data-id=\"6ccc734\"]').click(function(){\n\t\t\tjQuery('div[data-id=\"98c589d\"]').show();\n\t\t\tjQuery('div[data-id=\"ee19418\"]').hide();\n\t\t});\n\t\tjQuery('div[data-id=\"98c589d\"]').click(function(){\n\t\t\tjQuery('div[data-id=\"ee19418\"]').show();\n\t\t\tjQuery('div[data-id=\"98c589d\"]').hide();\n\t\t});\n\t});\n<\/script><\/div><fieldset id=\"field_5_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full hs_radio field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Choices<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_26'>\n\t\t\t<div class='gchoice gchoice_5_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_5_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_26_0' id='label_5_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_5_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_26_1' id='label_5_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_27\" class=\"gfield gfield--type-number gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_27'><span class='gform-field-label__text'>Last 4 digits of SSN<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_27' id='input_5_27' type='number' step='any'   value='' class='large'    placeholder='XXXX'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_28\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_28'><span class='gform-field-label__text'>Comments<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_5_28' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_29\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_29'>\n                            \n                            <span id='input_5_29_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_5_29_3' class='gform-field-label gform-field-label--type-sub '>First Name *<\/label>\n                                                    <input type='text' name='input_29.3' id='input_5_29_3' value=''   aria-required='true'   placeholder='Primary Policy Holder&#039;s First Name'  \/>\n                                                <\/span>\n                            \n                            <span id='input_5_29_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_5_29_6' class='gform-field-label gform-field-label--type-sub '>Last Name *<\/label>\n                                                            <input type='text' name='input_29.6' id='input_5_29_6' value=''   aria-required='true'   placeholder='Primary Policy Holder&#039;s First Name'  \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_31\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_31'><span class='gform-field-label__text'>Date of Birth<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_31'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_31'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_31' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_31' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_31' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_30\" class=\"gfield gfield--type-number gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_30'><span class='gform-field-label__text'>Last 4 digits of SSN<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_30' id='input_5_30' type='number' step='any'   value='' class='large'    placeholder='XXXX'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_34\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_34'><span class='gform-field-label__text'>Comments<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_5_34' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_40\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Text message consent (optional)<\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_40.1' id='input_5_40_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_40_1' ><span class='gform-field-label__text'>I agree to receive non-marketing text messages from Family Eye Physicians about my appointments, scheduling, and care-related updates at the phone number provided. Message frequency varies. Message and data rates may apply. Reply HELP for help or STOP to opt out at any time.<\/span><\/label><input type='hidden' name='input_40.2' value='I agree to receive non-marketing text messages from Family Eye Physicians about my appointments, scheduling, and care-related updates at the phone number provided. Message frequency varies. Message and data rates may apply. Reply HELP for help or STOP to opt out at any time.' class='gform_hidden' \/><input type='hidden' name='input_40.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_5_41\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_above gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Marketing text consent (optional)<\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_5_41'><div class='gfield_consent_description_text gform-theme__no-reset--children' tabindex='0'>Consent is not a condition of service. View our <a href=\"\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a> and <a href=\"\/sms-terms\/\" target=\"_blank\">SMS Terms<\/a>.<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_41.1' id='input_5_41_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_5_41\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_41_1' ><span class='gform-field-label__text'>I agree to receive marketing text messages from Family Eye Physicians, such as practice news and offers, at the phone number provided. Message frequency varies. Message and data rates may apply. Reply HELP for help or STOP to opt out at any time.<\/span><\/label><input type='hidden' name='input_41.2' value='I agree to receive marketing text messages from Family Eye Physicians, such as practice news and offers, at the phone number provided. Message frequency varies. Message and data rates may apply. Reply HELP for help or STOP to opt out at any time.' class='gform_hidden' \/><input type='hidden' name='input_41.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit Request<\/button>Submit Request<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='iRrmMs1ucmvm+p82ytNqDM\/p\/AAmpWqs7zaaUw1EDWn8syleKI8CsRdOKBOFrbi7wSQmZrHJW0ZHWJ5LmekrmhXdC78g5thHjPQfJH5ZZwdK8gI=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_5' id='gform_target_page_number_5' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_5' id='gform_source_page_number_5' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Book Dr. Al Khudari Select Below Family Eye Physicians 4459 N KedzieChicago, IL 60625 View Map Dr. Al Khudari Select Below Request an Appointment<\/p>","protected":false},"author":13,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"slim_seo":{"title":"Book - 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