(409,'2020-12-29 22:22:22','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - Michelle Marx','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>Michelle Marx</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>September</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>5</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1969</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>English </td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Female</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Single</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>White </td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>White</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>Newport Coast </td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>Newport </td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>Dr. Wasbin </td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>135</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>55</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>54 Lessay </td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Newport Coast </td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>CA</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>92657</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>94937646333</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>Mickyomarx@aol.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>9492359826</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>Profesional Dog:Animal Behavioral </td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>Nancy Marx </td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>Parent</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>nanomarx2@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9493764633</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>My addiction is with opiates (Subutex for the last-3 years) I suffer from chronic pain and didn’t want to use painkillers. Xanax for anxiety and agoraphobia. Alcohol daily just to feel I can function and don’t want to HAVE to take ANYMORE XANAX. </td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Subutex</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>4-6 mgs </td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Oral </td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Alcohol </td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>Every day</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Oral </td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Xanax </td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>2-2 1/2 mgs daily </td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Oral </td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>Betty Ford / Hoag Hospital </td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>09/11/2015</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>left BFC after 36 days. Dr ... an ex drug addict himself told me I was ‘Med-seeking,’ later to find out I had 3 Large tumors in my cervix that desperately needed surgery. I had no choice but to leave. There’s obviously much more to this than I can text.<br />\nThe people in residential ‘college dormitory type places were using, ODing, microwaving turtles in their homes for entertainment.<br />\nI was in so much pain from the tumors, I HAD TO leave. I was at my wits end and afraid for my life.</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Moderate</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>My past traumas have usually lead me to use a drug that would make me forget it and I could leave that reality asap. </td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>I’ve tried Methadone but never gave it a ‘real chance.’</p>\n<p>Suboxone I couldn’t use without violent  effects from the ‘Naltrexone’ in it.<br />\nSubutex seemed to help me control cravings, withdrawals and for a while helped me with my pain and I didn’t need to use pain meds. Now I feel that my body has changed and started to regret ever relying on it. I’ve had to regulate my use by going as far as I can without it And going back up in mgs to help withdrawal symptoms.</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Rather talk to Licensed Psychiatrist than answer questions like this online. There’s just too much pain in my history  </td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td>Again I don’t feel comfortable talking about this online. </td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td>Petroleum Jelly.</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>My right shoulder was smashed and had to be replaced with a metal plate and pins I believe that was done in 2016.<br />\nRemoval of three great size grapefruit sized tumor’s in my cervix area. All non cancerous.Benign. I have had a hysterectomy but I still have my ovaries.<br />\nHad cysts removed from I believe my right breast but they were found To be benign.</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Again another question that I would much rather speak to you in detail with a person then try to explain this online I am sorry thank you I really need your help though</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Ruptured appendix/appendicitis and major infection that had me taking IV antibiotics for over a month.</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Abuse, accidentally ran into door and lost consciousness for a while.</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Ran into a door and lost consciousness for an undetermined amount of time.</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>I believe I had a seizure last year November 2020 because of Social drug use that turned out to be bad but I don’t know that to be a fact.</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Elevated liver  enzymes and hepatitis see however I took medication that was supposed to stop it and it did for the most part as far as I know</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>21?years old. Terminated pregnancy.