{"id":316,"date":"2022-07-08T11:49:54","date_gmt":"2022-07-08T01:49:54","guid":{"rendered":"https:\/\/dentalsedation.website\/?page_id=316"},"modified":"2025-05-03T12:03:53","modified_gmt":"2025-05-03T02:03:53","slug":"elementor-316","status":"publish","type":"page","link":"https:\/\/dentalsedation.website\/index.php\/elementor-316\/","title":{"rendered":"Sedation Medical History"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"316\" class=\"elementor elementor-316\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2fe6065 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2fe6065\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-231dbe8\" data-id=\"231dbe8\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-162af14 elementor-widget elementor-widget-wpforms\" data-id=\"162af14\" data-element_type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<style id=\"wpforms-css-vars-elementor-widget-162af14\">\n\t\t\t\t.elementor-widget-wpforms.elementor-element-162af14 {\n\t\t\t\t--wpforms-label-color: #1C3F75;\n--wpforms-label-error-color: #F89521;\n--wpforms-button-border-radius: 6px;\n--wpforms-button-background-color: #518CAD;\n--wpforms-button-text-color: #FFFFFF;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-708\"><form id=\"wpforms-form-708\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"708\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/316\" data-token=\"199dbe8b922338b2465e7652f92169e7\" data-token-time=\"1777639433\"><div class=\"wpforms-head-container\"><div class=\"wpforms-title\">Dental Sedation: Medical History Form<\/div><\/div><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-708-field_2-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"2\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-708-field_2\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][2][first]\" aria-errormessage=\"wpforms-708-field_2-error\" required><label for=\"wpforms-708-field_2\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-708-field_2-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][2][last]\" aria-errormessage=\"wpforms-708-field_2-last-error\" required><label for=\"wpforms-708-field_2-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-708-field_3-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_3\">Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-708-field_3\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][3][date]\" aria-errormessage=\"wpforms-708-field_3-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-708-field_4-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_4\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-708-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" spellcheck=\"false\" aria-errormessage=\"wpforms-708-field_4-error\" required><\/div><div id=\"wpforms-708-field_5-container\" class=\"wpforms-field wpforms-field-address\" data-field-type=\"address\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-708-field_5\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][5][address1]\" aria-errormessage=\"wpforms-708-field_5-error\" required><label for=\"wpforms-708-field_5\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-708-field_5-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][5][address2]\" aria-errormessage=\"wpforms-708-field_5-address2-error\" ><label for=\"wpforms-708-field_5-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-708-field_5-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][5][city]\" aria-errormessage=\"wpforms-708-field_5-city-error\" required><label for=\"wpforms-708-field_5-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-708-field_5-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][5][state]\" value=\"New South Wales\" aria-errormessage=\"wpforms-708-field_5-state-error\" required><label for=\"wpforms-708-field_5-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-708-field_5-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][5][postal]\" aria-errormessage=\"wpforms-708-field_5-postal-error\" required><label for=\"wpforms-708-field_5-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-708-field_6-container\" class=\"wpforms-field wpforms-field-number\" data-field-type=\"number\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_6\">Mobile Phone: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-708-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" placeholder=\"0411111111\" step=\"any\" aria-errormessage=\"wpforms-708-field_6-error\" aria-describedby=\"wpforms-708-field_6-description\" required><div id=\"wpforms-708-field_6-description\" class=\"wpforms-field-description\">10 digit mobile phone number<\/div><\/div><div id=\"wpforms-708-field_8-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_8\">Female \/ Male <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-708-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" required=\"required\"><option value=\"Female\"  selected='selected' class=\"choice-1 depth-1\"  >Female<\/option><option value=\"Male\"  class=\"choice-2 depth-1\"  >Male<\/option><\/select><\/div><div id=\"wpforms-708-field_9-container\" class=\"wpforms-field wpforms-field-number wpf-num-limit\" data-field-type=\"number\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_9\">Weight (kg) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-708-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" value=\"70\" min=\"30\" max=\"150\" step=\"any\" aria-errormessage=\"wpforms-708-field_9-error\" aria-describedby=\"wpforms-708-field_9-description\" required><div id=\"wpforms-708-field_9-description\" class=\"wpforms-field-description\">Weight in KG<\/div><\/div><div id=\"wpforms-708-field_10-container\" class=\"wpforms-field wpforms-field-number wfp-num-limit\" data-field-type=\"number\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_10\">Height (metres) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-708-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" value=\"1.76\" min=\"1\" max=\"3\" step=\"any\" aria-errormessage=\"wpforms-708-field_10-error\" aria-describedby=\"wpforms-708-field_10-description\" required><div id=\"wpforms-708-field_10-description\" class=\"wpforms-field-description\">Height in metres<\/div><\/div><div id=\"wpforms-708-field_11-container\" class=\"wpforms-field wpforms-field-number wpforms-calculations-field\" data-field-type=\"number\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_11\">BMI<\/label><input type=\"number\" id=\"wpforms-708-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\" step=\"any\" readonly=\"readonly\" aria-errormessage=\"wpforms-708-field_11-error\" aria-describedby=\"wpforms-708-field_11-description\" ><div id=\"wpforms-708-field_11-description\" class=\"wpforms-field-description\">BMI will be calculated based on Weight and Height<\/div><\/div><div id=\"wpforms-708-field_12-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"12\"><h3 id=\"wpforms-708-field_12\" aria-errormessage=\"wpforms-708-field_12-error\">Do you currently, or have you previously suffered from any of the following conditions?