Comprehensive Male Panel

$450.00

Fulfilled By: LabCorp

Comprehensive Male Panel Includes:
070038: Total & Free Testosterone (LC/MS-MS) (Equilibrium Ultrafiltration)
140244: Estradiol, Sensitive (LC/MS-MS)
082016: Sex Hormone-Binding Globulin (SHBG)
004317: Progesterone
004465: Prolactin
010322: Prostate Specific Antigen (PSA)
004309: Follicle-stimulating hormone (FSH)
004283: Luteinizing hormone (LH)
224576: TSH, Free T4
010389: Free T3
004020: Dehydroepiandrosterone Sulfate (DHEA-S)
235010: Lipid Panel – LDL, HDL, Triglycerides, Total Cholesterol, Ratio hdl/ldl
167015: ApoB
120188: Lipoprotein(a)
010363: IGF-1
005013: CBC with differential
322000: Comprehensive Metabolic Panel (14)
004333: Fasting Insulin
081950: Vit D, 25 Hydroxy
001321: Iron serum + TIBC
004598: Ferritin
120766: High Sensitivity C-Reactive Protein
004051: Cortisol
001958: GGT
001453: HBa1c
003038: Basic Urinalysis

SKU: LCP-04 Categories: , ,

Description

Fulfilled By: LabCorp

Comprehensive Male Panel Includes:

070038 Total Testosterone (LC/MS-MS)

070038 Free Testosterone (Equilibrium Ultrafiltration)

140244 Estradiol, Sensitive (LC/MS-MS)

082016 Sex Hormone-Binding Globulin (SHBG)

004317 Progesterone

004465 Prolactin

010322 Prostate Specific Antigen (PSA)

004309 Follicle-stimulating hormone (FSH)

004283 Luteinizing hormone (LH)

224576  TSH, Free T4, Free T3

004020 Dehydroepiandrosterone Sulfate (DHEA-S)

235010 Lipid Panel – LDL, HDL, Triglycerides, Total Cholesterol, Ratio hdl/ldl

120188 Lipoprotein little a – Lp(a)

010363 IGF-1

005009 CBC with differential

322000 Comprehensive Metabolic Panel (14)

004333 Fasting Insulin

081950 Vit D, 25 Hydroxy

001321 Iron serum + TIBC

004598 Ferritin

167015  Apolipoprotein B

120766 High Sensitivity C-Reactive Protein

004051 Cortisol

001958 GGT

001453 HBa1c

003038 Basic Urinalysis

Additional information

LabCorp Code

070038|140244|082016|004317|004465|010322|004309|004283|224576|010389|004020|235010|167015|120188|010363|005013|322000|004333|081950|001321|004598|120766|004051|001958|001453|003038

