{"id":3439,"date":"2026-09-11T01:00:16","date_gmt":"2026-09-11T01:00:16","guid":{"rendered":"https:\/\/grandgenesisdental.com\/?page_id=3439"},"modified":"2026-09-13T22:00:21","modified_gmt":"2026-09-13T22:00:21","slug":"new-patients","status":"publish","type":"page","link":"https:\/\/grandgenesisdental.com\/ar\/new-patients\/","title":{"rendered":"\u0645\u0631\u0636\u0649 \u062c\u062f\u062f"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3439\" class=\"elementor elementor-3439\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-63bee65a elementor-section-height-min-height elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"63bee65a\" data-element_type=\"section\" data-e-type=\"section\" data-settings='{\"background_background\":\"classic\"}'>\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-7634df3d\" data-id=\"7634df3d\" data-element_type=\"column\" data-e-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-2672c90b elementor-mobile-align-center elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"2672c90b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-map-marker\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">9080 Yonge St, #10 &amp; #11, Richmond Hill, ON L4C 0Y7<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\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<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-25b35288\" data-id=\"25b35288\" data-element_type=\"column\" data-e-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-4a1d48bd elementor-align-end elementor-mobile-align-center elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"4a1d48bd\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"mailto:info@grandgenesisdental.com\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-envelope\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">info@grandgenesisdental.com<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\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<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-4d99c3b6\" data-id=\"4d99c3b6\" data-element_type=\"column\" data-e-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-5b05c9bf e-grid-align-left e-grid-align-mobile-center elementor-shape-rounded elementor-grid-0 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href=\"https:\/\/www.instagram.com\/grandgenesisdental\/\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-screen-only\">\u0625\u0646\u0633\u062a\u063a\u0631\u0627\u0645<\/span>\n\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fab fa-instagram\"><\/i>\t\t\t\t\t<\/a>\n\t\t\t\t<\/span>\n\t\t\t\t\t<\/div>\n\t\t\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<section class=\"elementor-section elementor-top-section elementor-element elementor-element-48a0b146 elementor-section-height-min-height elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"48a0b146\" data-element_type=\"section\" data-e-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-25 elementor-top-column elementor-element elementor-element-1360eed8\" data-id=\"1360eed8\" data-element_type=\"column\" data-e-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-69f52aa8 elementor-widget elementor-widget-image\" data-id=\"69f52aa8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"1024\" height=\"341\" src=\"https:\/\/grandgenesisdental.com\/wp-content\/uploads\/2026\/09\/aa-1024x341.png\" class=\"attachment-large size-large wp-image-3434\" alt=\"\" srcset=\"https:\/\/grandgenesisdental.com\/wp-content\/uploads\/2026\/09\/aa-1024x341.png 1024w, https:\/\/grandgenesisdental.com\/wp-content\/uploads\/2026\/09\/aa-300x100.png 300w, https:\/\/grandgenesisdental.com\/wp-content\/uploads\/2026\/09\/aa-768x256.png 768w, 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menu-item-object-page menu-item-3875\"><a href=\"https:\/\/grandgenesisdental.com\/ar\/our-services\/\" class=\"elementor-item\">\u062e\u062f\u0645\u0627\u062a\u0646\u0627<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-3866\"><a href=\"https:\/\/grandgenesisdental.com\/ar\/new-patients\/\" class=\"elementor-item\">\u0645\u0631\u0636\u0649 \u062c\u062f\u062f<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-3867\"><a href=\"https:\/\/grandgenesisdental.com\/ar\/reviews\/\" class=\"elementor-item\">\u0627\u0644\u062a\u0639\u0644\u064a\u0642\u0627\u062a<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-3876\"><a