:\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}],\"special_instructions\":[{\"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\"}]},\"form_field\":\"{field:google_analytics_client_id_1611601873760}\",\"field_map\":\"Form__c - Google Analytics Client ID\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - 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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>\",\"container_class\":\"\",\"element_class\":\"\",\"key\":\"html_1595377208202\",\"drawerDisabled\":false,\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3419\"},\"id\":\"176\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":2,\"label\":\"HTML\",\"type\":\"html\",\"default\":\"<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>\",\"container_class\":\"\",\"element_class\":\"\",\"key\":\"html_1595377354194\",\"drawerDisabled\":false,\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3423\"},\"id\":\"178\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":3,\"label\":\"Please Select One\",\"type\":\"listcheckbox\",\"key\":\"please_select_one_1595472330431\",\"label_pos\":\"default\",\"required\":false,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"I have executed an advance directive and have supplied a copy to the Clinic.\",\"value\":\"I have executed an advance directive and have supplied a copy to the Clinic.\",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"I have executed an advance directive and have been requested to supply a copy to the Clinic. \",\"value\":\"I have executed an advance directive and have been requested to supply a copy to the Clinic. \",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"I have not executed an advance directive. I have received information about advance directives from this Clinic\",\"value\":\"I have not executed an advance directive. I have received information about advance directives from this Clinic\",\"calc\":\"\",\"selected\":0,\"order\":2,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":3,\"new\":false,\"options\":[],\"label\":\"I have not executed any advance directives, and I do not wish to receive information about advance directives from this Clinic\",\"value\":\"I have not executed any advance directives and I do not wish to receive information about advance directives from this Clinic\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"drawerDisabled\":false,\"min_limit\":\"0\",\"max_limit\":\"1\",\"listcheckbox_field_limit_error_message\":\"Please select only one option.\",\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c3426\"},\"id\":\"191\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":4,\"type\":\"html\",\"label\":\"HTML\",\"default\":\"<p><b><u>8. RESEARCH STUDIES:</u></b><br></p>\",\"container_class\":\"\",\"element_class\":\"\",\"key\":\"html_1595377828019\",\"drawerDisabled\":false,\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3429\"},\"id\":\"180\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":5,\"label\":\"Are you currently a participant in any research study or project?\",\"type\":\"listselect\",\"key\":\"are_you_currently_a_participant_in_any_research_study_or_project_1595377903889\",\"label_pos\":\"default\",\"required\":0,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"\",\"value\":\"\",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"Yes\",\"value\":\"Yes\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No\",\"value\":\"No\",\"calc\":\"\",\"selected\":0,\"order\":2,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"></i> Import</a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"></span>\",\"default\":0}}},\"manual_value\":true}],\"container_class\":\"one-half first\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"drawerDisabled\":false,\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3432\"},\"id\":\"181\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":6,\"label\":\"If yes, please briefly describe what is being studied.