</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td>33281950.1609290752</td>\n</tr>\n<tr>\n<td valign=\"top\">Form record id:</td>\n<td>0123t000000mitmAAA</td>\n</tr>\n<tr>\n<td valign=\"top\">Lead record type id:</td>\n<td>0123t000000meiEAAQ</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(410,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>2001:ee0:56b5:a640:988e:ae79:4493:b9cd</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(411,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>120.56.115.125</b> and it was blocked for 20 minutes<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(412,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>2001:ee0:56b5:a640:988e:ae79:4493:b9cd</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(413,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>120.56.115.125</b> and it was blocked for 24 hours<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(414,'2020-12-30 01:06:02','45.79.210.65','artuc.xx@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Selçuk</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>artuc.xx@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>TR</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>Hello,<br />\nI heared about your successes.</p>\n<p>I have a brother who used drugs before, we need your help in getting him back to his normal life and wiping the trace of this thing from his brain.</p>\n<p>Could you please guide us what to do and how.</p>\n<p>Waiting to hear your reply<br />\nThanks</p>\n<p>Note: Message has been typed with help of a translator. It\'s so good if you can reply in Turkish as I don\'t know English.</td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Word of Mouth</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td>342872336.1609307533</td>\n</tr>\n<tr>\n<td valign=\"top\">record type id:</td>\n<td>0123t000000miusAAA</td>\n</tr>\n<tr>\n<td valign=\"top\">lead record type id:</td>\n<td>0123t000000meiCAAQ</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(415,'2020-12-30 01:06:02','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Selçuk - Contact Page','</p>\n<p>Selçuk</p>\n<p>artuc.xx@gmail.com</p>\n</p>\n<p>TR</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: artuc.xx@gmail.com <artuc.xx@gmail.com>','',NULL,'1.9.7'),(416,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>179.199.189.198</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(417,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>179.199.189.198</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(418,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>180.244.232.137</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(419,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>180.244.232.137</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(420,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>122.168.71.164</b> and it was blocked for 20 minutes<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(421,'2020-12-30 10:21:14','45.79.210.65','edenarmour@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Eden</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>edenarmour@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>Does medicaid pay for this treatment</td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Search Engine</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">record type id:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">lead record type id:</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(422,'2020-12-30 10:21:14','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Eden - Contact Page','</p>\n<p>Eden</p>\n<p>edenarmour@gmail.com</p>\n</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: edenarmour@gmail.com <edenarmour@gmail.com>','',NULL,'1.9.7'),(423,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>88.230.135.221</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(424,'2020-12-30 11:12:32','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Christopher Spikes</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>str8cashomie8@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>2145070314</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I could never afford the cost of ANR treatment, but I need help. Maybe I could work at the clinic for free until I\'ve paid back the cost. I\'m 29 currently taking 30mg. of Methadone every day for the last 7 years. I\'ve been unemployed for a while, at this time living with my mother. If there is an opprotunity for work in exchange for treatment please let me know, I have experience as a custodian and I don\'t mind sleeping outside.</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: str8cashomie8@gmail.com <str8cashomie8@gmail.com>','',NULL,'1.9.7'),(425,'2020-12-30 11:12:32','45.79.210.65','str8cashomie8@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Christopher Spikes</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>str8cashomie8@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>2145070314</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I could never afford the cost of ANR treatment, but I need help. Maybe I could work at the clinic for free until I\'ve paid back the cost. I\'m 29 currently taking 30mg. of Methadone every day for the last 7 years. I\'ve been unemployed for a while, at this time living with my mother. If there is an opprotunity for work in exchange for treatment please let me know, I have experience as a custodian and I don\'t mind sleeping outside.</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(426,'2020-12-30 12:21:50','45.79.210.65','monstersister1@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Linda Marie Salazar</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>monstersister1@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>7262224552</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>I am wamting help with my addiction to Opiates. I recently relapsed after being sober for 15 yrs. </td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Search Engine</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td>425849222.1609347913</td>\n</tr>\n<tr>\n<td valign=\"top\">record type id:</td>\n<td>0123t000000miusAAA</td>\n</tr>\n<tr>\n<td valign=\"top\">lead record type id:</td>\n<td>0123t000000meiCAAQ</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(427,'2020-12-30 12:21:50','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Linda Marie Salazar - Contact Page','</p>\n<p>Linda Marie Salazar</p>\n<p>monstersister1@gmail.com</p>\n<p>7262224552</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: monstersister1@gmail.com <monstersister1@gmail.com>','',NULL,'1.9.7'),(428,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>2409:4063:4e10:d45e:6de4:e878:d6cb:4559</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(429,'2020-12-30 