{"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\" decoding=\"async\" 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\" title=\"\">\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 decoding=\"async\" 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\" title=\"\">\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\" target=\"_blank\" rel=\"noopener\">\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 decoding=\"async\" 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\" title=\"\" 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_40\" 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_40'>URL<\/label><div class='gfield_description' id='gfield_description_5_40'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><div class='ginput_container'><input name='input_40' id='input_5_40' 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\"  ><legend class='gfield_label gform-field-label' >Main Button<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' >Name<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'>Email Address *<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--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'>Phone Number *<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'>Select Location<\/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' >Patient Address<\/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='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' selected='selected'>Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >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'>Gender<\/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'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input autocomplete=\"off\"  name='input_16' id='input_5_16' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_5_16_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_16_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input autocomplete=\"off\"  type='hidden' id='gforms_calendar_icon_input_5_16' class='gform_hidden' value='https:\/\/familyeyephysicians.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/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'>What Dates\/ Times are best for you? *<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'>Purpose of Visit *<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'>If Your Insurance<\/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'>Vision Insurance Provider<\/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'>Group ID<\/label><div class='ginput_container ginput_container_text'><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'>Member ID<\/label><div class='ginput_container ginput_container_text'><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'>Insurance Card Photo Upload<\/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'>Insurance Card Photo Upload<\/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\"  ><legend class='gfield_label gform-field-label' >Choices<\/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'>Last 4 digits of SSN<\/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\"  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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 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placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_31_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_31_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input autocomplete=\"off\"  type='hidden' id='gforms_calendar_icon_input_5_31' class='gform_hidden' value='https:\/\/familyeyephysicians.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/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'>Last 4 digits of SSN<\/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\"  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