\",\"type\":\"textbox\",\"key\":\"if_yes_please_briefly_describe_what_is_being_studied_1595378167869\",\"label_pos\":\"default\",\"required\":false,\"default\":\"\",\"placeholder\":\"(drug, medical device or other)\",\"container_class\":\"one-half \",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":false,\"admin_label\":\"\",\"help_text\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"custom_name_attribute\":\"\",\"personally_identifiable\":\"\",\"value\":\"\",\"drawerDisabled\":false,\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3435\"},\"id\":\"182\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":7,\"type\":\"textbox\",\"label\":\"Who can the Clinic contact with questions about the Study?\",\"key\":\"who_can_the_clinic_contact_with_questions_about_the_study_1595378048789\",\"label_pos\":\"default\",\"required\":false,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":false,\"admin_label\":\"\",\"help_text\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"custom_name_attribute\":\"\",\"personally_identifiable\":\"\",\"value\":\"\",\"drawerDisabled\":false,\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3438\"},\"id\":\"183\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":8,\"type\":\"html\",\"label\":\"HTML\",\"default\":\"<p><u><b>9. CONSENT TO PHOTO/VIDEO:</b></u>\\nI consent to the photographing, videotaping and/or video monitoring, including appropriate portions of my\\nbody, for medical and medical record documentation purposes, provided said photographs or videotapes are\\nmaintained and released in accordance with protected health information regulations.<br><u><b>10. CONSENT TO PHOTOGRAPH AT THE TIME OF REGISTRATION:</b></u>\\nI, or my authorized legal representative, hereby give consent to the medical practice to take my photograph at the\\ntime of registration. I understand this photograph will be stored in the medical practice’s ambulatory medical\\nrecord electronically as my photo identification.<br><u><b>11. 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>\",\"container_class\":\"\",\"element_class\":\"\",\"key\":\"html_1595378065772\",\"drawerDisabled\":false,\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3441\"},\"id\":\"184\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":9,\"label\":\"Email\",\"type\":\"email\",\"key\":\"email_1595378756380\",\"label_pos\":\"default\",\"required\":1,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"custom_name_attribute\":\"email\",\"personally_identifiable\":\"1\",\"value\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3444\"},\"id\":\"190\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":10,\"type\":\"html\",\"label\":\"HTML\",\"default\":\"<p><b><u>12. 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.<br><u><b>13. 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>\",\"container_class\":\"\",\"element_class\":\"\",\"key\":\"html_1595378187270\",\"drawerDisabled\":false,\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3447\"},\"id\":\"186\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":11,\"type\":\"html\",\"label\":\"HTML\",\"default\":\"<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>\",\"container_class\":\"\",\"element_class\":\"\",\"key\":\"html_1595378235171\",\"drawerDisabled\":false,\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3450\"},\"id\":\"187\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":12,\"label\":\"Patient\'s Signature\",\"type\":\"textbox\",\"key\":\"patient_s_signature_1595378336705\",\"label_pos\":\"default\",\"required\":1,\"default\":\"\",\"placeholder\":\"Type full name to sign.\",\"container_class\":\"one-half first\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":false,\"admin_label\":\"\",\"help_text\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"custom_name_attribute\":\"\",\"personally_identifiable\":\"\",\"value\":\"\",\"drawerDisabled\":false,\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3453\"},\"id\":\"188\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":13,\"label\":\"Date\",\"type\":\"date\",\"key\":\"date_1595378305184\",\"label_pos\":\"default\",\"required\":1,\"placeholder\":\"\",\"container_class\":\"one-half \",\"element_class\":\"\",\"manual_key\":false,\"admin_label\":\"\",\"help_text\":\"\",\"date_default\":1,\"date_format\":\"dddd, MMMM