-- Table structure for table `wp_nf3_fields`
--

CREATE TABLE `wp_nf3_fields` (
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  `field_label` longtext,
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  `required` bit(1) DEFAULT NULL,
  `default_value` longtext,
  `label_pos` varchar(15) DEFAULT NULL,
  `personally_identifiable` bit(1) DEFAULT NULL,
  UNIQUE KEY `id` (`id`)
) ENGINE=MyISAM AUTO_INCREMENT=1157 DEFAULT CHARSET=utf8mb4;

--
-- Dumping data for table `wp_nf3_fields`
--

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disease?</h3>','',_binary ''),(123,'Lung disease?','lung_disease_1604626931227','listselect',3,'2021-10-06 13:06:24',NULL,'Lung disease?','lung_disease_1604626931227',109,_binary '','','default',_binary ''),(124,'Please specify ','please_specify_1605028416339','textarea',3,'2021-10-06 13:06:24',NULL,'Please specify ','please_specify_1605028416339',110,_binary '','','default',_binary ''),(125,'Liver disease / infections?','liver_disease_infections_1578158255415','html',3,'2021-10-06 13:06:24',NULL,'Liver disease / infections?','liver_disease_infections_1578158255415',111,_binary '','<h3>Liver disease / infections?</h3>','',_binary ''),(126,'Liver disease / infections?','liver_disease_infections_1604626937884','listselect',3,'2021-10-06 13:06:24',NULL,'Liver disease / infections?','liver_disease_infections_1604626937884',112,_binary '','','default',_binary ''),(127,'Please specify','please_specify_1605028412732','textarea',3,'2021-10-06 13:06:24',NULL,'Please specify','please_specify_1605028412732',113,_binary '','','default',_binary ''),(128,'Kidney disease / problem?','kidney_disease_problem_1578158304108','html',3,'2021-10-06 13:06:24',NULL,'Kidney disease / problem?','kidney_disease_problem_1578158304108',114,_binary '','<h3>Kidney disease / problem?</h3>','',_binary ''),(129,'Kidney disease / problem?','kidney_disease_problem_1604626946354','listselect',3,'2021-10-06 13:06:24',NULL,'Kidney disease / problem?','kidney_disease_problem_1604626946354',115,_binary '','','default',_binary ''),(130,'Please specify','please_specify_1605028409028','textarea',3,'2021-10-06 13:06:24',NULL,'Please specify','please_specify_1605028409028',116,_binary '','','default',_binary ''),(131,'Diabetes?','diabetes_1578158392415','html',3,'2021-10-06 13:06:24',NULL,'Diabetes?','diabetes_1578158392415',117,_binary '','<h3>Diabetes?</h3>','',_binary ''),(132,'Diabetes?','diabetes_1604626953114','listselect',3,'2021-10-06 13:06:24',NULL,'Diabetes?','diabetes_1604626953114',118,_binary '','','default',_binary ''),(133,'Please specify ','please_specify_1605028404243','textarea',3,'2021-10-06 13:06:24',NULL,'Please specify ','please_specify_1605028404243',119,_binary '','','default',_binary ''),(134,'Ulcers?','ulcers_1578158420889','html',3,'2021-10-06 13:06:24',NULL,'Ulcers?','ulcers_1578158420889',120,_binary '','<h3>Ulcers?</h3>','',_binary ''),(135,'Ulcers?','ulcers_1604626961086','listselect',3,'2021-10-06 13:06:24',NULL,'Ulcers?','ulcers_1604626961086',121,_binary '','','default',_binary ''),(136,'Please specify ','please_specify_1605028399616','textarea',3,'2021-10-06 13:06:24',NULL,'Please specify ','please_specify_1605028399616',122,_binary '','','default',_binary ''),(137,'High Blood Pressure?','high_blood_pressure_1578158450500','html',3,'2021-10-06 13:06:24',NULL,'High Blood Pressure?','high_blood_pressure_1578158450500',123,_binary '','<h3>High Blood Pressure?</h3>','',_binary ''),(138,'High Blood Pressure?','high_blood_pressure_1604626968164','listselect',3,'2021-10-06 13:06:24',NULL,'High Blood Pressure?','high_blood_pressure_1604626968164',124,_binary '','','default',_binary ''),(139,'Please specify ','please_specify_1605028395159','textarea',3,'2021-10-06 13:06:24',NULL,'Please specify ','please_specify_1605028395159',125,_binary '','','default',_binary ''),(140,'Asthma or shortness of breath?','asthma_or_shortness_of_breath_1578158478661','html',3,'2021-10-06 13:06:24',NULL,'Asthma or shortness of breath?','asthma_or_shortness_of_breath_1578158478661',126,_binary '','<h3>Asthma or shortness of breath?</h3>','',_binary ''),(141,'Asthma or shortness of breath?','asthma_or_shortness_of_breath_1604626975405','listselect',3,'2021-10-06 13:06:24',NULL,'Asthma or shortness of breath?','asthma_or_shortness_of_breath_1604626975405',127,_binary '','','default',_binary ''),(142,'Please specify ','please_specify_1605028391770','textarea',3,'2021-10-06 13:06:24',NULL,'Please specify ','please_specify_1605028391770',128,_binary '','','default',_binary ''),(143,'Pregnancy?','pregnancy_1578158506066','html',3,'2021-10-06 13:06:24',NULL,'Pregnancy?','pregnancy_1578158506066',132,_binary '','<h3>Pregnancy?