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Title

Phone: 1 (877) 572 2582
Mon-Fri: 9:00 am – 5:00 pm EST

Email: info@MarekHealth.com
Best way to reach us

Copyright 2021 | All Rights Reserved
[fusion_form form_post_id="31998"]
<style>.fusion-form-form-wrapper .fusion-form-31998 .fusion-form-tooltip .fusion-form-tooltip-content{color:#ffffff !important;background-color:#333333 !important;border-color:#333333 !important;}.submitThanks{ text-align: center; text: bold; display:none; } .file-up-div{ display:none!important; } .panda-div{ margin: 0 auto; text-align: center; display:none; } .loading-gif{ width: 100px; {</style><div class="fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-31998" data-form-id="31998" data-config="{&quot;form_id&quot;:&quot;31998&quot;,&quot;form_post_id&quot;:&quot;31998&quot;,&quot;post_id&quot;:18887,&quot;form_type&quot;:&quot;url&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;field_labels&quot;:{&quot;who_referred_you_to_marek_health&quot;:&quot;Who referred you to Marek Health&quot;,&quot;f_n&quot;:&quot;First Name&quot;,&quot;l_n&quot;:&quot;Last Name&quot;,&quot;email&quot;:&quot;Email&quot;,&quot;pn&quot;:&quot;Phone&quot;,&quot;dob&quot;:&quot;Date of Birth&quot;,&quot;add&quot;:&quot;Address&quot;,&quot;add_2&quot;:&quot;&quot;,&quot;add_city&quot;:&quot;&quot;,&quot;add_state&quot;:&quot;&quot;,&quot;add_zip&quot;:&quot;&quot;,&quot;add_country&quot;:&quot;&quot;,&quot;dl&quot;:&quot;Driver License\/State ID #&quot;,&quot;dl_s&quot;:&quot;ID State Issued by&quot;,&quot;e_c&quot;:&quot;Emergency Contact Name&quot;,&quot;e_p&quot;:&quot;Emergency Contact Phone #&quot;,&quot;gender&quot;:&quot;Gender&quot;,&quot;med_his&quot;:&quot;Medical History&quot;,&quot;mh_og&quot;:&quot;Current Medical Issues&quot;,&quot;pcp&quot;:&quot;Primary Care Provider&quot;,&quot;pcp_p&quot;:&quot;Primary Care Phone #&quot;,&quot;pcp_add&quot;:&quot;PCP Address&quot;,&quot;mh_cpm&quot;:&quot;Current Prescription Medications &quot;,&quot;mh_otc&quot;:&quot;Current over the counter medications?&quot;,&quot;mh_all&quot;:&quot;Do you have allergies?&quot;,&quot;mh_ps&quot;:&quot;Have you had any prior surgeries?&quot;,&quot;mh_sas&quot;:&quot;Do you have issues with Anxiety, Sleep, or Sexual Performance?&quot;,&quot;fam_his&quot;:&quot;Medical history of first degree relatives (mother, father, sisters, brothers)?&quot;,&quot;adam&quot;:&quot;Do you suffer from any of the following conditions? (select all that apply)&quot;,&quot;m_freq&quot;:&quot;Frequency of night urination (times per night)&quot;,&quot;e_urine&quot;:&quot;Are you experiancing difficulty completing urination?&quot;,&quot;m_lump&quot;:&quot;Have you recently noticed any lumps, swelling, tenderness or pain in your testicles?&quot;,&quot;m_pros&quot;:&quot;Results from your last prostate exam (if applicable)&quot;,&quot;eve&quot;:&quot;Do you suffer from any of the following conditions? (select all that apply)&quot;,&quot;w_hp&quot;:&quot;Do you suffer from heavy, irregular or painful periods?&quot;,&quot;w_if_hp&quot;:&quot;Please list symptoms&quot;,&quot;w_mp&quot;:&quot;Date of last menstrual period&quot;,&quot;w_preg&quot;:&quot;Are you currently pregnant or breastfeeding?&quot;,&quot;w_num_p&quot;:&quot;Number of Pregnancies&quot;,&quot;conceive&quot;:&quot;Do you have plans to conceive soon? If no, what are you using for birth control?&quot;,&quot;w_blad&quot;:&quot;Do you suffer from frequent bladder or kidney infections?&quot;,&quot;w_lump&quot;:&quot;Have you recently note any breast lumps, tenderness, pain or nipple discharge?&quot;,&quot;w_pap&quot;:&quot;Date of last pap smear&quot;,&quot;hh_ex&quot;:&quot;Current exercise regimen&quot;,&quot;hh_diet&quot;:&quot;Current diet model?&quot;,&quot;hh_caf&quot;:&quot;Current caffeine intake?&quot;,&quot;hh_tob&quot;:&quot;Tobacco intake?&quot;,&quot;hh_mj&quot;:&quot;Marijuana intake?&quot;,&quot;hh_drug&quot;:&quot;Illegal drug use?&quot;,&quot;hh_use&quot;:&quot;Recreational drug intake? What? How often?&quot;,&quot;g_i&quot;:&quot;What are you interested in?&quot;,&quot;other&quot;:&quot;Other&quot;,&quot;g_d&quot;:&quot;What does your dream outcome working with Marek Health look like?&quot;,&quot;g_b&quot;:&quot;How much per year can you commit towards your dream outcome?&quot;,&quot;physical&quot;:&quot;Physical Exam Documents&quot;,&quot;labs&quot;:&quot;Upload Diagnostic Labwork Results&quot;,&quot;legal_agree&quot;:&quot;&quot;},&quot;field_logics&quot;:{&quot;who_referred_you_to_marek_health&quot;:&quot;&quot;,&quot;f_n&quot;:&quot;&quot;,&quot;l_n&quot;:&quot;&quot;,&quot;email&quot;:&quot;&quot;,&quot;pn&quot;:&quot;&quot;,&quot;dob&quot;:&quot;&quot;,&quot;add&quot;:&quot;&quot;,&quot;add_2&quot;:&quot;&quot;,&quot;add_city&quot;:&quot;&quot;,&quot;add_state&quot;:&quot;&quot;,&quot;add_zip&quot;:&quot;&quot;,&quot;add_country&quot;:&quot;&quot;,&quot;dl&quot;:&quot;&quot;,&quot;dl_s&quot;:&quot;&quot;,&quot;e_c&quot;:&quot;&quot;,&quot;e_p&quot;:&quot;&quot;,&quot;gender&quot;:&quot;[]&quot;,&quot;med_his&quot;:&quot;&quot;,&quot;mh_og&quot;:&quot;&quot;,&quot;pcp&quot;:&quot;&quot;,&quot;pcp_p&quot;:&quot;&quot;,&quot;pcp_add&quot;:&quot;&quot;,&quot;mh_cpm&quot;:&quot;&quot;,&quot;mh_otc&quot;:&quot;&quot;,&quot;mh_all&quot;:&quot;&quot;,&quot;mh_ps&quot;:&quot;&quot;,&quot;mh_sas&quot;:&quot;&quot;,&quot;fam_his&quot;:&quot;&quot;,&quot;adam&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;male\&quot;}]&quot;,&quot;m_freq&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;male\&quot;}]&quot;,&quot;e_urine&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;male\&quot;}]&quot;,&quot;m_lump&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;male\&quot;}]&quot;,&quot;m_pros&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;male\&quot;}]&quot;,&quot;eve&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;female\&quot;}]&quot;,&quot;w_hp&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;female\&quot;}]&quot;,&quot;w_if_hp&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;female\&quot;},{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;w_hp\&quot;,\&quot;value\&quot;:\&quot;YES\&quot;}]&quot;,&quot;w_mp&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;female\&quot;}]&quot;,&quot;w_preg&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;female\&quot;}]&quot;,&quot;w_num_p&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;female\&quot;}]&quot;,&quot;conceive&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;female\&quot;}]&quot;,&quot;w_blad&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;femlae\&quot;}]&quot;,&quot;w_lump&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;female\&quot;}]&quot;,&quot;w_pap&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;gender\&quot;,\&quot;value\&quot;:\&quot;female\&quot;}]&quot;,&quot;hh_ex&quot;:&quot;&quot;,&quot;hh_diet&quot;:&quot;&quot;,&quot;hh_caf&quot;:&quot;&quot;,&quot;hh_tob&quot;:&quot;&quot;,&quot;hh_mj&quot;:&quot;&quot;,&quot;hh_drug&quot;:&quot;&quot;,&quot;hh_use&quot;:&quot;[{\&quot;operator\&quot;:\&quot;and\&quot;,\&quot;comparison\&quot;:\&quot;equal\&quot;,\&quot;field\&quot;:\&quot;hh_drug\&quot;,\&quot;value\&quot;:\&quot;YES\&quot;}]&quot;,&quot;g_i&quot;:&quot;&quot;,&quot;other&quot;:&quot;&quot;,&quot;g_d&quot;:&quot;&quot;,&quot;g_b&quot;:&quot;&quot;,&quot;physical&quot;:&quot;&quot;,&quot;labs&quot;:&quot;&quot;,&quot;legal_agree&quot;:&quot;&quot;}}"><form action="localhost" method="post" class="fusion-form fusion-form-post fusion-form-31998" enctype="multipart/form-data"><div class="fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling" style="background-color: #070707;background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;" id="hhqForm" ><div class="fusion-builder-row fusion-row fusion-flex-align-items-flex-start" style="max-width:1248px;margin-left: calc(-4% / 2 );margin-right: calc(-4% / 2 );"><div class="fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#070707;padding: 0px 0px 0px 0px;"><div class="fusion-text fusion-text-1 fusion-text-no-margin" style="text-align:center;"><h4 style="font-family: Montserrat; font-weight: 400; font-size: 24px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">HEALTH HISTORY QUESTIONNAIRE</h4> </div><div class="fusion-text fusion-text-2" style="text-align:center;margin-right:20%;margin-left:20%;"><h3 style="font-family: Montserrat; font-weight: 400; font-size: 16px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400"><span style="font-weight: 400; font-family: Montserrat; line-height: 16px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">For starters, congratulations—we’re excited to see you’ve taken an interest in creating a better living for yourself through science.</span></h3> <p><span style="font-weight: 400; font-family: Montserrat; line-height: 16px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">I know you are just as excited as we are to get started however Marek is only able to take on a limited amount of patients per year. </span><span style="font-weight: 400;"><span style="font-family: Montserrat; font-weight: 400; line-height: 16px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">Please complete this health history questionnaire to make sure you qualify to join. If you are successful you will be redirected to our booking system to schedule your intake evaluation.