D YYYY\",\"year_range_start\":\"\",\"year_range_end\":\"\",\"value\":\"Tuesday, January 26 2021\",\"drawerDisabled\":false,\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3456\"},\"id\":\"189\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":15,\"type\":\"hidden\",\"label\":\"Record Type id\",\"key\":\"record_type_id_1609746731255\",\"default\":\"0123t000000mj31AAA\",\"admin_label\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3459\",\"drawerDisabled\":false},\"id\":\"416\"},{\"settings\":{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":16,\"type\":\"hidden\",\"label\":\"Lead record type 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Analytics Client Id\",\"key\":\"google_analytics_client_id_1611600580952\",\"default\":\"\",\"admin_label\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"cellcid\":\"c3872\",\"drawerDisabled\":false},\"id\":\"tmp-1\"}],\"actions\":[{\"settings\":{\"objectType\":\"Action\",\"objectDomain\":\"actions\",\"editActive\":false,\"type\":\"successmessage\",\"active\":\"1\",\"created_at\":\"2020-07-22 00:22:07\",\"label\":\"Success Message\",\"message\":\"Your form has been successfully submitted.\",\"order\":\"1\",\"payment_gateways\":\"\",\"payment_total\":\"0\",\"tag\":\"\",\"to\":\"{wp:admin_email}\",\"reply_to\":\"\",\"email_subject\":\"Ninja Forms Submission\",\"email_message\":\"{fields_table}\",\"email_message_plain\":\"\",\"from_name\":\"\",\"from_address\":\"\",\"email_format\":\"html\",\"cc\":\"\",\"bcc\":\"\",\"redirect_url\":\"\",\"submitter_email\":\"\",\"fields-save-toggle\":\"save_all\",\"exception_fields\":[],\"set_subs_to_expire\":\"0\",\"subs_expire_time\":\"90\",\"success_msg\":\"Your form has been successfully 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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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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 - 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First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":5,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:patient_s_signature_1595378336705}\",\"field_map\":\"Form__c - Patient Signature\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? 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Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":7,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:record_type_id_1609746731255}\",\"field_map\":\"Form__c - Record Type ID\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":8,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:lead_record_type_id_1609746726505}\",\"field_map\":\"Form__c - LeadRecordtypeId\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":9,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:patient_s_signature_1595378336705}\",\"field_map\":\"Form__c - Customer Name\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":9,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:date_1595378305184}\",\"field_map\":\"Form__c - Authorization Medical Date\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - 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\",'),(201,'nf_form_8_publishing_2','\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":{},\"max_options\":0,\"order\":10,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? 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Google Analytics Client ID\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - 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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 - 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Patient Name\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - 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Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:relationship_1596730187515}\",\"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 - 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\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":3,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:contact_information_1596730199301}\",\"field_map\":\"Form__c - Contact Information\",\"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\",\"'),(205,'nf_form_12_publishing_1','value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? 