</h3>','',_binary ''),(144,'Pregnancy?','pregnancy_1604626996778','listselect',3,'2021-10-06 15:27:21',NULL,'Pregnancy?','pregnancy_1604626996778',133,_binary '','','default',_binary ''),(145,'Please specify ','please_specify_1605028384580','textarea',3,'2021-10-06 13:06:24',NULL,'Please specify ','please_specify_1605028384580',134,_binary '','','default',_binary ''),(146,'Submit','submit_1578158786744','submit',3,'2021-10-06 13:06:24',NULL,'Submit','submit_1578158786744',138,_binary '','','',_binary ''),(147,'First Name','first_name_1621451097022','textbox',3,'2021-05-19 19:05:32',NULL,'First Name','first_name_1621451097022',2,_binary '','','default',_binary ''),(148,'First and Last Name - Emergency','first_and_last_name_-_emergency_1578278068350','textbox',3,'2021-10-06 13:06:24',NULL,'First and Last Name - Emergency','first_and_last_name_-_emergency_1578278068350',34,_binary '','','default',_binary ''),(149,'First Name','firstname_1578886543859','firstname',2,'2020-01-12 20:37:03',NULL,'First Name','firstname_1578886543859',1,_binary '','','default',_binary ''),(150,'Last Name','lastname_1578886546469','lastname',2,'2020-01-13 20:10:24',NULL,'Last Name','lastname_1578886546469',2,_binary '','','default',_binary ''),(151,'Email','email_1578886547794','email',2,'2021-01-04 11:34:31',NULL,'Email','email_1578886547794',3,_binary '','','default',_binary ''),(154,'Name','name_1599603566200','textbox',4,'2020-12-14 22:15:11',NULL,'Name','name_1599603566200',1,_binary '','','below',_binary ''),(155,'Email','email','email',4,'2020-12-21 16:13:45',NULL,'Email','email',2,_binary '','','below',_binary ''),(156,'Message','message','textarea',4,'2020-12-21 16:13:45',NULL,'Message','message',4,_binary '','','below',_binary ''),(157,'Submit','submit','submit',4,'2020-12-28 13:50:58',NULL,'Submit','submit',8,_binary '','','',_binary ''),(158,'Phone','phone_1591563736621','phone',4,'2020-06-07 21:02:41',NULL,'Phone','phone_1591563736621',3,_binary '','','default',_binary ''),(159,'Select','listselect_1592008421709','listselect',1,'2020-12-28 09:08:01',NULL,'Select','listselect_1592008421709',6,_binary '','','default',_binary ''),(160,'Primary Care Doctor','primary_care_doctor_1592336142626','textbox',3,'2021-10-06 13:06:24',NULL,'Primary Care Doctor','primary_care_doctor_1592336142626',19,_binary '','','default',_binary ''),(161,'Phone','phone_1592336104911','phone',3,'2021-10-06 13:06:24',NULL,'Phone','phone_1592336104911',20,_binary '','','default',_binary ''),(170,'Get Help','get_help_1578518434045','submit',7,'2021-01-25 19:13:06',NULL,'Get Help','get_help_1578518434045',5,_binary '','','',_binary ''),(171,'Full Name','full_name_1596381940509','firstname',7,'2020-08-02 15:25:49',NULL,'Full Name','full_name_1596381940509',1,_binary '','','default',_binary ''),(173,'Email','email_1578886547794','email',7,'2021-01-25 19:13:06',NULL,'Email','email_1578886547794',2,_binary '','','default',_binary ''),(174,'Phone','phone_1592844391785','phone',7,'2021-01-25 19:13:06',NULL,'Phone','phone_1592844391785',3,_binary '','','default',_binary ''),(175,'Paragraph Text','textarea_1592844417436','textarea',7,'2021-01-25 19:13:06',NULL,'Paragraph Text','textarea_1592844417436',4,_binary '','','default',_binary ''),(176,'HTML','html_1595377208202','html',8,'2020-07-23 01:34:25',NULL,'HTML','html_1595377208202',1,_binary '','<p><b><u>1. PROMISE TO PAY:\n</u></b>I understand that I am obligated to pay the account of the ANR Clinic in accordance with the regular rates and\nterms of the Clinic. If I fail to make payment when due and the account becomes delinquent or is turned over to a\ncollection agency or an attorney for collection, I agree to pay all collection agency fees, court costs and attorney’s\nfees. I also agree that any patient or guarantor overpayments on the above Clinic visit may be applied directly to\nany delinquent account for which I or my guarantor is legally responsible at the time of the collection of the\noverpayment.<br><b><u>2. PATIENT CONSENT FOR E-PRESCRIBING (ELECTRONIC PRESCRIBING):</u></b>\nI have been made aware and understand that the medical practices and offices may use an electronic\nprescription system which allows prescriptions and related information to be electronically sent between my\nproviders and my pharmacy. I have been informed and understand that my providers using the electronic\nprescribing system will be able to see information about medications I am already taking, including those\nprescribed by other providers. I give my consent to my providers to see this protected health information.