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ANR Clinic does not receive financial assistance from taxpayers (the county, city, state or federal government) to support our operations.</p><h3>How does the payment process work?</h3><ol><li>We may contact you to verify your information and what form of payment you would like to use before the service is provided.</li><li>We will then charge you a deposit equal to 50% of the cost of service in order to secure the date of service with the hospital.</li><li>The remaining balance will be reviewed with you and what you will need to pay payment prior to the day of service. Last payment is due no later than 5 days prior to hospital admission. Our office staff is available to discuss any questions you may have about the amount you may owe.</li></ol><h3>Will I know my portion of the bill for the procedure or service?</h3><p>Yes. You may receive an estimate during your pre-registration phone call, or you may ask for an estimate of your procedure at the time. </p><h3>When is my payment due?</h3><p>1. Initial payments (deposits) are due at the time of booking the date of service.</p><p>2. The remaining balance is due 5 days prior to the date of hospital admission.</p><h3>What if I must reschedule my procedure?</h3><p>• We understand that life can be unpredictable, and occasions may arise that the procedure needs to be postponed. In this case we will apply your paid deposit towards the next available treatment date. This will also be the case with any unforeseen circumstances beyond the reasonable control of the patient or provider.</p><p>• In the interest of the safety and welfare of our patients, visitors, and staff we may postpone procedures due to inclement weather or circumstances beyond our control. 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nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide 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(work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:record_type_id_1609419286353}\",\"field_map\":\"Form__c - Record Type ID\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":3,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:lead_record_type_id_1609419300434}\",\"field_map\":\"Form__c - LeadRecordtypeId\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? 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Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":3,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:date_1608653939847}\",\"field_map\":\"Form__c - Financial Policy Date\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - 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Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - 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Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - 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Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":{},\"max_options\":0,\"order\":4,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - 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class=\\\"MsoNormal\\\">Florida law requires that your health care provider or\\nhealth care facility recognize your rights while you are receiving medical care\\nand that you respect the health care provider’ s right to expect certain\\nbehavior on the part of patients. You may request a copy of the full text of\\nthis law from your health care provider or health care facility. A summary of\\nyour rights and responsibilities follows: <o:p></o:p></p><p class=\\\"MsoNormal\\\"><u>You have the right to: <o:p></o:p></u></p><p class=\\\"MsoNormal\\\">• A patient has the right to be treated with courtesy and\\nrespect, with appreciation of his or her individual dignity, and with\\nprotection of his or her need for privacy. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to a prompt and reasonable\\nresponse to questions and requests. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to know who is providing medical\\nservices and who is responsible for his or her care. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to know what patient support\\nservices are available, including whether an interpreter is available if he or\\nshe does not speak English. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to know what rules and regulations\\napply to his or her conduct. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to be given by the health care\\nprovider information concerning diagnosis, planned course of treatment,\\nalternatives, risks, and prognosis. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to refuse any treatment, except as\\notherwise provided by law. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to be given, upon request, full\\ninformation and necessary counseling on the availability of known financial\\nresources for his or her care. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient who is eligible for Medicare has the right to\\nknow, upon request and in advance of treatment, whether the health care\\nprovider or health care facility accepts the Medicare assignment rate. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to receive, upon request, prior to\\ntreatment, a reasonable estimate of charges for medical care. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to receive a copy of a reasonably\\nclear and understandable, itemized bill and, upon request, to have the charges\\nexplained. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to impartial access to medical\\ntreatment or accommodations, regardless of race, national origin, religion,\\nhandicap, or source of payment. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to treatment for any emergency\\nmedical condition that will deteriorate from failure to provide treatment. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to know if medical treatment is\\nfor purposes of experimental research and to give his or her consent or refusal\\nto participate in such experimental research. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient has the right to express grievances regarding\\nany violation of his or her rights, as stated in Florida law, through the\\ngrievance procedure of the health care provider or health care facility which\\nserved him or her and to the appropriate state licensing agency. <o:p></o:p></p><p class=\\\"MsoNormal\\\"><o:p>&nbsp;</o:p><u>You have the responsibility to:</u></p><p class=\\\"MsoNormal\\\">• A patient is responsible for providing to the health care\\nprovider, to the best of his or her knowledge, accurate and complete\\ninformation about present complaints, past illnesses, hospitalizations,\\nmedications, and other matters relating to his or her health. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient is responsible for reporting unexpected changes\\nin his or her condition to the health care provider. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient is responsible for reporting to the health care\\nprovider whether he or she comprehends a contemplated course of action and what\\nis expected of him or her. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient is responsible for following the treatment plan\\nrecommended by the health care provider. • A patient is responsible for his or\\nher actions if he or she refuses treatment or does not follow the health care\\nprovider’s instructions. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient is responsible for assuring that the financial\\nobligations of his or her health care are fulfilled as promptly as possible. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient is responsible for following the Clinic rules\\nand regulations affecting patient care and conduct. <o:p></o:p></p><p class=\\\"MsoNormal\\\">• A patient is responsible for keeping appointments and,\\nwhen he or she is unable to do so for any reason, for notifying the health care\\nprovider. <o:p></o:p></p><p class=\\\"MsoNormal\\\"><o:p>&nbsp;</o:p></p><p>\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n</p><p class=\\\"MsoNormal\\\"><i>The undersigned certifies that he/she has read the\\nforegoing, understands it, accepts its terms, has received a copy of it and is\\nthe patient or is duly authorized by the patient as their agent to execute\\nabove.&nbsp;<br><o:p></o:p>Any form of electronic signature, such as facsimile or email scan, shall be deemed to be an original signature.</i></p>\",\"container_class\":\"\",\"element_class\":\"\",\"key\":\"html_1596588884080\",\"drawerDisabled\":false,\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3362\"},\"id\":\"199\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":2,\"label\":\"Patient’s Signature or Legal Representative \",\"type\":\"firstname\",\"key\":\"patient_s_signature_or_legal_representative_1596589076753\",\"label_pos\":\"below\",\"required\":1,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"one-half 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Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or 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(work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:record_type_id_1609748077008}\",\"field_map\":\"Form__c - Record Type ID\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":3,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:lead_record_type_id_1609748094863}\",\"field_map\":\"Form__c - LeadRecordtypeId\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":3,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:patient_s_signature_or_legal_representative_1596589076753}\",\"field_map\":\"Form__c - Customer Name\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":{},\"max_options\":0,\"order\":4,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - 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Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - 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PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{'),(241,'nf_form_11_publishing_1','\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - 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Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"February\",\"value\":\"February\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"March\",\"value\":\"March\",\"calc\":\"\",\"selected\":0,\"order\":2,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":3,\"new\":false,\"options\":[],\"label\":\"April\",\"value\":\"April\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":6,\"new\":false,\"options\":[],\"label\":\"July\",\"value\":\"July\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":7,\"new\":false,\"options\":[],\"label\":\"August\",\"value\":\"August\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":10,\"new\":false,\"options\":[],\"label\":\"November\",\"value\":\"November\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":11,\"new\":false,\"options\":[],\"label\":\"December\",\"value\":\"December\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"<p>* 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Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"3\",\"value\":\"3\",\"calc\":\"\",\"selected\":0,\"order\":2,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":3,\"new\":false,\"options\":[],\"label\":\"4\",\"value\":\"4\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra 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class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":7,\"new\":false,\"options\":[],\"label\":\"8\",\"value\":\"8\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":8,\"new\":false,\"options\":[],\"label\":\"9\",\"value\":\"9\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":9,\"new\":false,\"options\":[],\"label\":\"10\",\"value\":\"10\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":10,\"new\":false,\"options\":[],\"label\":\"11\",\"value\":\"11\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":11,\"new\":false,\"options\":[],\"label\":\"12\",\"value\":\"12\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":12,\"new\":false,\"options\":[],\"label\":\"13\",\"value\":\"13\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":13,\"new\":false,\"options\":[],\"label\":\"14\",\"value\":\"14\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":14,\"new\":false,\"options\":[],\"label\":\"15\",\"value\":\"15\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":15,\"new\":false,\"options\":[],\"label\":\"16\",\"value\":\"16\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":16,\"new\":false,\"options\":[],\"label\":\"17\",\"value\":\"17\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":17,\"new\":false,\"options\":[],\"label\":\"18\",\"value\":\"18\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":18,\"new\":false,\"options\":[],\"label\":\"19\",\"value\":\"19\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":19,\"new\":false,\"options\":[],\"label\":\"20\",\"value\":\"20\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":20,\"new\":false,\"options\":[],\"label\":\"21\",\"value\":\"21\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc 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Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":22,\"new\":false,\"options\":[],\"label\":\"23\",\"value\":\"23\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":23,\"new\":false,\"options\":[],\"label\":\"24\",\"value\":\"24\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":24,\"new\":false,\"options\":[],\"label\":\"25\",\"value\":\"25\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":27,\"new\":false,\"options\":[],\"label\":\"28\",\"value\":\"28\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":28,\"new\":false,\"options\":[],\"label\":\"29\",\"value\":\"29\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":29,\"new\":false,\"options\":[],\"label\":\"30\",\"value\":\"30\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Male\",\"value\":\"male\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"Female\",\"value\":\"Female\",\"calc\":\"\",\"selected\":0,\"order\":2,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true}],\"container_class\":\"\",\"element_class\":\"req\",\"admin_label\":\"\",\"help_text\":\"\",\"drawerDisabled\":\"\",\"desc_text\":\"<p>* 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Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Single\",\"value\":\"Single\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"Married\",\"value\":\"Married\",\"calc\":\"\",\"selected\":0,\"order\":2,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra 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aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No\",\"value\":\"No\",\"calc\":\"\",\"selected\":0,\"order\":2,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"drawerDisabled\":\"\",\"desc_text\":\"<p>* Required<br></p>\",\"wrap_styles_show_advanced_css\":\"0\",\"label_styles_show_advanced_css\":\"0\",\"element_styles_show_advanced_css\":\"0\",\"cellcid\":\"c4448\",\"field_label\":\"Kidney disease / 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