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Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":4,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:method_of_disclosure_1596730216406}\",\"field_map\":\"Form__c - Method of Disclosure\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":5,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:name_1596731554558}\",\"field_map\":\"Form__c - Customer Name 2\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":6,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:relationship_1596731341925}\",\"field_map\":\"Form__c - Relationship to Patient 2\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instructions\":{\"header\":\"Data Handling Instructions\",\"default\":\"\",\"options\":[{\"label\":\"-None-\",\"value\":\"none\"},{\"label\":\"Check for duplicates in this field\",\"value\":\"DuplicateCheck\"},{\"label\":\"This is a date interval (ex: 2 days)\",\"value\":\"DateInterval\"},{\"label\":\"Format Date for Salesforce\",\"value\":\"DateFormat\"},{\"label\":\"File Upload\",\"value\":\"FileUpload\"},{\"label\":\"Format for true/false\",\"value\":\"ForceBoolean\"},{\"label\":\"Keep ampersands and quotes\",\"value\":\"KeepCharacters\"},{\"label\":\"Format for Currency\",\"value\":\"SalesforceCurrency\"},{\"label\":\"Separate selections with semi-colon\",\"value\":\"SemicolonDelimiter\"}]}}}},{\"errors\":[],\"max_options\":0,\"order\":7,\"new\":false,\"options\":{\"form_field\":[],\"field_map\":[],\"special_instructions\":[]},\"form_field\":\"{field:contact_information_1596731344669}\",\"field_map\":\"Form__c - Contact Information 2\",\"special_instructions\":\"\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"salesforce_field_map\",\"type\":\"option-repeater\",\"label\":\"Salesforce Field Map <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New</a>\",\"width\":\"full\",\"group\":\"primary\",\"tmpl_row\":\"nf-tmpl-salesforce-custom-field-map-row\",\"value\":[],\"columns\":{\"form_field\":{\"header\":\"Form Field\",\"default\":\"\",\"options\":[]},\"field_map\":{\"header\":\"Salesforce Field\",\"default\":\"\",\"options\":[{\"label\":\"None\",\"value\":\"None\"},{\"label\":\"Form__c - Owner ID\",\"value\":\"Form__c - Owner ID\"},{\"label\":\"Form__c - Record Type ID\",\"value\":\"Form__c - Record Type ID\"},{\"label\":\"Form__c - LeadRecordtypeId\",\"value\":\"Form__c - LeadRecordtypeId\"},{\"label\":\"Form__c - Address\",\"value\":\"Form__c - Address\"},{\"label\":\"Form__c - Emergency Email\",\"value\":\"Form__c - Emergency Email\"},{\"label\":\"Form__c - All Traffic Sources\",\"value\":\"Form__c - All Traffic Sources\"},{\"label\":\"Form__c - Emergency Phone\",\"value\":\"Form__c - Emergency Phone\"},{\"label\":\"Form__c - Alternate Phone\",\"value\":\"Form__c - Alternate Phone\"},{\"label\":\"Form__c - Amount Per Day\",\"value\":\"Form__c - Amount Per Day\"},{\"label\":\"Form__c - Annual Revenue\",\"value\":\"Form__c - Annual Revenue\"},{\"label\":\"Form__c - Areyoucurrentlyaparticipant\",\"value\":\"Form__c - Areyoucurrentlyaparticipant\"},{\"label\":\"Form__c - Financial Date\",\"value\":\"Form__c - Financial Date\"},{\"label\":\"Form__c - Best time to Call\",\"value\":\"Form__c - Best time to Call\"},{\"label\":\"Form__c - Browser\",\"value\":\"Form__c - Browser\"},{\"label\":\"Form__c - Campaign\",\"value\":\"Form__c - Campaign\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - City\",\"value\":\"Form__c - City\"},{\"label\":\"Form__c - Company Id\",\"value\":\"Form__c - Company Id\"},{\"label\":\"Form__c - Company\",\"value\":\"Form__c - Company\"},{\"label\":\"Form__c - Contact Method\",\"value\":\"Form__c - Contact Method\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - Country\",\"value\":\"Form__c - Country\"},{\"label\":\"Form__c - First Name\",\"value\":\"Form__c - First Name\"},{\"label\":\"Form__c - Customer Name\",\"value\":\"Form__c - Customer Name\"},{\"label\":\"Form__c - Customer Phone