<br><b><u>3. CONSENT TO RELEASE HEALTH INFORMATION:</u></b>\nI understand this Clinic uses an electronic medical record. I understand that the electronic medical record\ncontains information about my health from my past, current and future health care providers. I agree that this\nhealth information may be released through the Clinic’s electronic medical record or by other means (for\nexample, fax, telephone, email, or hand delivery): (1) to the Clinic; (2) to my past, current and future health care\nproviders and other health care organizations that provide care to me; and (3) to any other person named in my\nmedical record who pays for my treatment. These people may use my health information: (1) to treat me; (2) to\nget paid for my treatment, and (3) to do health care operations activities (for example, managing my care,\nproviding quality care, patient safety activities, and other activities necessary to run the Clinic). I understand that\nthese people will have access to all my health information in the medical record, including behavioral health and\nsubstance use disorder information (for example, drug and alcohol treatment), my medical history, diagnosis,\nhospital records, clinic and doctor visit information, medications, allergies, lab test results, radiology reports,\nsexual and reproductive health information, communicable disease- related information (for example, sexually\ntransmitted diseases), and HIV/AIDS-related information. I understand that I may take back this consent at any\ntime, except if my health information has already been released to someone. I also understand that I may\nrequest a list of the health care organizations that have received my substance use disorder information. This\nconsent will expire one year after my death.<br><b><u>4. NOTICE OF PRIVACY PRACTICES:</u></b>\nRequired pursuant to Health Insurance Portability and Accountability Act of 1996 (HIPAA), I acknowledge that I\nhave received a copy of the ANR Clinic’s Notice of Privacy Practices. I hereby consent to the use and\ndisclosure of my protected health information, including information generated through use of virtual health or\ntelemedicine services, as described in the Notice of Privacy Practices. This will include all of my protected health\ninformation generated during hospitalization and outpatient treatment at the Clinic, including but not limited to\ntreatment for mental health, drug and alcohol abuse, communicable diseases such as HIV/AIDS, developmental\ndisabilities, genetic testing, and other types of treatment received.<br><b><u>5. GENERAL CONSENT FOR TESTS, TREATMENT, AND SERVICES:</u></b>\nI have been informed of the treatment procedures considered necessary for me and that the treatments/\nprocedures will be directed by a physician or independent Advanced Practitioner, in accordance with state laws,\nscope of practice, and licensure of medical staff.</p><p><b><u>6. CONSENT FOR VIRTUAL HEALTH/TELEMEDICINE SERVICES:</u></b>\nI hereby consent to engaging in virtual health or telemedicine services, where available, as part of my treatment. I\nunderstand that “virtual health” or “telemedicine services” includes the practice of health care delivery, diagnosis,\nconsultation, treatment, transfers of medical data, and education using interactive audio, video, or data\ncommunications when the health care provider and patient are not in the same physical location.\nThe interactive electronic systems used for these services will incorporate network and software security\nprotocols to protect the confidentiality of patient identification and imaging data and will include measures to\nsafeguard the data to ensure its integrity against intentional or unintentional corruption. I understand that the\npotential benefits of receiving care in this manner include improved access to care and the ability to obtain\nthe expertise of a distant specialist. The potential risks include problems with information transmittal, including\nbut not limited to poor data transfer which may include a poor video and data quality experience, or lack of\naccess to my complete medical record by the remote physician. I understand that all information, including\nimages, will be part of my medical record available to me if requested and with the same restrictions on\ndissemination without my consent. I understand I may withdraw my consent at any time.