(383,'nf_form_22_publishing_3','rm__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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":18,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:relationship_to_patient_1635814160917}\",\"field_map\":\"Form__c - Relationship to Patient\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":19,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:phone_1635814170369}\",\"field_map\":\"Form__c - Emergency Phone\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":20,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:email_1635814199238}\",\"field_map\":\"Form__c - Emergency Email\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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? 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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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":21,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:allergies_1635814213453}\",\"field_map\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":22,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:city_1578075946838}\",\"field_map\":\"Form__c - City\",\"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\",\"va'),(384,'nf_form_22_publishing_4','lue\":\"Form__c - Title\"},{\"label\":\"Form__c - Account\",\"value\":\"Form__c - Account\"},{\"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 - 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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 - 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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 - 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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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":23,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:state_1578075979677}\",\"field_map\":\"Form__c - State\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":23,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:any_additional_issues_we_should_be_aware_of_1635814246528}\",\"field_map\":\"Form__c - Any additional issue of new patient\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":24,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:preferred_pharmacy_1635814374925}\",\"field_map\":\"Form__c - Preferred Pharmacy\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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? 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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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":25,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:listcountry_1578076020448}\",\"field_map\":\"Form__c - Country\",\"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 - 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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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":26,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:primary_phone_1578076148286}\",\"field_map\":\"Form__c - Primary Phone\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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? 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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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":26,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:location_phone_number_1635964802168}\",\"field_map\":\"Form__c - Preferred pharmacy Location/phone number\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":27,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:email_1578076138596}\",\"field_map\":\"Form__c - Email\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":27,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:primary_doctor_-_location_phone_number_1636037238631}\",\"field_map\":\"Form__c - Primarycare doctor location/phone number\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":28,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:race_1635965184686}\",\"field_map\":\"Form__c - Race\",\"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\"},{\"labe'),(389,'nf_form_22_publishing_6','l\":\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":29,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:ethnicity_1635965264111}\",\"field_map\":\"Form__c - Ethnicity\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":30,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:ssn_1635794503698}\",\"field_map\":\"Form__c - Social Security #\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":31,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:street_address_1635814469603}\",\"field_map\":\"Form__c - Street\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":45,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:prior_suicide_attempts_1604626774735}\",\"field_map\":\"Form__c - Prior suicide attempts?\",\"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 - Account\",\"value\":\"Form__c - Account\"},{\"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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer Name\"},{\"label\":\"Form__c - Any medical condition of new patient\",\"value\":\"Form__c - Any medical condition of new patient\"},{\"label\":\"Form__c - Any additional issue of new patient\",\"value\":\"Form__c - Any additional issue of new patient\"},{\"label\":\"Form__c - Preferred pharmacy Location/phone number\",\"value\":\"Form__c - Preferred pharmacy Location/phone number\"},{\"label\":\"Form__c - Primarycare doctor location/phone number\",\"value\":\"Form__c - Primarycare doctor location/phone number\"}]},\"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\":78,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:heart_disease_1604626922511}\",\"field_map\":\"Form__c - Heart disease?\",\"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 - 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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 - 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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 - Account\",\"value\":\"Form__c - Account\"},{\"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? 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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\"},{\"label\":\"Form__c - Opportunity\",\"value\":\"Form__c - Opportunity\"},{\"label\":\"Form__c - Temporary Customer Name\",\"value\":\"Form__c - Temporary Customer 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