Number\",\"value\":\"Form__c - Customer Phone Number\"},{\"label\":\"Form__c - Data.com Key\",\"value\":\"Form__c - Data.com Key\"},{\"label\":\"Form__c - DateDt\",\"value\":\"Form__c - DateDt\"},{\"label\":\"Form__c - Date Of Birth\",\"value\":\"Form__c - Date Of Birth\"},{\"label\":\"Form__c - Date\",\"value\":\"Form__c - Date\"},{\"label\":\"Form__c - Date of Enrolment\",\"value\":\"Form__c - Date of Enrolment\"},{\"label\":\"Form__c - Datetime of Enrollment\",\"value\":\"Form__c - Datetime of Enrollment\"},{\"label\":\"Form__c - Delete From Salesforce\",\"value\":\"Form__c - Delete From Salesforce\"},{\"label\":\"Form__c - Description\",\"value\":\"Form__c - Description\"},{\"label\":\"Form__c - Device\",\"value\":\"Form__c - Device\"},{\"label\":\"Form__c - Last Name\",\"value\":\"Form__c - Last Name\"},{\"label\":\"Form__c - Do Not Call\",\"value\":\"Form__c - Do Not Call\"},{\"label\":\"Form__c - Dose\",\"value\":\"Form__c - Dose\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Drug Name\",\"value\":\"Form__c - Drug Name\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Email Opt Out\",\"value\":\"Form__c - Email Opt Out\"},{\"label\":\"Form__c - Email\",\"value\":\"Form__c - Email\"},{\"label\":\"Form__c - Are you currently involve in research?\",\"value\":\"Form__c - Are you currently involve in research?\"},{\"label\":\"Form__c - Ethnicity\",\"value\":\"Form__c - Ethnicity\"},{\"label\":\"Form__c - Fax Opt Out\",\"value\":\"Form__c - Fax Opt Out\"},{\"label\":\"Form__c - Fax\",\"value\":\"Form__c - Fax\"},{\"label\":\"Form__c - First Click Campaign\",\"value\":\"Form__c - First Click Campaign\"},{\"label\":\"Form__c - First Click Channel\",\"value\":\"Form__c - First Click Channel\"},{\"label\":\"Form__c - First Click Content\",\"value\":\"Form__c - First Click Content\"},{\"label\":\"Form__c - First Click Landing Page\",\"value\":\"Form__c - First Click Landing Page\"},{\"label\":\"Form__c - First Click Medium\",\"value\":\"Form__c - First Click Medium\"},{\"label\":\"Form__c - First Click Referrer\",\"value\":\"Form__c - First Click Referrer\"},{\"label\":\"Form__c - First Click Source\",\"value\":\"Form__c - First Click Source\"},{\"label\":\"Form__c - First Click Term\",\"value\":\"Form__c - First Click Term\"},{\"label\":\"Form__c - First Form\",\"value\":\"Form__c - First Form\"},{\"label\":\"Form__c - First and Last Name Emergency\",\"value\":\"Form__c - First and Last Name Emergency\"},{\"label\":\"Form__c - Follow Up?\",\"value\":\"Form__c - Follow Up?\"},{\"label\":\"Form__c - For_How_Long\",\"value\":\"Form__c - For_How_Long\"},{\"label\":\"Form__c - For How Long?\",\"value\":\"Form__c - For How Long?\"},{\"label\":\"Form__c - Form Url\",\"value\":\"Form__c - Form Url\"},{\"label\":\"Form__c - Formatted Customer Name\",\"value\":\"Form__c - Formatted Customer Name\"},{\"label\":\"Form__c - Formatted Customer Phone Number\",\"value\":\"Form__c - Formatted Customer Phone Number\"},{\"label\":\"Form__c - Frequency\",\"value\":\"Form__c - Frequency\"},{\"label\":\"Form__c - GA Client ID (Formula)\",\"value\":\"Form__c - GA Client ID (Formula)\"},{\"label\":\"Form__c - GCLID Google Ads\",\"value\":\"Form__c - GCLID Google Ads\"},{\"label\":\"Form__c - GCLID\",\"value\":\"Form__c - GCLID\"},{\"label\":\"Form__c - General remarks\",\"value\":\"Form__c - General remarks\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Client ID\",\"value\":\"Form__c - Google Analytics Client ID\"},{\"label\":\"Form__c - Google Analytics Link\",\"value\":\"Form__c - Google Analytics Link\"},{\"label\":\"Form__c - Google Analytics Tracking ID\",\"value\":\"Form__c - Google Analytics Tracking ID\"},{\"label\":\"Form__c - What is being studied?\",\"value\":\"Form__c - What is being studied?\"},{\"label\":\"Form__c - Contact Person with Clinic\",\"value\":\"Form__c - Contact Person with Clinic\"},{\"label\":\"Form__c - Patient Signature\",\"value\":\"Form__c - Patient Signature\"},{\"label\":\"Form__c - Height\",\"value\":\"Form__c - Height\"},{\"label\":\"Form__c - Patient Name\",\"value\":\"Form__c - Patient Name\"},{\"label\":\"Form__c - Contact Information\",\"value\":\"Form__c - Contact Information\"},{\"label\":\"Form__c - How can we help you?