<\/h3><\/div><div id=\"wpforms-708-field_14-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"14\"><fieldset><legend class=\"wpforms-field-label\">Stroke <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_14\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_14_1\" name=\"wpforms[fields][14][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_14_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_14_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_14_2\" name=\"wpforms[fields][14][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_14_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_14_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_15-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"15\"><fieldset><legend class=\"wpforms-field-label\">Shortness of breath <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_15_1\" name=\"wpforms[fields][15][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_15_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_15_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_15_2\" name=\"wpforms[fields][15][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_15_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_15_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_16-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Chest pain <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_16\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_16_1\" name=\"wpforms[fields][16][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_16_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_16_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_16_2\" name=\"wpforms[fields][16][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_16_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_16_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_17-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">Palpitations <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_17\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_17_1\" name=\"wpforms[fields][17][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_17_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_17_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_17_2\" name=\"wpforms[fields][17][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_17_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_17_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_18-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Rheumatic fever <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_18\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_18_1\" name=\"wpforms[fields][18][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_18_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_18_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_18_2\" name=\"wpforms[fields][18][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_18_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_18_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_20-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"20\"><fieldset><legend class=\"wpforms-field-label\">Heart attack <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_20\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_20_1\" name=\"wpforms[fields][20][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_20_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_20_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_20_2\" name=\"wpforms[fields][20][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_20_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_20_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_21-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"21\"><fieldset><legend class=\"wpforms-field-label\">High blood pressure <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_21\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_21_1\" name=\"wpforms[fields][21][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_21_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_21_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_21_2\" name=\"wpforms[fields][21][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_21_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_21_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_22-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"22\"><fieldset><legend class=\"wpforms-field-label\">Asthma <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_22\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_22_1\" name=\"wpforms[fields][22][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_22_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_22_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_22_2\" name=\"wpforms[fields][22][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_22_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_22_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_23-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"23\"><fieldset><legend class=\"wpforms-field-label\">Persistent cough <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_23\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_23_1\" name=\"wpforms[fields][23][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_23_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_23_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_23_2\" name=\"wpforms[fields][23][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_23_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_23_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_24-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">Other lung diseases <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_24_1\" name=\"wpforms[fields][24][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_24_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_24_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_24_2\" name=\"wpforms[fields][24][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_24_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_24_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_25-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"25\"><fieldset><legend class=\"wpforms-field-label\">Anaemia <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_25\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_25_1\" name=\"wpforms[fields][25][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_25_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_25_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_25_2\" name=\"wpforms[fields][25][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_25_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_25_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_58-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"58\"><fieldset><legend class=\"wpforms-field-label\">Sleep apnoea <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_58\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_58_1\" name=\"wpforms[fields][58][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_58_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_58_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_58_2\" name=\"wpforms[fields][58][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_58_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_58_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_26-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"26\"><fieldset><legend class=\"wpforms-field-label\">Diabetes <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_26\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_26_1\" name=\"wpforms[fields][26][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_26_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_26_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_26_2\" name=\"wpforms[fields][26][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_26_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_26_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_27-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">Bleeding disorder <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_27\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_27_1\" name=\"wpforms[fields][27][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_27_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_27_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_27_2\" name=\"wpforms[fields][27][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_27_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_27_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_28-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"28\"><fieldset><legend class=\"wpforms-field-label\">Kidney \/ Liver problems <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_28\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_28_1\" name=\"wpforms[fields][28][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_28_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_28_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_28_2\" name=\"wpforms[fields][28][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_28_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_28_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_29-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"29\"><fieldset><legend