</span> </span></p> </div><div class="fusion-text fusion-text-3"><h3 style="font-family: Roboto; font-weight: 400; font-size: 20px;" data-fusion-font="true" data-fusion-google-font="Roboto" data-fusion-google-variant="400">Demographics</h3> </div></div><style type="text/css">.fusion-body .fusion-builder-column-0{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-0 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-0{width:100% !important;order : 0;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-0{width:100% !important;order : 0;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-select-field fusion-form-label-above" data-form-id="31998"><label for="who_referred_you_to_marek_health">Who referred you to Marek Health</label><div class="fusion-select-wrapper"><select tabindex="" id="who_referred_you_to_marek_health" name="who_referred_you_to_marek_health" class="fusion-form-input" data-holds-private-data="false"><option value="" disabled selected>Select an option</option><option value="Derek from MPMD" >Derek from MPMD</option><option value="Stan Efferding" >Stan Efferding</option><option value="PowerProject" >PowerProject</option><option value="Another patient" >Another patient</option><option value="Other" >Other</option></select><div class="select-arrow"><svg width="12" height="8" viewBox="0 0 12 8" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M1.5 1.75L6 6.25L10.5 1.75" stroke="#6D6D6D" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"/> </svg></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-1{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-1 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-1{width:100% !important;order : 0;}.fusion-builder-column-1 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-1{width:100% !important;order : 0;}.fusion-builder-column-1 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-text fusion-text-4"><h3 style="font-family: Roboto; font-weight: 400; font-size: 20px;" data-fusion-font="true" data-fusion-google-font="Roboto" data-fusion-google-variant="400">Patient Information</h3> </div></div><style type="text/css">.fusion-body .fusion-builder-column-2{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-2 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="f_n">First Name <abbr class="fusion-form-element-required" title="required">*</abbr></label></div><input type="text" name="f_n" id="f_n" value="" class="fusion-form-input" required="true" aria-required="true" placeholder="as it appears on your ID*" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-3{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-3 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-3{width:50% !important;order : 0;}.fusion-builder-column-3 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-3{width:100% !important;order : 0;}.fusion-builder-column-3 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="l_n">Last Name <abbr class="fusion-form-element-required" title="required">*</abbr></label></div><input type="text" name="l_n" id="l_n" value="" class="fusion-form-input" required="true" aria-required="true" placeholder="as it appears on your ID*" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-4{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-4 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-4{width:50% !important;order : 0;}.fusion-builder-column-4 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-4{width:100% !important;order : 0;}.fusion-builder-column-4 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-email-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="email">Email</label></div><input type="email" name="email" id="email" value="" class="fusion-form-input" placeholder="Email" data-holds-private-data="false"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-5{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-5 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-5{width:100% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-5{width:100% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-phone-number-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="pn">Phone</label></div><div class="fusion-form-input-with-icon"><i class="fa-phone-square-alt fas"></i><input type="phone-number" name="pn" id="pn" value="" class="fusion-form-input" data-holds-private-data="false" pattern="[0-9()#&+*-=.]+" title="Only numbers and phone characters are accepted."/></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-6{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-6 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-6{width:100% !important;order : 0;}.fusion-builder-column-6 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-6{width:100% !important;order : 0;}.fusion-builder-column-6 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div id="#dob" class="fusion-form-field fusion-form-date-field fusion-form-label-above #dob" data-form-id="31998"><label for="dob">Date of Birth</label><div class="fusion-form-tooltip"><i class="awb-icon-question-circle"></i><span class="fusion-form-tooltip-content">Must enter date as YYYY-MM-DD</span></div><div class="fusion-form-input-with-icon"><i class="fa-calendar-alt fas"></i><input autocomplete="no" type="date" data-format="Y-m-d" tabindex="" id="dob" name="dob" data-type="desktop" value="" data-holds-private-data="false" class="fusion-form-input" placeholder="YYYY-MM-DD"autocomplete="no"/></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-7{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-7 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-7{width:100% !important;order : 0;}.fusion-builder-column-7 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-7{width:100% !important;order : 0;}.fusion-builder-column-7 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="add">Address</label></div><input type="text" name="add" id="add" value="" class="fusion-form-input" placeholder="Street Address" data-holds-private-data="false" minlength="0"/></div><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><input type="text" name="add_2" id="add_2" value="" class="fusion-form-input" placeholder="Address Line 2" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-8{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-8 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-8{width:100% !important;order : 0;}.fusion-builder-column-8 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-8{width:100% !important;order : 0;}.fusion-builder-column-8 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><input type="text" name="add_city" id="add_city" value="" class="fusion-form-input" placeholder="City" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-9{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-9 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-9{width:50% !important;order : 0;}.fusion-builder-column-9 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-9{width:100% !important;order : 0;}.fusion-builder-column-9 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-select-field fusion-form-label-above" data-form-id="31998"><div class="fusion-select-wrapper"><select tabindex="" id="add_state" name="add_state" class="fusion-form-input" data-holds-private-data="false"><option value="Alabama" >Alabama</option><option value="Alaska" >Alaska</option><option value="Arizona" >Arizona</option><option value="Arkansas" >Arkansas</option><option value="California" >California</option><option value="Colorado" >Colorado</option><option value="Connecticut" >Connecticut</option><option value="Delaware" >Delaware</option><option value="District Of Columbia" >District Of Columbia</option><option value="Florida" >Florida</option><option value="Georgia" >Georgia</option><option value="Hawaii" >Hawaii</option><option value="Idaho" >Idaho</option><option value="Illinois" >Illinois</option><option value="Indiana" >Indiana</option><option value="Iowa" >Iowa</option><option value="Kansas" >Kansas</option><option value="Kentucky" >Kentucky</option><option value="Louisiana" >Louisiana</option><option value="Maine" >Maine</option><option value="Maryland" >Maryland</option><option value="Massachusetts" >Massachusetts</option><option value="Michigan" >Michigan</option><option value="Minnesota" >Minnesota</option><option value="Mississippi" >Mississippi</option><option value="Missouri" >Missouri</option><option value="Montana" >Montana</option><option value="Nebraska" >Nebraska</option><option value="Nevada" >Nevada</option><option value="New Hampshire" >New Hampshire</option><option value="New Jersey" >New Jersey</option><option value="New Mexico" >New Mexico</option><option value="New York" >New York</option><option value="North Carolina" >North Carolina</option><option value="North Dakota" >North Dakota</option><option value="Ohio" >Ohio</option><option value="Oklahoma" >Oklahoma</option><option value="Oregon" >Oregon</option><option value="Pennsylvania" >Pennsylvania</option><option value="Rhode Island" >Rhode Island</option><option value="South Carolina" >South Carolina</option><option value="South Dakota" >South Dakota</option><option value="Tennessee" >Tennessee</option><option value="Texas" >Texas</option><option value="Utah" >Utah</option><option value="Vermont" >Vermont</option><option value="Virginia" >Virginia</option><option value="Washington" >Washington</option><option value="West Virginia" >West Virginia</option><option value="Wisconsin" >Wisconsin</option><option value="Wyoming" >Wyoming</option><option value="Armed Forces (AA)" >Armed Forces (AA)</option><option value="Armed Forces (AE)" >Armed Forces (AE)</option><option value="Armed Forces (AP)" >Armed Forces (AP)</option></select><div class="select-arrow"><svg width="12" height="8" viewBox="0 0 12 8" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M1.5 1.75L6 6.25L10.5 1.75" stroke="#6D6D6D" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"/> </svg></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-10{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-10 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-10{width:50% !important;order : 0;}.fusion-builder-column-10 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-10{width:100% !important;order : 0;}.fusion-builder-column-10 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-11 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><input type="text" name="add_zip" id="add_zip" value="" class="fusion-form-input" placeholder="Postal / Zip Code" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-11{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-11 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-11{width:50% !important;order : 0;}.fusion-builder-column-11 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-11{width:100% !important;order : 0;}.fusion-builder-column-11 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-12 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div id="country" class="fusion-form-field fusion-form-select-field fusion-form-label-above country" data-form-id="31998"><div class="fusion-select-wrapper"><select tabindex="" id="add_country" name="add_country" class="fusion-form-input" required="true" aria-required="true" data-holds-private-data="false"><option value="" disabled selected>Country</option><option value="Afghanistan" >Afghanistan</option><option value="Åland Islands" >Åland Islands</option><option value="Albania" >Albania</option><option value="Algeria" >Algeria</option><option value="American Samoa" >American Samoa</option><option value="Andorra" >Andorra</option><option value="Angola" >Angola</option><option value="Anguilla" >Anguilla</option><option value="Antarctica" >Antarctica</option><option value="Antigua and Barbuda" >Antigua and Barbuda</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="Azerbaijan" >Azerbaijan</option><option value="Bahamas" >Bahamas</option><option value="Bahrain" >Bahrain</option><option value="Bangladesh" >Bangladesh</option><option value="Barbados" >Barbados</option><option value="Belarus" >Belarus</option><option value="Belgium" >Belgium</option><option value="Belize" >Belize</option><option value="Benin" >Benin</option><option value="Bermuda" >Bermuda</option><option