12:50:39','45.79.210.65','waismannben@gmail.com,\\nolga@anrclinicus.com,\\nanrclinicflorida@gmail.com','Bradley Porche - Authorization Form – Consent to Medical Treatment','<p><table></table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','/2020/12/ninja-forms-submission.csv',NULL,'1.9.7'),(430,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>2409:4063:4e10:d45e:6de4:e878:d6cb:4559</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(431,'2020-12-30 13:13:30','45.79.210.65','waismannben@gmail.com,\\nolga@anrclinicus.com,\\nanrclinicflorida@gmail.com','test - Authorization Form – Consent to Medical Treatment','<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<p><b><u>1. PROMISE TO PAY:<br />\n</u></b>I understand that I am obligated to pay the account of the ANR Clinic in accordance with the regular rates and<br />\nterms of the Clinic. If I fail to make payment when due and the account becomes delinquent or is turned over to a<br />\ncollection agency or an attorney for collection, I agree to pay all collection agency fees, court costs and attorney’s<br />\nfees. I also agree that any patient or guarantor overpayments on the above Clinic visit may be applied directly to<br />\nany delinquent account for which I or my guarantor is legally responsible at the time of the collection of the<br />\noverpayment.<br /><b><u>2. PATIENT CONSENT FOR E-PRESCRIBING (ELECTRONIC PRESCRIBING):</u></b><br />\nI have been made aware and understand that the medical practices and offices may use an electronic<br />\nprescription system which allows prescriptions and related information to be electronically sent between my<br />\nproviders and my pharmacy. I have been informed and understand that my providers using the electronic<br />\nprescribing system will be able to see information about medications I am already taking, including those<br />\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><br />\nI understand this Clinic uses an electronic medical record. I understand that the electronic medical record<br />\ncontains information about my health from my past, current and future health care providers. I agree that this<br />\nhealth information may be released through the Clinic’s electronic medical record or by other means (for<br />\nexample, fax, telephone, email, or hand delivery): (1) to the Clinic; (2) to my past, current and future health care<br />\nproviders and other health care organizations that provide care to me; and (3) to any other person named in my<br />\nmedical record who pays for my treatment. These people may use my health information: (1) to treat me; (2) to<br />\nget paid for my treatment, and (3) to do health care operations activities (for example, managing my care,<br />\nproviding quality care, patient safety activities, and other activities necessary to run the Clinic). I understand that<br />\nthese people will have access to all my health information in the medical record, including behavioral health and<br />\nsubstance use disorder information (for example, drug and alcohol treatment), my medical history, diagnosis,<br />\nhospital records, clinic and doctor visit information, medications, allergies, lab test results, radiology reports,<br />\nsexual and reproductive health information, communicable disease- related information (for example, sexually<br />\ntransmitted diseases), and HIV/AIDS-related information. I understand that I may take back this consent at any<br />\ntime, except if my health information has already been released to someone. I also understand that I may<br />\nrequest a list of the health care organizations that have received my substance use disorder information. This<br />\nconsent will expire one year after my death.<br /><b><u>4. NOTICE OF PRIVACY PRACTICES:</u></b><br />\nRequired pursuant to Health Insurance Portability and Accountability Act of 1996 (HIPAA), I acknowledge that I<br />\nhave received a copy of the ANR Clinic’s Notice of Privacy Practices. I hereby consent to the use and<br />\ndisclosure of my protected health information, including information generated through use of virtual health or<br />\ntelemedicine services, as described in the Notice of Privacy Practices. This will include all of my protected health<br />\ninformation generated during hospitalization and outpatient treatment at the Clinic, including but not limited to<br />\ntreatment for mental health, drug and alcohol abuse, communicable diseases such as HIV/AIDS, developmental<br />\ndisabilities, genetic testing, and other types of treatment received.<br /><b><u>5. GENERAL CONSENT FOR TESTS, TREATMENT, AND SERVICES:</u></b><br />\nI have been informed of the treatment procedures considered necessary for me and that the treatments/<br />\nprocedures will be directed by a physician or independent Advanced Practitioner, in accordance with state laws,<br />\nscope of practice, and licensure of medical staff.</p>\n<p><b><u>6. CONSENT FOR VIRTUAL HEALTH/TELEMEDICINE SERVICES:</u></b><br />\nI hereby consent to engaging in virtual health or telemedicine services, where available, as part of my treatment. I<br />\nunderstand that “virtual health” or “telemedicine services” includes the practice of health care delivery, diagnosis,<br />\nconsultation, treatment, transfers of medical data, and education using interactive audio, video, or data<br />\ncommunications when the health care provider and patient are not in the same physical location.<br />\nThe interactive electronic systems used for these services will incorporate network and software security<br />\nprotocols to protect the confidentiality of patient identification and imaging data and will include measures to<br />\nsafeguard the data to ensure its integrity against intentional or unintentional corruption. I understand that the<br />\npotential benefits of receiving care in this manner include improved access to care and the ability to obtain<br />\nthe expertise of a distant specialist. The potential risks include problems with information transmittal, including<br />\nbut not limited to poor data transfer which may include a poor video and data quality experience, or lack of<br />\naccess to my complete medical record by the remote physician. I understand that all information, including<br />\nimages, will be part of my medical record available to me if requested and with the same restrictions on<br />\ndissemination without my consent. I understand I may withdraw my consent at any time.