&nbsp;<br></p>','',_binary ''),(177,'Submit','submit_1595377330903','submit',8,'2021-10-20 19:55:01',NULL,'Submit','submit_1595377330903',18,_binary '','','',_binary ''),(178,'HTML','html_1595377354194','html',8,'2020-07-22 00:25:01',NULL,'HTML','html_1595377354194',2,_binary '','<p><b><u>7. ADVANCE DIRECTIVE ACKNOWLEDGEMENT:\n</u></b>Federal law requires that patients be provided information about their rights to make advance health care\ndecisions, including Living Will, Durable Medical Power of Attorney or designation of surrogate decision made for\nhealth care decisions. If you have already completed any of these documents, please inform your physician and\nthe Clinic.<br></p>','',_binary ''),(180,'HTML','html_1595377828019','html',8,'2021-10-20 19:55:32',NULL,'HTML','html_1595377828019',4,_binary '','<p><b><u>8. RESEARCH STUDIES:</u></b></p><p><b><u></u></b></p><p>Are you currently a participant in any research study or project: (If yes, please briefly describe what is being studied)</p>','',_binary ''),(181,'Are you currently a participant in any research study or project?','are_you_currently_a_participant_in_any_research_study_or_project_1595377903889','listselect',8,'2021-01-04 07:52:48',NULL,'Are you currently a participant in any research study or project?','are_you_currently_a_participant_in_any_research_study_or_project_1595377903889',5,_binary '','','default',_binary ''),(182,'If yes, please briefly describe what is being studied.','if_yes_please_briefly_describe_what_is_being_studied_1595378167869','textbox',8,'2021-01-04 07:52:48',NULL,'If yes, please briefly describe what is being studied.','if_yes_please_briefly_describe_what_is_being_studied_1595378167869',6,_binary '','','default',_binary ''),(183,'Who can the Clinic contact with questions about the Study?','who_can_the_clinic_contact_with_questions_about_the_study_1595378048789','textbox',8,'2021-10-20 19:55:01',NULL,'Who can the Clinic contact with questions about the Study?','who_can_the_clinic_contact_with_questions_about_the_study_1595378048789',8,_binary '','','default',_binary ''),(184,'HTML','html_1595378065772','html',8,'2021-10-20 20:59:41',NULL,'HTML','html_1595378065772',9,_binary '','<p><u><b>9. E-MAIL:</b></u>\nI hereby consent to provide my e-mail address, so that representatives from the Clinc can e-mail information to\nme about health education or disease prevention and up-to-date information about the Clinic, its affiliated\nphysicians, and our services. I understand I will be able to change my preference at any time. Email Address:&nbsp;</p>','',_binary ''),(186,'HTML','html_1595378187270','html',8,'2021-10-20 21:00:13',NULL,'HTML','html_1595378187270',11,_binary '','<p><b><u>10. CELL PHONES:</u></b>\nI hereby consent to provide my telephone number(s), including my wireless telephone number(s), so that\nrepresentatives from the Clinic, its successors or assigns can contact me in any manner including but not limited\nto by manually placing a call, by using an automatic telephone dialing system or an artificial or prerecorded\nvoice, by texting, or by e-mailing, regarding any matter, including but not limited to my medical treatment,\nprescriptions, scheduling, billing or collection matters. This consent includes any updated or additional contact\ninformation that I may provide. I understand that I will be able to change my preference at any time.</p><p><br><u><b>11. VIDEOTAPING/RECORDING:</b></u>\nI understand and agree not to photograph, videotape, audiotape, record or otherwise capture imaging or sound on\nany device. I also understand it is my responsibility to assure those accompanying me comply with this requirement.</p>','',_binary ''),(187,'HTML','html_1595378235171','html',8,'2021-10-20 19:55:01',NULL,'HTML','html_1595378235171',12,_binary '','<p>The undersigned certifies that s/he has read the foregoing, understands it, accepts its terms, and has received a copy of. I hereby agree to all terms and conditions set forth above and understand that any sections of this consent that I do not consent to, I have struck through and initialed the section that does not have my consent or permission. Any form of electronic signature, such as facsimile or email scan, shall be deemed to be an original signature.