value="Bhutan" >Bhutan</option><option value="Bolivia" >Bolivia</option><option value="Bonaire, Sint Eustatius and Saba" >Bonaire, Sint Eustatius and Saba</option><option value="Bosnia and Herzegovina" >Bosnia and Herzegovina</option><option value="Botswana" >Botswana</option><option value="Bouvet Island" >Bouvet Island</option><option value="Brazil" >Brazil</option><option value="British Indian Ocean Territory" >British Indian Ocean Territory</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="Cambodia" >Cambodia</option><option value="Cameroon" >Cameroon</option><option value="Canada" >Canada</option><option value="Cape Verde" >Cape Verde</option><option value="Cayman Islands" >Cayman Islands</option><option value="Central African Republic" >Central African Republic</option><option value="Chad" >Chad</option><option value="Chile" >Chile</option><option value="China" >China</option><option value="Christmas Island" >Christmas Island</option><option value="Cocos Islands" >Cocos Islands</option><option value="Colombia" >Colombia</option><option value="Comoros" >Comoros</option><option value="Congo, Democratic Republic of the" >Congo, Democratic Republic of the</option><option value="Congo, Republic of the" >Congo, Republic of the</option><option value="Cook Islands" >Cook Islands</option><option value="Costa Rica" >Costa Rica</option><option value="Côte d'Ivoire" >Côte d'Ivoire</option><option value="Croatia" >Croatia</option><option value="Cuba" >Cuba</option><option value="Curaçao" >Curaçao</option><option value="Cyprus" >Cyprus</option><option value="Czech Republic" >Czech Republic</option><option value="Denmark" >Denmark</option><option value="Djibouti" >Djibouti</option><option value="Dominica" >Dominica</option><option value="Dominican Republic" >Dominican Republic</option><option value="Ecuador" >Ecuador</option><option value="Egypt" >Egypt</option><option value="El Salvador" >El Salvador</option><option value="Equatorial Guinea" >Equatorial Guinea</option><option value="Eritrea" >Eritrea</option><option value="Estonia" >Estonia</option><option value="Eswatini (Swaziland)" >Eswatini (Swaziland)</option><option value="Ethiopia" >Ethiopia</option><option value="Falkland Islands" >Falkland Islands</option><option value="Faroe Islands" >Faroe Islands</option><option value="Fiji" >Fiji</option><option value="Finland" >Finland</option><option value="France" >France</option><option value="French Guiana" >French Guiana</option><option value="French Polynesia" >French Polynesia</option><option value="French Southern Territories" >French Southern Territories</option><option value="Gabon" >Gabon</option><option value="Gambia" >Gambia</option><option value="Georgia" >Georgia</option><option value="Germany" >Germany</option><option value="Ghana" >Ghana</option><option value="Gibraltar" >Gibraltar</option><option value="Greece" >Greece</option><option value="Greenland" >Greenland</option><option value="Grenada" >Grenada</option><option value="Guadeloupe" >Guadeloupe</option><option value="Guam" >Guam</option><option value="Guatemala" >Guatemala</option><option value="Guernsey" >Guernsey</option><option value="Guinea" >Guinea</option><option value="Guinea-Bissau" >Guinea-Bissau</option><option value="Guyana" >Guyana</option><option value="Haiti" >Haiti</option><option value="Heard and McDonald Islands" >Heard and McDonald Islands</option><option value="Holy See" >Holy See</option><option value="Honduras" >Honduras</option><option value="Hong Kong" >Hong Kong</option><option value="Hungary" >Hungary</option><option value="Iceland" >Iceland</option><option value="India" >India</option><option value="Indonesia" >Indonesia</option><option value="Iran" >Iran</option><option value="Iraq" >Iraq</option><option value="Ireland" >Ireland</option><option value="Isle of Man" >Isle of Man</option><option value="Israel" >Israel</option><option value="Italy" >Italy</option><option value="Jamaica" >Jamaica</option><option value="Japan" >Japan</option><option value="Jersey" >Jersey</option><option value="Jordan" >Jordan</option><option value="Kazakhstan" >Kazakhstan</option><option value="Kenya" >Kenya</option><option value="Kiribati" >Kiribati</option><option value="Kuwait" >Kuwait</option><option value="Kyrgyzstan" >Kyrgyzstan</option><option value="Lao People's Democratic Republic" >Lao People's Democratic Republic</option><option value="Latvia" >Latvia</option><option value="Lebanon" >Lebanon</option><option value="Lesotho" >Lesotho</option><option value="Liberia" >Liberia</option><option value="Libya" >Libya</option><option value="Liechtenstein" >Liechtenstein</option><option value="Lithuania" >Lithuania</option><option value="Luxembourg" >Luxembourg</option><option value="Macau" >Macau</option><option value="Macedonia" >Macedonia</option><option value="Madagascar" >Madagascar</option><option value="Malawi" >Malawi</option><option value="Malaysia" >Malaysia</option><option value="Maldives" >Maldives</option><option value="Mali" >Mali</option><option value="Malta" >Malta</option><option value="Marshall Islands" >Marshall Islands</option><option value="Martinique" >Martinique</option><option value="Mauritania" >Mauritania</option><option value="Mauritius" >Mauritius</option><option value="Mayotte" >Mayotte</option><option value="Mexico" >Mexico</option><option value="Micronesia" >Micronesia</option><option value="Moldova" >Moldova</option><option value="Monaco" >Monaco</option><option value="Mongolia" >Mongolia</option><option value="Montenegro" >Montenegro</option><option value="Montserrat" >Montserrat</option><option value="Morocco" >Morocco</option><option value="Mozambique" >Mozambique</option><option value="Myanmar" >Myanmar</option><option value="Namibia" >Namibia</option><option value="Nauru" >Nauru</option><option value="Nepal" >Nepal</option><option value="Netherlands" >Netherlands</option><option value="New Caledonia" >New Caledonia</option><option value="New Zealand" >New Zealand</option><option value="Nicaragua" >Nicaragua</option><option value="Niger" >Niger</option><option value="Nigeria" >Nigeria</option><option value="Niue" >Niue</option><option value="Norfolk Island" >Norfolk Island</option><option value="North Korea" >North Korea</option><option value="Northern Mariana Islands" >Northern Mariana Islands</option><option value="Norway" >Norway</option><option value="Oman" >Oman</option><option value="Pakistan" >Pakistan</option><option value="Palau" >Palau</option><option value="Palestine, State of" >Palestine, State of</option><option value="Panama" >Panama</option><option value="Papua New Guinea" >Papua New Guinea</option><option value="Paraguay" >Paraguay</option><option value="Peru" >Peru</option><option value="Philippines" >Philippines</option><option value="Pitcairn" >Pitcairn</option><option value="Poland" >Poland</option><option value="Portugal" >Portugal</option><option value="Puerto Rico" >Puerto Rico</option><option value="Qatar" >Qatar</option><option value="Réunion" >Réunion</option><option value="Romania" >Romania</option><option value="Russia" >Russia</option><option value="Rwanda" >Rwanda</option><option value="Saint Barthélemy" >Saint Barthélemy</option><option value="Saint Helena" >Saint Helena</option><option value="Saint Kitts and Nevis" >Saint Kitts and Nevis</option><option value="Saint Lucia" >Saint Lucia</option><option value="Saint Martin" >Saint Martin</option><option value="Saint Pierre and Miquelon" >Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines" >Saint Vincent and the Grenadines</option><option value="Samoa" >Samoa</option><option value="San Marino" >San Marino</option><option value="Sao Tome and Principe" >Sao Tome and Principe</option><option value="Saudi Arabia" >Saudi Arabia</option><option value="Senegal" >Senegal</option><option value="Serbia" >Serbia</option><option value="Seychelles" >Seychelles</option><option value="Sierra Leone" >Sierra Leone</option><option value="Singapore" >Singapore</option><option value="Sint Maarten" >Sint Maarten</option><option value="Slovakia" >Slovakia</option><option value="Slovenia" >Slovenia</option><option value="Solomon Islands" >Solomon Islands</option><option value="Somalia" >Somalia</option><option value="South Africa" >South Africa</option><option value="South Georgia" >South Georgia</option><option value="South Korea" >South Korea</option><option value="South Sudan" >South Sudan</option><option value="Spain" >Spain</option><option value="Sri Lanka" >Sri Lanka</option><option value="Sudan" >Sudan</option><option value="Suriname" >Suriname</option><option value="Svalbard and Jan Mayen Islands" >Svalbard and Jan Mayen Islands</option><option value="Sweden" >Sweden</option><option value="Switzerland" >Switzerland</option><option value="Syria" >Syria</option><option value="Taiwan" >Taiwan</option><option value="Tajikistan" >Tajikistan</option><option value="Tanzania" >Tanzania</option><option value="Thailand" >Thailand</option><option value="Timor-Leste" >Timor-Leste</option><option value="Togo" >Togo</option><option value="Tokelau" >Tokelau</option><option value="Tonga" >Tonga</option><option value="Trinidad and Tobago" >Trinidad and Tobago</option><option value="Tunisia" >Tunisia</option><option value="Turkey" >Turkey</option><option value="Turkmenistan" >Turkmenistan</option><option value="Turks and Caicos Islands" >Turks and Caicos Islands</option><option value="Tuvalu" >Tuvalu</option><option value="Uganda" >Uganda</option><option value="Ukraine" >Ukraine</option><option value="United Arab Emirates" >United Arab Emirates</option><option value="United Kingdom" >United Kingdom</option><option value="United States" selected >United States</option><option value="Uruguay" >Uruguay</option><option value="US Minor Outlying Islands" >US Minor Outlying Islands</option><option value="Uzbekistan" >Uzbekistan</option><option value="Vanuatu" >Vanuatu</option><option value="Venezuela" >Venezuela</option><option value="Vietnam" >Vietnam</option><option value="Virgin Islands, British" >Virgin Islands, British</option><option value="Virgin Islands, U.S." >Virgin Islands, U.S.