\",\"value\":\"Form__c - How can we help you?\"},{\"label\":\"Form__c - IP Address\",\"value\":\"Form__c - IP Address\"},{\"label\":\"Form__c - Id\",\"value\":\"Form__c - Id\"},{\"label\":\"Form__c - Ifsowhen2B\",\"value\":\"Form__c - Ifsowhen2B\"},{\"label\":\"Form__c - Ifyespleasebriefly\",\"value\":\"Form__c - Ifyespleasebriefly\"},{\"label\":\"Form__c - Industry\",\"value\":\"Form__c - Industry\"},{\"label\":\"Form__c - Institution or Clinic\",\"value\":\"Form__c - Institution or Clinic\"},{\"label\":\"Form__c - Keywords\",\"value\":\"Form__c - Keywords\"},{\"label\":\"Form__c - Method of Disclosure\",\"value\":\"Form__c - Method of Disclosure\"},{\"label\":\"Form__c - Landing Page URL\",\"value\":\"Form__c - Landing Page URL\"},{\"label\":\"Form__c - Last Click Campaign\",\"value\":\"Form__c - Last Click Campaign\"},{\"label\":\"Form__c - Last Click Channel\",\"value\":\"Form__c - Last Click Channel\"},{\"label\":\"Form__c - Last Click Content\",\"value\":\"Form__c - Last Click Content\"},{\"label\":\"Form__c - Last Click Landing Page\",\"value\":\"Form__c - Last Click Landing Page\"},{\"label\":\"Form__c - Last Click Medium\",\"value\":\"Form__c - Last Click Medium\"},{\"label\":\"Form__c - Last Click Referrer\",\"value\":\"Form__c - Last Click Referrer\"},{\"label\":\"Form__c - Last Click Source/Medium\",\"value\":\"Form__c - Last Click Source/Medium\"},{\"label\":\"Form__c - Last Click Source\",\"value\":\"Form__c - Last Click Source\"},{\"label\":\"Form__c - Last Click Term\",\"value\":\"Form__c - Last Click Term\"},{\"label\":\"Form__c - Last Transfer Date\",\"value\":\"Form__c - Last Transfer Date\"},{\"label\":\"Form__c - Latitude\",\"value\":\"Form__c - Latitude\"},{\"label\":\"Form__c - Customer Name 1\",\"value\":\"Form__c - Customer Name 1\"},{\"label\":\"Form__c - Location\",\"value\":\"Form__c - Location\"},{\"label\":\"Form__c - Location (approx.)\",\"value\":\"Form__c - Location (approx.)\"},{\"label\":\"Form__c - Longitude\",\"value\":\"Form__c - Longitude\"},{\"label\":\"Form__c - Relationship to Patient 1\",\"value\":\"Form__c - Relationship to Patient 1\"},{\"label\":\"Form__c - Contact Information 1\",\"value\":\"Form__c - Contact Information 1\"},{\"label\":\"Form__c - Method of Disclosure 1\",\"value\":\"Form__c - Method of Disclosure 1\"},{\"label\":\"Form__c - MaritalStatus\",\"value\":\"Form__c - MaritalStatus\"},{\"label\":\"Form__c - Customer Name 2\",\"value\":\"Form__c - Customer Name 2\"},{\"label\":\"Form__c - Medication\",\"value\":\"Form__c - Medication\"},{\"label\":\"Form__c - Medium\",\"value\":\"Form__c - Medium\"},{\"label\":\"Form__c - Message\",\"value\":\"Form__c - Message\"},{\"label\":\"Form__c - Relationship to Patient 2\",\"value\":\"Form__c - Relationship to Patient 2\"},{\"label\":\"Form__c - Method of Use\",\"value\":\"Form__c - Method of Use\"},{\"label\":\"Form__c - Mobile\",\"value\":\"Form__c - Mobile\"},{\"label\":\"Form__c - Name\",\"value\":\"Form__c - Name\"},{\"label\":\"Form__c - No. of Employees\",\"value\":\"Form__c - No. of Employees\"},{\"label\":\"Form__c - Number of Website Visits\",\"value\":\"Form__c - Number of Website Visits\"},{\"label\":\"Form__c - Contact Information 2\",\"value\":\"Form__c - Contact Information 2\"},{\"label\":\"Form__c - Occupation\",\"value\":\"Form__c - Occupation\"},{\"label\":\"Form__c - Operating System\",\"value\":\"Form__c - Operating System\"},{\"label\":\"Form__c - Other Relevant Personal Remarks\",\"value\":\"Form__c - Other Relevant Personal Remarks\"},{\"label\":\"Form__c - Pages visited\",\"value\":\"Form__c - Pages visited\"},{\"label\":\"Form__c - ParagraphText\",\"value\":\"Form__c - ParagraphText\"},{\"label\":\"Form__c - Method of Disclosure 3\",\"value\":\"Form__c - Method of Disclosure 3\"},{\"label\":\"Form__c - Person Id\",\"value\":\"Form__c - Person Id\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - Phone\",\"value\":\"Form__c - Phone\"},{\"label\":\"Form__c - PleaseSelectOne\",\"value\":\"Form__c - PleaseSelectOne\"},{\"label\":\"Form__c - Please_Specify\",\"value\":\"Form__c - Please_Specify\"},{\"label\":\"Form__c - Please specify and describe reactions\",\"value\":\"Form__c - Please specify and describe reactions\"},{\"label\":\"Form__c - Pleasespecify19B\",\"value\":\"Form__c - Pleasespecify19B\"},{\"label\":\"Form__c - Pleasespecify21B\",\"value\":\"Form__c - Pleasespecify21B\"},{\"label\":\"Form__c - Pleasespecify7B\",\"value\":\"Form__c - Pleasespecify7B\"},{\"label\":\"Form__c - Preferred Language\",\"value\":\"Form__c - Preferred Language\"},{\"label\":\"Form__c - Preferred Pharmacy\",\"value\":\"Form__c - Preferred Pharmacy\"},{\"label\":\"Form__c - Customer Name 3\",\"value\":\"Form__c - Customer Name 3\"},{\"label\":\"Form__c - Primary Care Doctor\",\"value\":\"Form__c - Primary Care Doctor\"},{\"label\":\"Form__c - Primary Phone\",\"value\":\"Form__c - Primary Phone\"},{\"label\":\"Form__c - Relationship to Patient 3\",\"value\":\"Form__c - Relationship to Patient 3\"},{\"label\":\"Form__c - Race\",\"value\":\"Form__c - Race\"},{\"label\":\"Form__c - Rating\",\"value\":\"Form__c - Rating\"},{\"label\":\"Form__c - Referrer\",\"value\":\"Form__c - Referrer\"},{\"label\":\"Form__c - Referring URL\",\"value\":\"Form__c - Referring URL\"},{\"label\":\"Form__c - Relationship to Patient\",\"value\":\"Form__c - Relationship to Patient\"},{\"label\":\"Form__c - Route\",\"value\":\"Form__c - Route\"},{\"label\":\"Form__c - Select\",\"value\":\"Form__c - Select\"},{\"label\":\"Form__c - Contact Information 3\",\"value\":\"Form__c - Contact Information 3\"},{\"label\":\"Form__c - Social Security #\",\"value\":\"Form__c - Social Security #\"},{\"label\":\"Form__c - Some Number\",\"value\":\"Form__c - Some Number\"},{\"label\":\"Form__c - Source\",\"value\":\"Form__c - Source\"},{\"label\":\"Form__c - State\",\"value\":\"Form__c - State\"},{\"label\":\"Form__c - Street\",\"value\":\"Form__c - Street\"},{\"label\":\"Form__c - Submitted at\",\"value\":\"Form__c - Submitted at\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Spent on Website\",\"value\":\"Form__c - Time Spent on Website\"},{\"label\":\"Form__c - Time Zone\",\"value\":\"Form__c - Time Zone\"},{\"label\":\"Form__c - Title\",\"value\":\"Form__c - Title\"},{\"label\":\"Form__c - Website\",\"value\":\"Form__c - Website\"},{\"label\":\"Form__c - Weight\",\"value\":\"Form__c - Weight\"},{\"label\":\"Form__c - When Date\",\"value\":\"Form__c - When Date\"},{\"label\":\"Form__c - WhocantheCliniccontact\",\"value\":\"Form__c - WhocantheCliniccontact\"},{\"label\":\"Form__c - 10B Please specify\",\"value\":\"Form__c - 10B Please specify\"},{\"label\":\"Form__c - 11B Please specify\",\"value\":\"Form__c - 11B Please specify\"},{\"label\":\"Form__c - 12B Please specify\",\"value\":\"Form__c - 12B Please specify\"},{\"label\":\"Form__c - 13B Please specify\",\"value\":\"Form__c - 13B Please specify\"},{\"label\":\"Form__c - 14B Please specify\",\"value\":\"Form__c - 14B Please specify\"},{\"label\":\"Form__c - 15B Please specify\",\"value\":\"Form__c - 15B Please specify\"},{\"label\":\"Form__c - 16B Please specify\",\"value\":\"Form__c - 16B Please specify\"},{\"label\":\"Form__c - 17B Please specify\",\"value\":\"Form__c - 17B Please specify\"},{\"label\":\"Form__c - 18B Please specify\",\"value\":\"Form__c - 18B Please specify\"},{\"label\":\"Form__c - 19B Please specify\",\"value\":\"Form__c - 19B Please specify\"},{\"label\":\"Form__c - 1A\",\"value\":\"Form__c - 1A\"},{\"label\":\"Form__c - 1B\",\"value\":\"Form__c - 1B\"},{\"label\":\"Form__c - 21B Please specify\",\"value\":\"Form__c - 21B Please specify\"},{\"label\":\"Form__c - 2B If so, when?\",\"value\":\"Form__c - 2B If so, when?