&nbsp;</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<p><b><u>7. ADVANCE DIRECTIVE ACKNOWLEDGEMENT:<br />\n</u></b>Federal law requires that patients be provided information about their rights to make advance health care<br />\ndecisions, including Living Will, Durable Medical Power of Attorney or designation of surrogate decision made for<br />\nhealth care decisions. If you have already completed any of these documents, please inform your physician and<br />\nthe Clinic.</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Select One:</td>\n<td>I have executed an advance directive and have supplied a copy to the Clinic.</td>\n</tr>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<p><b><u>8. RESEARCH STUDIES:</u></b></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Are you currently a participant in any research study or project?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If yes, please briefly describe what is being studied.:</td>\n<td>test</td>\n</tr>\n<tr>\n<td valign=\"top\">Who can the Clinic contact with questions about the Study?:</td>\n<td>tresdt</td>\n</tr>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<p><u><b>9. CONSENT TO PHOTO/VIDEO:</b></u><br />\nI consent to the photographing, videotaping and/or video monitoring, including appropriate portions of my<br />\nbody, for medical and medical record documentation purposes, provided said photographs or videotapes are<br />\nmaintained and released in accordance with protected health information regulations.<br /><u><b>10. CONSENT TO PHOTOGRAPH AT THE TIME OF REGISTRATION:</b></u><br />\nI, or my authorized legal representative, hereby give consent to the medical practice to take my photograph at the<br />\ntime of registration. I understand this photograph will be stored in the medical practice’s ambulatory medical<br />\nrecord electronically as my photo identification.<br /><u><b>11. E-MAIL:</b></u><br />\nI hereby consent to provide my e-mail address, so that representatives from the Clinc can e-mail information to<br />\nme about health education or disease prevention and up-to-date information about the Clinic, its affiliated<br />\nphysicians, and our services. I understand I will be able to change my preference at any time. Email Address:&nbsp;</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>test@email.com</td>\n</tr>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<p><b><u>12. CELL PHONES:</u></b><br />\nI hereby consent to provide my telephone number(s), including my wireless telephone number(s), so that<br />\nrepresentatives from the Clinic, its successors or assigns can contact me in any manner including but not limited<br />\nto by manually placing a call, by using an automatic telephone dialing system or an artificial or prerecorded<br />\nvoice, by texting, or by e-mailing, regarding any matter, including but not limited to my medical treatment,<br />\nprescriptions, scheduling, billing or collection matters. This consent includes any updated or additional contact<br />\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><br />\nI understand and agree not to photograph, videotape, audiotape, record or otherwise capture imaging or sound on<br />\nany device. I also understand it is my responsibility to assure those accompanying me comply with this requirement.</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<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.</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Patient\'s Signature:</td>\n<td>test</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>Wednesday, December 30 2020</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(432,'2020-12-30 13:20:07','45.79.210.65','mdelledera1981@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Marlene</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>mdelledera1981@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>4346657755</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>This sounds too good to be true.  My son relapsed after 2 1/2 months in detox/ rehab.  He now refuses to go back but if I can afford your treatment, this may be the answer.  Will you be able to identify if he needs more psych therapy after receiving ANR treatmnt?  He has suffered several concussions due to sports and accidents.  We have Anthem BCBS insurane.  Will insurance cover part of the cost?  How much does treatment cost?  Please reply!!!!The Florida center is closest to us.</td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Search Engine</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td>1489751773.1609351551</td>\n</tr>\n<tr>\n<td valign=\"top\">record type id:</td>\n<td>0123t000000miusAAA</td>\n</tr>\n<tr>\n<td valign=\"top\">lead record type id:</td>\n<td>0123t000000meiCAAQ</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(433,'2020-12-30 13:20:07','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Marlene - Contact Page','</p>\n<p>Marlene</p>\n<p>mdelledera1981@gmail.com</p>\n<p>4346657755</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: mdelledera1981@gmail.com <mdelledera1981@gmail.com>','',NULL,'1.9.7'),(434,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>88.230.135.221</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(435,'2020-12-30 13:30:05','45.79.210.65','reneguerrero4977@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Rene Guerrero</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>reneguerrero4977@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>7262224552</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>Seeking help to break off the heroin addiction.  </td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Search Engine</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td>425849222.1609347913</td>\n</tr>\n<tr>\n<td valign=\"top\">record type id:</td>\n<td>0123t000000miusAAA</td>\n</tr>\n<tr>\n<td valign=\"top\">lead record type id:</td>\n<td>0123t000000meiCAAQ</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(436,'2020-12-30 13:30:05','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Rene Guerrero - Contact Page','</p>\n<p>Rene Guerrero</p>\n<p>reneguerrero4977@gmail.com</p>\n<p>7262224552</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: reneguerrero4977@gmail.com <reneguerrero4977@gmail.com>','',NULL,'1.9.7'),(437,'2020-12-30 13:39:10','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - Amber Daniels','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>Amber Daniels</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>July</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>2</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1982</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>382903243</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>English </td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Female</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Single</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>White</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>Caucasian </td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>Walmart </td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>8434559219</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>115</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>4’11”</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>269 IvyStone drive apt B</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Myrtle Beach</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Sc</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>29588</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>8434559219</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>aamberrllynn0702@icloud.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>Kal Kassel </td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>Family friend </td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>kalassel@aol.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8548540054</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Heroin</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>1gram/day</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Iv</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Meth</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>.5g/month</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Iv</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>Shoreline </td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>03/11/2019</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>I  get restless legs the worst & it’s the worst symptom of withdrawal for me.. </td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Severe</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>It’s hard for me to concentrate on  anything for more than a few hours without using crossing my mind</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>I’ve tried both..  went to methadone clinic for about a year but never got dosage over 55mg bc I heard how hard it was to come off that.. so I pretty much used the whole time bc my councilor said it wasn’t enough to block my cravings.. suboxone I did ok for about 4 moths in a controlled environment but still had cravings even tho I was past withdrawals </td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>Broken ankles.. had to have rods & screws in both</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>I had abscess & cellulitis.. </td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Kidney infection </td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>The kidney infection I stated for the er visit above </td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td>411553581.1609351773</td>\n</tr>\n<tr>\n<td valign=\"top\">Form record id:</td>\n<td>0123t000000mitmAAA</td>\n</tr>\n<tr>\n<td valign=\"top\">Lead record type id:</td>\n<td>0123t000000meiEAAQ</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(438,'2020-12-30 14:10:18','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - DeepakBugendai','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>DeepakBugendai</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>September</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>1</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1986</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>afadaf</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>Asian</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>aaddd</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>sdffggg</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>75</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>156</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>dffff</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Patna</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Bihar</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>898989</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>IN</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>123872938028</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>deepakk@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>dfgg</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>Child</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>deepak.kumar121@outlook.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>1238729380</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>Hi </td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>effeff</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>1</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>fgghgdgh</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>gggg</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/31/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>Hi</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td>1409396737.1605792064</td>\n</tr>\n<tr>\n<td valign=\"top\">Form record id:</td>\n<td>0123t000000mitmAAA</td>\n</tr>\n<tr>\n<td valign=\"top\">Lead record type id:</td>\n<td>0123t000000meiEAAQ</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(439,'2020-12-30 14:17:31','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Rhiannon </td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>808skyehi@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I want to get off of using buprenorphine. Is this treatment covered by insurance?</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: 808skyehi@gmail.com <808skyehi@gmail.com>','',NULL,'1.9.7'),(440,'2020-12-30 14:17:31','45.79.210.65','808skyehi@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Rhiannon </td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>808skyehi@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I want to get off of using buprenorphine. Is this treatment covered by insurance?</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7');

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