</option><option value="Wallis and Futuna" >Wallis and Futuna</option><option value="Western Sahara" >Western Sahara</option><option value="Yemen" >Yemen</option><option value="Zambia" >Zambia</option><option value="Zimbabwe" >Zimbabwe</option></select><div class="select-arrow"><svg width="12" height="8" viewBox="0 0 12 8" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M1.5 1.75L6 6.25L10.5 1.75" stroke="#6D6D6D" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"/> </svg></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-12{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-12 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-12{width:50% !important;order : 0;}.fusion-builder-column-12 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-12{width:100% !important;order : 0;}.fusion-builder-column-12 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-13 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="dl">Driver License/State ID #</label></div><input type="text" name="dl" id="dl" value="" class="fusion-form-input" placeholder="Required for order fulfillment" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-13{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-13 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-13{width:50% !important;order : 0;}.fusion-builder-column-13 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-13{width:100% !important;order : 0;}.fusion-builder-column-13 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-14 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-select-field fusion-form-label-above" data-form-id="31998"><label for="dl_s">ID State Issued by</label><div class="fusion-select-wrapper"><select tabindex="" id="dl_s" name="dl_s" class="fusion-form-input" data-holds-private-data="false"><option value="Alabama" >Alabama</option><option value="Alaska" >Alaska</option><option value="Arizona" >Arizona</option><option value="Arkansas" >Arkansas</option><option value="California" >California</option><option value="Colorado" >Colorado</option><option value="Connecticut" >Connecticut</option><option value="Delaware" >Delaware</option><option value="District Of Columbia" >District Of Columbia</option><option value="Florida" >Florida</option><option value="Georgia" >Georgia</option><option value="Hawaii" >Hawaii</option><option value="Idaho" >Idaho</option><option value="Illinois" >Illinois</option><option value="Indiana" >Indiana</option><option value="Iowa" >Iowa</option><option value="Kansas" >Kansas</option><option value="Kentucky" >Kentucky</option><option value="Louisiana" >Louisiana</option><option value="Maine" >Maine</option><option value="Maryland" >Maryland</option><option value="Massachusetts" >Massachusetts</option><option value="Michigan" >Michigan</option><option value="Minnesota" >Minnesota</option><option value="Mississippi" >Mississippi</option><option value="Missouri" >Missouri</option><option value="Montana" >Montana</option><option value="Nebraska" >Nebraska</option><option value="Nevada" >Nevada</option><option value="New Hampshire" >New Hampshire</option><option value="New Jersey" >New Jersey</option><option value="New Mexico" >New Mexico</option><option value="New York" >New York</option><option value="North Carolina" >North Carolina</option><option value="North Dakota" >North Dakota</option><option value="Ohio" >Ohio</option><option value="Oklahoma" >Oklahoma</option><option value="Oregon" >Oregon</option><option value="Pennsylvania" >Pennsylvania</option><option value="Rhode Island" >Rhode Island</option><option value="South Carolina" >South Carolina</option><option value="South Dakota" >South Dakota</option><option value="Tennessee" >Tennessee</option><option value="Texas" >Texas</option><option value="Utah" >Utah</option><option value="Vermont" >Vermont</option><option value="Virginia" >Virginia</option><option value="Washington" >Washington</option><option value="West Virginia" >West Virginia</option><option value="Wisconsin" >Wisconsin</option><option value="Wyoming" >Wyoming</option><option value="Armed Forces (AA)" >Armed Forces (AA)</option><option value="Armed Forces (AE)" >Armed Forces (AE)</option><option value="Armed Forces (AP)" >Armed Forces (AP)</option></select><div class="select-arrow"><svg width="12" height="8" viewBox="0 0 12 8" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M1.5 1.75L6 6.25L10.5 1.75" stroke="#6D6D6D" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"/> </svg></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-14{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-14 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-14{width:50% !important;order : 0;}.fusion-builder-column-14 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-14{width:100% !important;order : 0;}.fusion-builder-column-14 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-15 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="e_c">Emergency Contact Name</label></div><input type="text" name="e_c" id="e_c" value="" class="fusion-form-input" placeholder="First and Last" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-15{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-15 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-15{width:50% !important;order : 0;}.fusion-builder-column-15 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-15{width:100% !important;order : 0;}.fusion-builder-column-15 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-16 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-phone-number-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="e_p">Emergency Contact Phone #</label></div><div class="fusion-form-input-with-icon"><i class="fa-phone-square-alt fas"></i><input type="phone-number" name="e_p" id="e_p" value="" class="fusion-form-input" data-holds-private-data="false" pattern="[0-9()#&+*-=.]+" title="Only numbers and phone characters are accepted."/></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-16{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-16 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-16{width:50% !important;order : 0;}.fusion-builder-column-16 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-16{width:100% !important;order : 0;}.fusion-builder-column-16 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-17 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-select-field fusion-form-label-above" data-form-id="31998"><label for="gender">Gender</label><div class="fusion-select-wrapper"><select tabindex="" id="gender" name="gender" class="fusion-form-input" data-holds-private-data="false"><option value="select one" selected >select one</option><option value="male" >Male</option><option value="female" >Female</option></select><div class="select-arrow"><svg width="12" height="8" viewBox="0 0 12 8" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M1.5 1.75L6 6.25L10.5 1.75" stroke="#6D6D6D" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"/> </svg></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-17{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-17 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-17{width:100% !important;order : 0;}.fusion-builder-column-17 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-17{width:100% !important;order : 0;}.fusion-builder-column-17 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-18 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#070707;padding: 0px 0px 0px 0px;"><div class="fusion-text fusion-text-5"><h3 style="font-family: Montserrat; font-weight: 400; font-size: 20px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">Personal Health History</h3> </div></div><style type="text/css">.fusion-body .fusion-builder-column-18{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-18 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-18{width:100% !important;order : 0;}.fusion-builder-column-18 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-18{width:100% !important;order : 0;}.fusion-builder-column-18 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-19 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="med_his">Medical History</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="med_his" name="med_his" class="fusion-form-input" data-holds-private-data="false"></textarea></div><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="mh_og">Current Medical Issues</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="mh_og" name="mh_og" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-19{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-19 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-19{width:100% !important;order : 0;}.fusion-builder-column-19 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-19{width:100% !important;order : 0;}.fusion-builder-column-19 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-20 fusion_builder_column_1_2 1_2 fusion-flex-column fusion-flex-align-self-stretch"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-end fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="pcp">Primary Care Provider</label></div><input type="text" name="pcp" id="pcp" value="" class="fusion-form-input" placeholder="First Last" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-20{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-20 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-20{width:50% !important;order : 0;}.fusion-builder-column-20 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-20{width:100% !important;order : 0;}.fusion-builder-column-20 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-21 fusion_builder_column_1_2 1_2 fusion-flex-column fusion-flex-align-self-stretch"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-end fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-phone-number-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="pcp_p">Primary Care Phone #</label></div><div class="fusion-form-input-with-icon"><i class="fa-phone-square-alt fas"></i><input type="phone-number" name="pcp_p" id="pcp_p" value="" class="fusion-form-input" data-holds-private-data="false" pattern="[0-9()#&+*-=.]+" title="Only numbers and phone characters are accepted."/></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-21{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-21 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-21{width:50% !important;order : 0;}.fusion-builder-column-21 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-21{width:100% !important;order : 0;}.fusion-builder-column-21 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-22 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="pcp_add">PCP Address</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="pcp_add" name="pcp_add" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-22{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-22 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-22{width:100% !important;order : 0;}.fusion-builder-column-22 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-22{width:100% !important;order : 0;}.fusion-builder-column-22 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-23 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="mh_cpm">Current Prescription Medications </label><textarea cols="40" minlength="0" rows="4" tabindex="" id="mh_cpm" name="mh_cpm" class="fusion-form-input" placeholder="List them here" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-23{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-23 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-23{width:100% !important;order : 0;}.fusion-builder-column-23 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-23{width:100% !important;order : 0;}.fusion-builder-column-23 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-24 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="mh_otc">Current over the counter medications?