<br></p>','',_binary ''),(188,'Patient\'s Signature','patient_s_signature_1595378336705','textbox',8,'2021-10-20 19:55:01',NULL,'Patient\'s Signature','patient_s_signature_1595378336705',13,_binary '','','default',_binary ''),(189,'Date','date_1595378305184','date',8,'2021-10-20 19:55:01',NULL,'Date','date_1595378305184',14,_binary '','','default',_binary ''),(190,'Email','email_1595378756380','email',8,'2021-10-20 19:55:01',NULL,'Email','email_1595378756380',10,_binary '','','default',_binary ''),(191,'Please Select One','please_select_one_1595472330431','listcheckbox',8,'2021-01-04 07:52:48',NULL,'Please Select One','please_select_one_1595472330431',3,_binary '','','default',_binary ''),(194,'Name','name','textbox',10,'2020-12-20 20:23:15',NULL,'Name','name',1,_binary '','','above',_binary ''),(195,'Email','email','email',10,'2020-12-20 20:23:15',NULL,'Email','email',2,_binary '','','above',_binary ''),(196,'Message','message','textarea',10,'2020-12-20 20:23:15',NULL,'Message','message',4,_binary '','','above',_binary ''),(197,'Get Help Now','get_help_now_1596156716803','submit',10,'2021-01-25 18:57:38',NULL,'Get Help Now','get_help_now_1596156716803',8,_binary '','','',_binary ''),(198,'Phone','phone_1595537768121','phone',10,'2020-07-31 00:23:06',NULL,'Phone','phone_1595537768121',3,_binary '','','default',_binary ''),(199,'HTML','html_1596588884080','html',11,'2020-08-05 03:38:42',NULL,'HTML','html_1596588884080',1,_binary '','<p class=\"MsoNormal\">Florida law requires that your health care provider or\nhealth care facility recognize your rights while you are receiving medical care\nand that you respect the health care provider’ s right to expect certain\nbehavior on the part of patients. You may request a copy of the full text of\nthis law from your health care provider or health care facility. A summary of\nyour rights and responsibilities follows: <o:p></o:p></p><p class=\"MsoNormal\"><u>You have the right to: <o:p></o:p></u></p><p class=\"MsoNormal\">• A patient has the right to be treated with courtesy and\nrespect, with appreciation of his or her individual dignity, and with\nprotection of his or her need for privacy. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to a prompt and reasonable\nresponse to questions and requests. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to know who is providing medical\nservices and who is responsible for his or her care. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to know what patient support\nservices are available, including whether an interpreter is available if he or\nshe does not speak English. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to know what rules and regulations\napply to his or her conduct. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to be given by the health care\nprovider information concerning diagnosis, planned course of treatment,\nalternatives, risks, and prognosis. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to refuse any treatment, except as\notherwise provided by law. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to be given, upon request, full\ninformation and necessary counseling on the availability of known financial\nresources for his or her care. <o:p></o:p></p><p class=\"MsoNormal\">• A patient who is eligible for Medicare has the right to\nknow, upon request and in advance of treatment, whether the health care\nprovider or health care facility accepts the Medicare assignment rate. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to receive, upon request, prior to\ntreatment, a reasonable estimate of charges for medical care. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to receive a copy of a reasonably\nclear and understandable, itemized bill and, upon request, to have the charges\nexplained. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to impartial access to medical\ntreatment or accommodations, regardless of race, national origin, religion,\nhandicap, or source of payment. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to treatment for any emergency\nmedical condition that will deteriorate from failure to provide treatment. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to know if medical treatment is\nfor purposes of experimental research and to give his or her consent or refusal\nto participate in such experimental research. <o:p></o:p></p><p class=\"MsoNormal\">• A patient has the right to express grievances regarding\nany violation of his or her rights, as stated in Florida law, through the\ngrievance procedure of the health care provider or health care facility which\nserved him or her and to the appropriate state licensing agency. <o:p></o:p></p><p class=\"MsoNormal\"><o:p>&nbsp;</o:p><u>You have the responsibility to:</u></p><p class=\"MsoNormal\">• A patient is responsible for providing to the health care\nprovider, to the best of his or her knowledge, accurate and complete\ninformation about present complaints, past illnesses, hospitalizations,\nmedications, and other