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<!doctype html>
<html lang="en">
<head>
<meta charset="utf-8">
<title>Acme Care Example - Fasten Connect</title>
<base href="/">
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="icon" type="image/x-icon" href="favicon.ico">
<link rel="stylesheet" href="https://cdn.fastenhealth.com/connect/dev/fasten-stitch.css"></head>
<body>
<script src="https://cdn.fastenhealth.com/connect/dev/fasten-stitch.js" type="module"></script>
<style type="text/css">
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<div style="display:table;width:100%">
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</div>
<div class="header-text httar htvam">
<h1 id="header_53" class="form-header" data-component="header">New Patient Registration</h1>
<div id="subHeader_53" class="form-subHeader">Your Health Is our Priority</div>
</div>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_54">
<label class="form-label form-label-left form-label-auto" id="label_54" for="first_54" aria-hidden="false"> Name </label>
<div id="cid_54" class="form-input" data-layout="full">
<div data-wrapper-react="true">
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
<input type="text" id="first_54" name="q54_name[first]" class="form-textbox" data-defaultvalue="" autoComplete="section-input_54 given-name" size="10" data-component="first" aria-labelledby="label_54 sublabel_54_first" value="" />
<label class="form-sub-label" for="first_54" id="sublabel_54_first" style="min-height:13px">First Name</label>
</span>
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
<input type="text" id="last_54" name="q54_name[last]" class="form-textbox" data-defaultvalue="" autoComplete="section-input_54 family-name" size="15" data-component="last" aria-labelledby="label_54 sublabel_54_last" value="" />
<label class="form-sub-label" for="last_54" id="sublabel_54_last" style="min-height:13px">Last Name</label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_birthdate" id="id_56">
<label class="form-label form-label-left form-label-auto" id="label_56" for="input_56" aria-hidden="false"> Birth Date </label>
<div id="cid_56" class="form-input" data-layout="full">
<div data-wrapper-react="true">
<span class="form-sub-label-container" style="vertical-align:top">
<select name="q56_birthDate[month]" id="input_56_month" class="form-dropdown" data-component="birthdate-month" aria-labelledby="label_56 sublabel_56_month">
<option value="">Please select a month</option>
<option value="1">January</option>
<option value="2">February</option>
<option value="3">March</option>
<option value="4">April</option>
<option value="5">May</option>
<option value="6">June</option>
<option value="7">July</option>
<option value="8">August</option>
<option value="9">September</option>
<option value="10">October</option>
<option value="11">November</option>
<option value="12">December</option>
</select>
<label class="form-sub-label" for="input_56_month" id="sublabel_56_month" style="min-height:13px">Month</label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<select name="q56_birthDate[day]" id="input_56_day" class="form-dropdown" data-component="birthdate-day" aria-labelledby="label_56 sublabel_56_day">
<option value="">Please select a day</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<label class="form-sub-label" for="input_56_day" id="sublabel_56_day" style="min-height:13px">Day</label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<select name="q56_birthDate[year]" id="input_56_year" class="form-dropdown" data-component="birthdate-year" aria-labelledby="label_56 sublabel_56_year">
<option value="">Please select a year</option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
</select>
<label class="form-sub-label" for="input_56_year" id="sublabel_56_year" style="min-height:13px">Year</label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_12">
<label class="form-label form-label-left form-label-auto" id="label_12" for="input_12" aria-hidden="false"> Email Address </label>
<div id="cid_12" class="form-input" data-layout="half">
<input type="text" id="input_12" name="q12_emailAddress" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_12" value="" />
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_14">
<label class="form-label form-label-left form-label-auto" id="label_14" for="input_14" aria-hidden="false"> Home Phone </label>
<div id="cid_14" class="form-input" data-layout="half">
<input type="text" id="input_14" name="q14_homePhone" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_14" value="" />
</div>
</li>
<li class="form-line" data-type="control_dropdown" id="id_16">
<label class="form-label form-label-left form-label-auto" id="label_16" for="input_16" aria-hidden="false"> Preferred Method of Contact </label>
<div id="cid_16" class="form-input" data-layout="half">
<select class="form-dropdown" id="input_16" name="q16_preferredMethod" style="width:310px" data-component="dropdown" aria-label="Preferred Method of Contact">
<option value="">Please Select</option>
<option value="Mail">Mail</option>
<option value="Cell Phone">Cell Phone</option>
<option value="Work Phone">Work Phone</option>
<option value="Home Phone">Home Phone</option>
</select>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_17">
<label class="form-label form-label-left form-label-auto" id="label_17" for="input_17" aria-hidden="false"> Driver's License </label>
<div id="cid_17" class="form-input" data-layout="half">
<input type="text" id="input_17" name="q17_driversLicense" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_17" value="" />
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_18">
<label class="form-label form-label-left form-label-auto" id="label_18" for="input_18" aria-hidden="false"> Social Security Number </label>
<div id="cid_18" class="form-input" data-layout="half">
<input type="text" id="input_18" name="q18_socialSecurity" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_18" value="" />
</div>
</li>
<li class="form-line" data-type="control_radio" id="id_19">
<label class="form-label form-label-left form-label-auto" id="label_19" aria-hidden="false"> Single </label>
<div id="cid_19" class="form-input" data-layout="full">
<div class="form-multiple-column" data-columncount="2" role="group" aria-labelledby="label_19" data-component="radio">
<span class="form-radio-item">
<span class="dragger-item"></span>
<input type="radio" aria-describedby="label_19" class="form-radio" id="input_19_0" name="q19_single" value="Single" />
<label id="label_input_19_0" for="input_19_0">Single</label>
</span>
<span class="form-radio-item">
<span class="dragger-item"></span>
<input type="radio" aria-describedby="label_19" class="form-radio" id="input_19_1" name="q19_single" value="Married" />
<label id="label_input_19_1" for="input_19_1">Married</label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item"></span>
<input type="radio" aria-describedby="label_19" class="form-radio" id="input_19_2" name="q19_single" value="Divorced" />
<label id="label_input_19_2" for="input_19_2">Divorced</label>
</span>
<span class="form-radio-item">
<span class="dragger-item"></span>
<input type="radio" aria-describedby="label_19" class="form-radio" id="input_19_3" name="q19_single" value="Widowed" />
<label id="label_input_19_3" for="input_19_3">Widowed</label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_28">
<label class="form-label form-label-left form-label-auto" id="label_28" for="input_28" aria-hidden="false"> Current Employer </label>
<div id="cid_28" class="form-input" data-layout="half">
<input type="text" id="input_28" name="q28_currentEmployer" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_28" value="" />
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_30">
<label class="form-label form-label-left form-label-auto" id="label_30" for="input_30" aria-hidden="false"> Primary Care Provider </label>
<div id="cid_30" class="form-input" data-layout="half">
<input type="text" id="input_30" name="q30_primaryCare" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_30" value="" />
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_31">
<label class="form-label form-label-left form-label-auto" id="label_31" for="input_30" aria-hidden="false"> Attach Medical Records</label>
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</li>
<li class="form-line" data-type="control_button" id="id_52">
<div id="cid_52" class="form-input-wide" data-layout="full">
<div data-align="center" class="form-buttons-wrapper form-buttons-center jsTest-button-wrapperField">
<button type="button" class="form-submit-button submit-button jf-form-buttons jsTest-submitField " data-component="button" data-content="">Submit Form</button>
</div>
</div>
</li>
</ul>
</div>
</form>
</body>
</html>