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="mh_otc" name="mh_otc" class="fusion-form-input" placeholder="List them here" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-24{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-24 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-24{width:100% !important;order : 0;}.fusion-builder-column-24 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-24{width:100% !important;order : 0;}.fusion-builder-column-24 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-25 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="mh_all">Do you have allergies?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="mh_all" name="mh_all" class="fusion-form-input" placeholder="List them here" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-25{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-25 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-25{width:100% !important;order : 0;}.fusion-builder-column-25 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-25{width:100% !important;order : 0;}.fusion-builder-column-25 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-26 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="mh_ps">Have you had any prior surgeries?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="mh_ps" name="mh_ps" class="fusion-form-input" placeholder="List them here" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-26{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-26 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-26{width:100% !important;order : 0;}.fusion-builder-column-26 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-26{width:100% !important;order : 0;}.fusion-builder-column-26 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-27 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-checkbox-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Do you have issues with Anxiety, Sleep, or Sexual Performance?</span></div><fieldset><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-mh_sas-1-0" type="checkbox" value="Anxiety" name="mh_sas[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-mh_sas-1-0">Anxiety</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-mh_sas-1-1" type="checkbox" value="Sleeping Difficulties" name="mh_sas[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-mh_sas-1-1">Sleeping Difficulties</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-mh_sas-1-2" type="checkbox" value="Sexual Difficulties" name="mh_sas[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-mh_sas-1-2">Sexual Difficulties</label></div></fieldset></div></div><style type="text/css">.fusion-body .fusion-builder-column-27{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-27 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-27{width:100% !important;order : 0;}.fusion-builder-column-27 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-27{width:100% !important;order : 0;}.fusion-builder-column-27 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-28 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="fam_his">Medical history of first degree relatives (mother, father, sisters, brothers)?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="fam_his" name="fam_his" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-28{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-28 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-28{width:100% !important;order : 0;}.fusion-builder-column-28 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-28{width:100% !important;order : 0;}.fusion-builder-column-28 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-29 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-checkbox-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Do you suffer from any of the following conditions? (select all that apply)</span></div><fieldset><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-0" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-0">Decrease in Libido (sex drive)</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-1" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-1">Lack of Energy</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-2" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-2">Decrease in Strength and/or Endurance</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-3" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-3">Lost Height</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-4" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-4">Sad and/or Grumpy</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-5" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-5">Erections Less Strong</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-6" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-6">Recent Deterioration in Ability to Play Sports</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-7" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-7">Recent Deterioration in Work Performance</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-8" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-8">Falling Asleep Shortly After Dinner</label></div></fieldset></div><div class="fusion-form-field fusion-form-number-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="m_freq">Frequency of night urination (times per night)</label></div><input type="number" name="m_freq" id="m_freq" value="" class="fusion-form-input" data-holds-private-data="false" min="0" max="10"/></div><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Are you experiancing difficulty completing urination?</span></div><fieldset><div class="fusion-form-radio"><input tabindex="" id="radio-e_urine-1-0" type="radio" value="YES" name="e_urine" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-e_urine-1-0">YES</label></div><div class="fusion-form-radio"><input tabindex="" id="radio-e_urine-1-1" type="radio" value="NO" name="e_urine" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-e_urine-1-1">NO</label></div></fieldset></div><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Have you recently noticed any lumps, swelling, tenderness or pain in your testicles?</span></div><fieldset><div class="fusion-form-radio"><input tabindex="" id="radio-m_lump-2-0" type="radio" value="YES" name="m_lump" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-m_lump-2-0">YES</label></div><div class="fusion-form-radio"><input tabindex="" id="radio-m_lump-2-1" type="radio" value="NO" name="m_lump" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-m_lump-2-1">NO</label></div></fieldset></div><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><label for="m_pros">Results from your last prostate exam (if applicable)</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="m_pros" name="m_pros" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-29{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-29 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-29{width:100% !important;order : 0;}.fusion-builder-column-29 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-29{width:100% !important;order : 0;}.fusion-builder-column-29 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-30 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-checkbox-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Do you suffer from any of the following conditions? (select all that apply)</span></div><fieldset><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-0" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-0">Hot Flashes</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-1" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-1">Lack of Energy</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-2" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-2">Diminished Sex Drive</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-3" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-3">Decreased Enjoyment of Life</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-4" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-4">Moody or Easily Irritated</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-5" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-5">Difficulty concentrating / shot-term memory loss</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-6" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-6">Muscle Loss</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-7" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-7">Bladder Leakage</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-8" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-8">Excess Bodyfat</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-9" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-9">Restless Sleep / Sleep Disturbances</label></div></fieldset></div><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Do you suffer from heavy, irregular or painful periods?</span></div><fieldset><div class="fusion-form-radio"><input tabindex="" id="radio-w_hp-3-0" type="radio" value="YES" name="w_hp" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_hp-3-0">YES</label></div><div class="fusion-form-radio"><input tabindex="" id="radio-w_hp-3-1" type="radio" value="NO" name="w_hp" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_hp-3-1">NO</label></div></fieldset></div><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><label for="w_if_hp">Please list symptoms</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="w_if_hp" name="w_if_hp" class="fusion-form-input" data-holds-private-data="false"></textarea></div><div class="fusion-form-field fusion-form-date-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><label for="w_mp">Date of last menstrual period</label><input autocomplete="no" type="date" data-format="" tabindex="" id="w_mp" name="w_mp" data-type="custom" value="" data-holds-private-data="false" class="fusion-form-input"autocomplete="no"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-30{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-30 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-30{width:100% !important;order : 0;}.fusion-builder-column-30 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-30{width:100% !important;order : 0;}.fusion-builder-column-30 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-31 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Are you currently pregnant or breastfeeding?