matters relating to his or her health. <o:p></o:p></p><p class=\"MsoNormal\">• A patient is responsible for reporting unexpected changes\nin his or her condition to the health care provider. <o:p></o:p></p><p class=\"MsoNormal\">• A patient is responsible for reporting to the health care\nprovider whether he or she comprehends a contemplated course of action and what\nis expected of him or her. <o:p></o:p></p><p class=\"MsoNormal\">• A patient is responsible for following the treatment plan\nrecommended by the health care provider. • A patient is responsible for his or\nher actions if he or she refuses treatment or does not follow the health care\nprovider’s instructions. <o:p></o:p></p><p class=\"MsoNormal\">• A patient is responsible for assuring that the financial\nobligations of his or her health care are fulfilled as promptly as possible. <o:p></o:p></p><p class=\"MsoNormal\">• A patient is responsible for following the Clinic rules\nand regulations affecting patient care and conduct. <o:p></o:p></p><p class=\"MsoNormal\">• A patient is responsible for keeping appointments and,\nwhen he or she is unable to do so for any reason, for notifying the health care\nprovider. <o:p></o:p></p><p class=\"MsoNormal\"><o:p>&nbsp;</o:p></p><p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n</p><p class=\"MsoNormal\"><i>The undersigned certifies that he/she has read the\nforegoing, understands it, accepts its terms, has received a copy of it and is\nthe patient or is duly authorized by the patient as their agent to execute\nabove.&nbsp;<br><o:p></o:p>Any form of electronic signature, such as facsimile or email scan, shall be deemed to be an original signature.</i></p>','',_binary ''),(200,'Patient’s Signature or Legal Representative ','patient_s_signature_or_legal_representative_1596589076753','firstname',11,'2020-08-05 00:59:06',NULL,'Patient’s Signature or Legal Representative ','patient_s_signature_or_legal_representative_1596589076753',2,_binary '','','below',_binary ''),(201,'Date','date_1596589093931','date',11,'2020-08-05 00:59:06',NULL,'Date','date_1596589093931',3,_binary '','','below',_binary ''),(202,'Submit','submit_1596589109627','submit',11,'2021-01-25 18:59:31',NULL,'Submit','submit_1596589109627',7,_binary '','','',_binary ''),(203,'Patient Name','patient_name_1596730078797','firstname',12,'2020-08-07 07:45:28',NULL,'Patient Name','patient_name_1596730078797',1,_binary '','','default',_binary ''),(204,'Date of Birth','date_of_birth_1596730089048','date',12,'2020-08-07 07:45:28',NULL,'Date of Birth','date_of_birth_1596730089048',2,_binary '','','default',_binary ''),(205,'HTML','html_1596730110112','html',12,'2020-08-07 07:45:28',NULL,'HTML','html_1596730110112',3,_binary '','<p>I hereby authorize ANR Clinic (ANR) to release my patient health information as described below:&nbsp;<br></p>','',_binary ''),(206,'Name','name_1596730176300','firstname',12,'2020-08-07 07:45:28',NULL,'Name','name_1596730176300',4,_binary '','','default',_binary ''),(207,'Relationship','relationship_1596730187515','textbox',12,'2020-08-07 07:45:28',NULL,'Relationship','relationship_1596730187515',5,_binary '','','default',_binary ''),(208,'Contact Information','contact_information_1596730199301','textbox',12,'2020-08-07 07:45:28',NULL,'Contact Information','contact_information_1596730199301',6,_binary '','','default',_binary ''),(209,'Method of Disclosure','method_of_disclosure_1596730216406','listselect',12,'2020-08-07 07:45:28',NULL,'Method of Disclosure','method_of_disclosure_1596730216406',7,_binary '','','default',_binary 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You may receive an estimate during your pre-registration phone call, or you may ask for an estimate of your procedure at the time.</p><p>When is my payment due?</p><ul><li>Initial payments (deposits) are due at the time of booking the date of service.</li><li>The remaining balance is due by the date indicated to you by our Coordinators in the “Travel” email</li></ul><p>What if I must reschedule my procedure?</p><ul><li>We understand that life can be unpredictable, and occasions may arise that the procedure needs to be postponed. In this case we will apply your paid deposit towards the next available treatment date. This will also be the case with any unforeseen circumstances beyond the reasonable control of the patient or provider. </li><li>In the interest of the safety and welfare of our patients, visitors, and staff we may postpone procedures due to inclement weather or circumstances beyond our control. 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