class=\"wpforms-field-label\">Thyroid problems <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_29\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_29_1\" name=\"wpforms[fields][29][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_29_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_29_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_29_2\" name=\"wpforms[fields][29][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_29_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_29_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_30-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"30\"><fieldset><legend class=\"wpforms-field-label\">Indigestion or heartburn <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_30\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_30_1\" name=\"wpforms[fields][30][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_30_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_30_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_30_2\" name=\"wpforms[fields][30][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_30_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_30_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_31-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"31\"><fieldset><legend class=\"wpforms-field-label\">Stomach ulcers <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_31\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_31_1\" name=\"wpforms[fields][31][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_31_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_31_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_31_2\" name=\"wpforms[fields][31][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_31_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_31_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_32-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"32\"><fieldset><legend class=\"wpforms-field-label\">Epilepsy \/ fitting <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_32\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_32_1\" name=\"wpforms[fields][32][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_32_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_32_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_32_2\" name=\"wpforms[fields][32][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_32_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_32_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_33-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"33\"><fieldset><legend class=\"wpforms-field-label\">Dizziness <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_33\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_33_1\" name=\"wpforms[fields][33][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_33_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_33_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_33_2\" name=\"wpforms[fields][33][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_33_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_33_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_34-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"34\"><fieldset><legend class=\"wpforms-field-label\">Arthritis <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_34\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_34_1\" name=\"wpforms[fields][34][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_34_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_34_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_34_2\" name=\"wpforms[fields][34][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_34_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_34_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_35-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\">Infectious diseases: HIV, Hep B, Hep C or other <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_35\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_35_1\" name=\"wpforms[fields][35][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_35_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_35_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_35_2\" name=\"wpforms[fields][35][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_35_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_35_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_36-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"36\"><fieldset><legend class=\"wpforms-field-label\">Cancer <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_36\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_36_1\" name=\"wpforms[fields][36][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_36_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_36_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_36_2\" name=\"wpforms[fields][36][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_36_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_36_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_38-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"38\"><fieldset><legend class=\"wpforms-field-label\">Have you had anaesthetics before? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_38\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_38_1\" name=\"wpforms[fields][38][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_38_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_38_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_38_2\" name=\"wpforms[fields][38][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_38_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_38_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_39-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"textarea\" data-field-id=\"39\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_39\">Please describe your previous experiences with anaesthetics <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-708-field_39\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][39]\" aria-errormessage=\"wpforms-708-field_39-error\" required><\/textarea><\/div><div id=\"wpforms-708-field_40-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"40\"><fieldset><legend class=\"wpforms-field-label\">Do you smoke or vape? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_40\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_40_1\" name=\"wpforms[fields][40][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_40_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_40_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_40_2\" name=\"wpforms[fields][40][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_40_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_40_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_61-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"number\" data-field-id=\"61\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_61\">How many per day? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-708-field_61\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][61]\" step=\"any\" aria-errormessage=\"wpforms-708-field_61-error\" required><\/div><div id=\"wpforms-708-field_59-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"59\"><fieldset><legend class=\"wpforms-field-label\">Do you drink? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_59\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_59_1\" name=\"wpforms[fields][59][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_59_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_59_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_59_2\" name=\"wpforms[fields][59][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_59_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_59_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_41-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"number\" data-field-id=\"41\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_41\">How many drinks per week <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-708-field_41\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][41]\" step=\"any\" aria-errormessage=\"wpforms-708-field_41-error\" required><\/div><div id=\"wpforms-708-field_42-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"42\"><fieldset><legend class=\"wpforms-field-label\">Do you suffer from any allergies? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_42\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_42_1\" name=\"wpforms[fields][42][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_42_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_42_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_42_2\" name=\"wpforms[fields][42][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_42_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_42_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_43-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"textarea\" data-field-id=\"43\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_43\">Please describe your allergies <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-708-field_43\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-708-field_43-error\" required><\/textarea><\/div><div id=\"wpforms-708-field_60-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"60\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you currently or have you previously taken any recreational drugs? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_60\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_60_1\" name=\"wpforms[fields][60][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_60_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_60_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_60_2\" name=\"wpforms[fields][60][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_60_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_60_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_44-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"44\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Are you pregnant? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-708-field_44\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_44_1\" name=\"wpforms[fields][44][]\" value=\"Yes\" aria-errormessage=\"wpforms-708-field_44_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_44_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-708-field_44_2\" name=\"wpforms[fields][44][]\" value=\"No\" aria-errormessage=\"wpforms-708-field_44_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-708-field_44_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-708-field_45-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"45\"><h3 id=\"wpforms-708-field_45\" aria-errormessage=\"wpforms-708-field_45-error\">Please list the medications you are currently taking. Including any over the counter medication, vitamins or contraceptive pills<\/h3><\/div><div id=\"wpforms-708-field_46-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-trigger\" data-field-type=\"text\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_46\">Name, Strength and Dose<\/label><input type=\"text\" id=\"wpforms-708-field_46\" class=\"wpforms-field-medium\" name=\"wpforms[fields][46]\" placeholder=\"Paracetamol, 2 tablets, three times daily when required\" aria-errormessage=\"wpforms-708-field_46-error\" ><\/div><div id=\"wpforms-708-field_47-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-type=\"text\" data-field-id=\"47\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_47\">Name, Strength and Dose 2<\/label><input type=\"text\" id=\"wpforms-708-field_47\" class=\"wpforms-field-medium\" name=\"wpforms[fields][47]\" placeholder=\"Paracetamol, 2 tablets, three times daily when required\" aria-errormessage=\"wpforms-708-field_47-error\" ><\/div><div id=\"wpforms-708-field_48-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-type=\"text\" data-field-id=\"48\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_48\">Name, Strength and Dose 3<\/label><input type=\"text\" id=\"wpforms-708-field_48\" class=\"wpforms-field-medium\" name=\"wpforms[fields][48]\" placeholder=\"Paracetamol, 2 tablets, three times daily when required\" aria-errormessage=\"wpforms-708-field_48-error\" ><\/div><div id=\"wpforms-708-field_49-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-type=\"text\" data-field-id=\"49\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_49\">Name, Strength and Dose 4<\/label><input type=\"text\" id=\"wpforms-708-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" placeholder=\"Paracetamol, 2 tablets, three times daily when required\" aria-errormessage=\"wpforms-708-field_49-error\" ><\/div><div id=\"wpforms-708-field_50-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-type=\"text\" data-field-id=\"50\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_50\">Name, Strength and Dose 5<\/label><input type=\"text\" id=\"wpforms-708-field_50\" class=\"wpforms-field-medium\" name=\"wpforms[fields][50]\" placeholder=\"Paracetamol, 2 tablets, three times daily when required\" aria-errormessage=\"wpforms-708-field_50-error\" ><\/div><div id=\"wpforms-708-field_51-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-type=\"text\" data-field-id=\"51\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_51\">Name, Strength and Dose 6<\/label><input type=\"text\" id=\"wpforms-708-field_51\" class=\"wpforms-field-medium\" name=\"wpforms[fields][51]\" placeholder=\"Paracetamol, 2 tablets, three times daily when required\" aria-errormessage=\"wpforms-708-field_51-error\" ><\/div><div id=\"wpforms-708-field_52-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-type=\"text\" data-field-id=\"52\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_52\">Name, Strength and Dose 7<\/label><input type=\"text\" id=\"wpforms-708-field_52\" class=\"wpforms-field-medium\" name=\"wpforms[fields][52]\" placeholder=\"Paracetamol, 2 tablets, three times daily when required\" aria-errormessage=\"wpforms-708-field_52-error\" ><\/div><div id=\"wpforms-708-field_53-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-type=\"text\" data-field-id=\"53\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_53\">Name, Strength and Dose 8<\/label><input type=\"text\" id=\"wpforms-708-field_53\" class=\"wpforms-field-medium\" name=\"wpforms[fields][53]\" placeholder=\"Paracetamol, 2 tablets, three times daily when required\" aria-errormessage=\"wpforms-708-field_53-error\" ><\/div><div id=\"wpforms-708-field_54-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-type=\"text\" data-field-id=\"54\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-708-field_54\">Name, Strength and Dose 9<\/label><input type=\"text\" 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class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"708\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/pages\/316\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-708\" class=\"wpforms-submit\" data-alt-text=\"Sending\u2026\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/dentalsedation.website\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Dental Sedation: Medical History FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Name * FirstLast Date of Birth *Email * Address * Address Line 1Address Line 2CityState \/ Province \/ RegionPostal Code Mobile Phone: *10 digit mobile phone numberFemale \/ Male *FemaleMaleWeight (kg) *Weight [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-316","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/pages\/316","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/comments?post=316"}],"version-history":[{"count":23,"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/pages\/316\/revisions"}],"predecessor-version":[{"id":1092,"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/pages\/316\/revisions\/1092"}],"wp:attachment":[{"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/media?parent=316"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}