</span></div><fieldset><div class="fusion-form-radio"><input tabindex="" id="radio-w_preg-4-0" type="radio" value="YES" name="w_preg" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_preg-4-0">YES</label></div><div class="fusion-form-radio"><input tabindex="" id="radio-w_preg-4-1" type="radio" value="NO" name="w_preg" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_preg-4-1">NO</label></div></fieldset></div></div><style type="text/css">.fusion-body .fusion-builder-column-31{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-31 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-31{width:50% !important;order : 0;}.fusion-builder-column-31 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-31{width:100% !important;order : 0;}.fusion-builder-column-31 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-32 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-number-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="w_num_p">Number of Pregnancies</label></div><input type="number" name="w_num_p" id="w_num_p" value="" class="fusion-form-input" data-holds-private-data="false" min="0" max="10"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-32{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-32 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-32{width:50% !important;order : 0;}.fusion-builder-column-32 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-32{width:100% !important;order : 0;}.fusion-builder-column-32 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-33 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><label for="conceive">Do you have plans to conceive soon? If no, what are you using for birth control?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="conceive" name="conceive" class="fusion-form-input" data-holds-private-data="false"></textarea></div><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Do you suffer from frequent bladder or kidney infections?</span></div><fieldset><div class="fusion-form-radio"><input tabindex="" id="radio-w_blad-5-0" type="radio" value="YES" name="w_blad" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_blad-5-0">YES</label></div><div class="fusion-form-radio"><input tabindex="" id="radio-w_blad-5-1" type="radio" value="NO" name="w_blad" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_blad-5-1">NO</label></div></fieldset></div><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Have you recently note any breast lumps, tenderness, pain or nipple discharge?</span></div><fieldset><div class="fusion-form-radio"><input tabindex="" id="radio-w_lump-6-0" type="radio" value="YES" name="w_lump" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_lump-6-0">YES</label></div><div class="fusion-form-radio"><input tabindex="" id="radio-w_lump-6-1" type="radio" value="NO" name="w_lump" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_lump-6-1">NO</label></div></fieldset></div><div class="fusion-form-field fusion-form-date-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><label for="w_pap">Date of last pap smear</label><input autocomplete="no" type="date" data-format="" tabindex="" id="w_pap" name="w_pap" data-type="custom" value="" data-holds-private-data="false" class="fusion-form-input"autocomplete="no"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-33{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-33 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-33{width:100% !important;order : 0;}.fusion-builder-column-33 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-33{width:100% !important;order : 0;}.fusion-builder-column-33 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-34 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#070707;padding: 0px 0px 0px 0px;"><div class="fusion-text fusion-text-6"><h3 style="font-family: Montserrat; font-weight: 400; font-size: 20px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">Health Habits</h3> </div></div><style type="text/css">.fusion-body .fusion-builder-column-34{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-34 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-34{width:100% !important;order : 0;}.fusion-builder-column-34 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-34{width:100% !important;order : 0;}.fusion-builder-column-34 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-35 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="hh_ex">Current exercise regimen</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="hh_ex" name="hh_ex" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-35{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-35 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-35{width:100% !important;order : 0;}.fusion-builder-column-35 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-35{width:100% !important;order : 0;}.fusion-builder-column-35 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-36 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="hh_diet">Current diet model?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="hh_diet" name="hh_diet" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-36{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-36 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-36{width:100% !important;order : 0;}.fusion-builder-column-36 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-36{width:100% !important;order : 0;}.fusion-builder-column-36 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-37 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="hh_caf">Current caffeine intake?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="hh_caf" name="hh_caf" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-37{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-37 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-37{width:100% !important;order : 0;}.fusion-builder-column-37 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-37{width:100% !important;order : 0;}.fusion-builder-column-37 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-38 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="hh_tob">Tobacco intake?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="hh_tob" name="hh_tob" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-38{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-38 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-38{width:100% !important;order : 0;}.fusion-builder-column-38 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-38{width:100% !important;order : 0;}.fusion-builder-column-38 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-39 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="hh_mj">Marijuana intake?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="hh_mj" name="hh_mj" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-39{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-39 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-39{width:100% !important;order : 0;}.fusion-builder-column-39 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-39{width:100% !important;order : 0;}.fusion-builder-column-39 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-40 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Illegal drug use?</span></div><fieldset><div class="fusion-form-radio option-inline"><input tabindex="" id="radio-hh_drug-7-0" type="radio" value="YES" name="hh_drug" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-hh_drug-7-0">YES</label></div><div class="fusion-form-radio option-inline"><input tabindex="" id="radio-hh_drug-7-1" type="radio" value="NO" name="hh_drug" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-hh_drug-7-1">NO</label></div></fieldset></div><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><label for="hh_use">Recreational drug intake? What? How often?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="hh_use" name="hh_use" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-40{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-40 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-40{width:100% !important;order : 0;}.fusion-builder-column-40 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-40{width:100% !important;order : 0;}.fusion-builder-column-40 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-41 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#070707;padding: 0px 0px 0px 0px;"><div class="fusion-text fusion-text-7"><h3 style="font-family: Montserrat; font-weight: 400; font-size: 20px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">Goals</h3> </div></div><style type="text/css">.fusion-body .fusion-builder-column-41{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-41 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-41{width:100% !important;order : 0;}.fusion-builder-column-41 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-41{width:100% !important;order : 0;}.fusion-builder-column-41 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-42 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-checkbox-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">What are you interested in?</span></div><fieldset><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-0" type="checkbox" value="Hormone optimization" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-0">Hormone optimization</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-1" type="checkbox" value="Cognitive enhancement" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-1">Cognitive enhancement</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-2" type="checkbox" value="Sexual enhancement" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-2">Sexual enhancement</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-3" type="checkbox" value="Sleep optimization" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-3">Sleep optimization</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-4" type="checkbox" value="Longevity" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-4">Longevity</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-5" type="checkbox" value="Anti-ageing" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-5">Anti-ageing</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-6" type="checkbox" value="Fat Loss" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-6">Fat Loss</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-7" type="checkbox" value="Hair loss" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-7">Hair loss</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-8" type="checkbox" value="Injury recovery" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-8">Injury recovery</label></div></fieldset></div><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="other">Other</label></div><input type="text" name="other" id="other" value="" class="fusion-form-input" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-42{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-42 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-42{width:100% !important;order : 0;}.fusion-builder-column-42 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-42{width:100% !important;order : 0;}.fusion-builder-column-42 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-43 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="g_d">What does your dream outcome working with Marek Health look like?