\"},{\"label\":\"Form__c - 3B Please specify and describe reactions\",\"value\":\"Form__c - 3B Please specify and describe reactions\"},{\"label\":\"Form__c - 5B Please specify\",\"value\":\"Form__c - 5B Please specify\"},{\"label\":\"Form__c - 7B Please specify\",\"value\":\"Form__c - 7B Please specify\"},{\"label\":\"Form__c - 8B Please specify\",\"value\":\"Form__c - 8B Please specify\"},{\"label\":\"Form__c - 9B Please specify\",\"value\":\"Form__c - 9B Please specify\"},{\"label\":\"Form__c - Zip\",\"value\":\"Form__c - Zip\"},{\"label\":\"Form__c - form_field_10\",\"value\":\"Form__c - form_field_10\"},{\"label\":\"Form__c - nf_field_102\",\"value\":\"Form__c - nf_field_102\"},{\"label\":\"Form__c - nf_field_105\",\"value\":\"Form__c - nf_field_105\"},{\"label\":\"Form__c - nf_field_108\",\"value\":\"Form__c - nf_field_108\"},{\"label\":\"Form__c - nf_field_111\",\"value\":\"Form__c - nf_field_111\"},{\"label\":\"Form__c - nf_field_114\",\"value\":\"Form__c - nf_field_114\"},{\"label\":\"Form__c - nf_field_117\",\"value\":\"Form__c - nf_field_117\"},{\"label\":\"Form__c - nf_field_120\",\"value\":\"Form__c - nf_field_120\"},{\"label\":\"Form__c - nf_field_123\",\"value\":\"Form__c - nf_field_123\"},{\"label\":\"Form__c - nf_field_126\",\"value\":\"Form__c - nf_field_126\"},{\"label\":\"Form__c - Sex\",\"value\":\"Form__c - Sex\"},{\"label\":\"Form__c - Marital Status\",\"value\":\"Form__c - Marital Status\"},{\"label\":\"Form__c - Craving scale while clean\",\"value\":\"Form__c - Craving scale while clean\"},{\"label\":\"Form__c - Methadone or Suboxone Maintenance?\",\"value\":\"Form__c - Methadone or Suboxone Maintenance?\"},{\"label\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\",\"value\":\"Form__c - Haveyoueverreceivedpsychiatrictreatment\"},{\"label\":\"Form__c - Prior suicide attempts?\",\"value\":\"Form__c - Prior suicide attempts?\"},{\"label\":\"Form__c - Allergies (Medications, Food, etc.)?\",\"value\":\"Form__c - Allergies (Medications, Food, etc.)?\"},{\"label\":\"Form__c - Past Surgeries\",\"value\":\"Form__c - Past Surgeries\"},{\"label\":\"Form__c - Hospitalization in the last two years?\",\"value\":\"Form__c - Hospitalization in the last two years?\"},{\"label\":\"Form__c - Adverse reactions to anesthesia\",\"value\":\"Form__c - Adverse reactions to anesthesia\"},{\"label\":\"Form__c - Emergency room visits in the last year?\",\"value\":\"Form__c - Emergency room visits in the last year?\"},{\"label\":\"Form__c - Accidents? (work, car etc)\",\"value\":\"Form__c - Accidents? (work, car etc)\"},{\"label\":\"Form__c - Head Injuries?\",\"value\":\"Form__c - Head Injuries?\"},{\"label\":\"Form__c - Loss of consciousness?\",\"value\":\"Form__c - Loss of consciousness?\"},{\"label\":\"Form__c - Loss of consciousness? Seizures?\",\"value\":\"Form__c - Loss of consciousness? Seizures?\"},{\"label\":\"Form__c - Heart disease?\",\"value\":\"Form__c - Heart disease?\"},{\"label\":\"Form__c - Lung disease?\",\"value\":\"Form__c - Lung disease?\"},{\"label\":\"Form__c - Liver disease / infections?\",\"value\":\"Form__c - Liver disease / infections?\"},{\"label\":\"Form__c - Kidney disease / problem?\",\"value\":\"Form__c - Kidney disease / problem?\"},{\"label\":\"Form__c - Diabetes?\",\"value\":\"Form__c - Diabetes?\"},{\"label\":\"Form__c - Ulcers?\",\"value\":\"Form__c - Ulcers?\"},{\"label\":\"Form__c - High Blood Pressure?\",\"value\":\"Form__c - High Blood Pressure?\"},{\"label\":\"Form__c - Asthma or shortness of breath?\\\"\",\"value\":\"Form__c - Asthma or shortness of breath?\\\"\"},{\"label\":\"Form__c - Obstructive sleep apnea?\",\"value\":\"Form__c - Obstructive sleep apnea?\"},{\"label\":\"Form__c - Pregnancy\",\"value\":\"Form__c - Pregnancy\"},{\"label\":\"Form__c - Month\",\"value\":\"Form__c - Month\"},{\"label\":\"Form__c - Day\",\"value\":\"Form__c - Day\"},{\"label\":\"Form__c - Year\",\"value\":\"Form__c - Year\"},{\"label\":\"Form__c - Method of Disclosure 2\",\"value\":\"Form__c - Method of Disclosure 2\"},{\"label\":\"Form__c - Guardian’s Signature\",\"value\":\"Form__c - Guardian’s Signature\"},{\"label\":\"Form__c - Financial Policy Date\",\"value\":\"Form__c - Financial Policy Date\"},{\"label\":\"Form__c - Authorization Medical Date\",\"value\":\"Form__c - Authorization Medical Date\"},{\"label\":\"Form__c - Patient Date Of Birth\",\"value\":\"Form__c - Patient Date Of Birth\"},{\"label\":\"Form__c - Patient Signature Date\",\"value\":\"Form__c - Patient Signature Date\"},{\"label\":\"Form__c - When\",\"value\":\"Form__c - When\"},{\"label\":\"Form__c - Gurdian Signature Date\",\"value\":\"Form__c - Gurdian Signature Date\"}]},\"special_instr