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="g_d" name="g_d" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-43{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-43 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-43{width:100% !important;order : 0;}.fusion-builder-column-43 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-43{width:100% !important;order : 0;}.fusion-builder-column-43 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-44 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-select-field fusion-form-label-above" data-form-id="31998"><label for="g_b">How much per year can you commit towards your dream outcome? <abbr class="fusion-form-element-required" title="required">*</abbr></label><div class="fusion-select-wrapper"><select tabindex="" id="g_b" name="g_b" class="fusion-form-input" required="true" aria-required="true" data-holds-private-data="false"><option value="$1000-2000" >$1000-2000</option><option value="$2000-3000" >$2000-3000</option><option value="$4000-6000" >$4000-6000</option><option value="$6000-10000" >$6000-10000</option><option value="$10000+" >$10000+</option></select><div class="select-arrow"><svg width="12" height="8" viewBox="0 0 12 8" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M1.5 1.75L6 6.25L10.5 1.75" stroke="#6D6D6D" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"/> </svg></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-44{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-44 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-44{width:100% !important;order : 0;}.fusion-builder-column-44 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-44{width:100% !important;order : 0;}.fusion-builder-column-44 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-45 fusion_builder_column_1_1 1_1 fusion-flex-column file-up-div"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-upload-field fusion-form-label-above" data-form-id="31998"><label for="physical">Physical Exam Documents</label><div class="fusion-form-input-with-icon"><i class=" fa-upload fas"></i><div class="fusion-form-upload-field-container"><input type="file" id="physical" name="physical" value="" class="fusion-form-input" placeholder="Click or drag a file to this area to upload." data-size="20"/><input type="text" disabled value="" class="fusion-form-upload-field" placeholder="Click or drag a file to this area to upload." data-holds-private-data="false"/><div ><style>.fusion-button.button-1{border-radius:0px 0px 0px 0px;}</style><a class="fusion-button button-flat button-medium button-default button-1 fusion-button-default-span fusion-button-default-type fusion-form-upload-field-button" target="_self" href="javascript:void();"><span class="fusion-button-text">Choose File</span></a></div></div></div></div><div id="labwork" class="fusion-form-field fusion-form-upload-field fusion-form-label-above" data-form-id="31998"><label for="labs">Upload Diagnostic Labwork Results</label><div class="fusion-form-input-with-icon"><i class=" fa-upload fas"></i><div class="fusion-form-upload-field-container"><input type="file" id="labs" name="labs" value="" class="fusion-form-input" placeholder="Click or drag a file to this area to upload." data-size="18"/><input type="text" disabled value="" class="fusion-form-upload-field" placeholder="Click or drag a file to this area to upload." data-holds-private-data="false"/><div ><style>.fusion-button.button-2{border-radius:0px 0px 0px 0px;}</style><a class="fusion-button button-flat button-medium button-default button-2 fusion-button-default-span fusion-button-default-type fusion-form-upload-field-button" target="_self" href="javascript:void();"><span class="fusion-button-text">Choose File</span></a></div></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-45{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-45 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-45{width:100% !important;order : 0;}.fusion-builder-column-45 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-45{width:100% !important;order : 0;}.fusion-builder-column-45 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-46 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-checkbox-field fusion-form-label-above" data-form-id="31998"><fieldset><div class="fusion-form-checkbox option-inline"><input tabindex="" id="checkbox-legal_agree-5-0" type="checkbox" value="agree" name="legal_agree[]" class="fusion-form-input" required="true" aria-required="true" data-holds-private-data="false"/><label for="checkbox-legal_agree-5-0">I have read, understand, and agree with the <a href="https://marekhealth.com/terms-and-conditions/" target="_blank" style="text-decoration: underline; ">terms</a>, <a href="https://marekhealth.com/privacy" target="_blank" style="text-decoration: underline; ">privacy policy</a>, <a href="#" target="_blank" style="text-decoration: underline; ">notice of direct pay</a>, and <a href="#" target="_blank" style="text-decoration: underline; ">consent to telemedecine</a>.</label></div></fieldset></div><div id="submitBtn" class="fusion-form-field fusion-form-submit-field fusion-form-label-above" data-form-id="31998"><div style="text-align:center;"><style>.fusion-button.button-3{border-radius:0px 0px 0px 0px;}</style><button type="submit" class="fusion-button button-flat fusion-button-default-size button-default button-3 fusion-button-span-no form-form-submit button-default" data-form-number="31998" id="submitBtn" tabindex=""><span class="fusion-button-text">Submit</span></button></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-46{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-46 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-46{width:100% !important;order : 0;}.fusion-builder-column-46 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-46{width:100% !important;order : 0;}.fusion-builder-column-46 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div></div><style type="text/css">.fusion-body .fusion-flex-container.fusion-builder-row-1{ padding-top : 0px;margin-top : 50PX;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}</style></div><div class="fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container submitThanks nonhundred-percent-fullwidth non-hundred-percent-height-scrolling" style="background-color: #070707;background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;" id="submitThanks" ><div class="fusion-builder-row fusion-row fusion-flex-align-items-flex-start" style="max-width:1248px;margin-left: calc(-4% / 2 );margin-right: calc(-4% / 2 );"><div class="fusion-layout-column fusion_builder_column fusion-builder-column-47 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-separator" style="align-self: center;margin-left: auto;margin-right: auto;width:100%;max-width:10px;"><div class="fusion-separator-border sep-double" style="border-color:#e0dede;border-top-width:1px;border-bottom-width:1px;"></div></div><div class="fusion-text fusion-text-8" style="text-align:center;"><h4 style="text-align: center;">Thanks for your submission</h4> <h4 style="text-align: center;">We are generating your intake paperwork for signature below.</h4> </div></div><style type="text/css">.fusion-body .fusion-builder-column-47{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-47 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-47{width:100% !important;order : 0;}.fusion-builder-column-47 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-47{width:100% !important;order : 0;}.fusion-builder-column-47 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-48 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div ><span class=" fusion-imageframe imageframe-none imageframe-1 hover-type-none loading-gif" id="loading-gif"><img width="1181" height="1181" title="loading" src="https://marekhealth.com/wp-content/uploads/2021/11/loading.gif" alt class="img-responsive wp-image-31710"/></span></div><iframe id="pandaFrame" width='100%' height='425px' frameBorder="0"></iframe> <script> window.addEventListener('message', (event) => { const type = event.data && event.data.type; const payload = event.data && event.data.payload; switch (type) { case 'session_view.document.loaded': console.log('Session view is loaded'); break; case 'session_view.document.completed': console.log('Document is completed'); console.log(payload); break; case 'session_view.document.exception': console.log('Exception during document finalization'); console.log(payload); } }); </script></div><style type="text/css">.fusion-body .fusion-builder-column-48{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-48 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-48{width:50% !important;order : 0;}.fusion-builder-column-48 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-48{width:100% !important;order : 0;}.fusion-builder-column-48 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-49 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-text fusion-text-9" style="text-align:center;"><h3 style="text-align: center;">After Signing the Document</h3> </div><div style="text-align:center;"><style>.fusion-button.button-4{border-radius:0px 0px 0px 0px;}</style><a class="fusion-button button-flat fusion-button-default-size button-default button-4 fusion-button-default-span fusion-button-default-type" target="_self" href="https://bookings.marekhealth.com/#/customer/paidintake"><span class="fusion-button-text">Book Intake Meeting</span></a></div></div><style type="text/css">.fusion-body .fusion-builder-column-49{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-49 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-49{width:50% !important;order : 0;}.fusion-builder-column-49 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-49{width:100% !important;order : 0;}.fusion-builder-column-49 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div></div><style type="text/css">.fusion-body .fusion-flex-container.fusion-builder-row-2{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}</style></div><input type="hidden" name="fusion_privacy_store_ip_ua" value="false"><input type="hidden" name="fusion_privacy_expiration_interval" value="48"><input type="hidden" name="privacy_expiration_action" value="anonymize"></form></div>
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