href=\"https:\/\/grandgenesisdental.com\/ar\/contact-us\/\" class=\"elementor-item\">\u0627\u062a\u0635\u0644 \u0628\u0646\u0627<\/a><\/li>\n<\/ul>\t\t\t<\/nav>\n\t\t\t\t\t<div class=\"elementor-menu-toggle\" role=\"button\" tabindex=\"0\" aria-label=\"\u062a\u0628\u062f\u064a\u0644 \u0627\u0644\u0642\u0627\u0626\u0645\u0629\" aria-expanded=\"false\">\n\t\t\t<i aria-hidden=\"true\" role=\"presentation\" class=\"elementor-menu-toggle__icon--open eicon-menu-bar\"><\/i><i aria-hidden=\"true\" role=\"presentation\" class=\"elementor-menu-toggle__icon--close eicon-close\"><\/i>\t\t<\/div>\n\t\t\t\t\t<nav class=\"elementor-nav-menu--dropdown elementor-nav-menu__container\" aria-hidden=\"true\">\n\t\t\t\t<ul id=\"menu-2-43bc6184\" class=\"elementor-nav-menu\"><li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-home menu-item-3871\"><a href=\"https:\/\/grandgenesisdental.com\/ar\/\" class=\"elementor-item\" tabindex=\"-1\">\u0627\u0644\u0631\u0626\u064a\u0633\u064a\u0629<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-3870\"><a href=\"https:\/\/grandgenesisdental.com\/ar\/about-us\/\" class=\"elementor-item\" tabindex=\"-1\">\u0645\u0646 \u0646\u062d\u0646<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-3875\"><a href=\"https:\/\/grandgenesisdental.com\/ar\/our-services\/\" class=\"elementor-item\" tabindex=\"-1\">\u062e\u062f\u0645\u0627\u062a\u0646\u0627<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-3866\"><a href=\"https:\/\/grandgenesisdental.com\/ar\/new-patients\/\" class=\"elementor-item\" tabindex=\"-1\">\u0645\u0631\u0636\u0649 \u062c\u062f\u062f<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-3867\"><a href=\"https:\/\/grandgenesisdental.com\/ar\/reviews\/\" class=\"elementor-item\" tabindex=\"-1\">\u0627\u0644\u062a\u0639\u0644\u064a\u0642\u0627\u062a<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-3876\"><a href=\"https:\/\/grandgenesisdental.com\/ar\/contact-us\/\" class=\"elementor-item\" tabindex=\"-1\">\u0627\u062a\u0635\u0644 \u0628\u0646\u0627<\/a><\/li>\n<\/ul>\t\t\t<\/nav>\n\t\t\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<div class=\"elementor-column elementor-col-25 elementor-top-column elementor-element elementor-element-260298c4\" data-id=\"260298c4\" data-element_type=\"column\" data-e-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-21dc2928 elementor-position-inline-start elementor-widget__width-initial elementor-view-default elementor-mobile-position-block-start elementor-widget elementor-widget-icon-box\" data-id=\"21dc2928\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<a href=\"tel:+19055978700\" class=\"elementor-icon\" tabindex=\"-1\" aria-label=\"(905) 597-8700\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-phone-alt\"><\/i>\t\t\t\t<\/a>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"tel:+19055978700\">\n\t\t\t\t\t\t\t(905) 597-8700\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\t\u0627\u062a\u0635\u0644 \u0628\u0646\u0627 \u0627\u0644\u064a\u0648\u0645\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\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<div class=\"elementor-column elementor-col-25 elementor-top-column elementor-element elementor-element-d92dcbb\" data-id=\"d92dcbb\" data-element_type=\"column\" data-e-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-30c9d246 elementor-widget__width-auto elementor-widget elementor-widget-button\" data-id=\"30c9d246\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"\/ar\/request-appointment\/\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">\u0627\u062d\u062c\u0632<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\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<div class=\"elementor-element elementor-element-7b78718 e-flex e-con-boxed e-con e-parent\" data-id=\"7b78718\" data-element_type=\"container\" data-e-type=\"container\" data-settings='{\"background_background\":\"classic\"}'>\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f8a473a elementor-widget elementor-widget-heading\" data-id=\"f8a473a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">\u0645\u0631\u062d\u0628\u064b\u0627 \u0628\u0643\u0645 \u0641\u064a \u0639\u064a\u0627\u062f\u0629 \u062c\u0631\u0627\u0646\u062f \u062c\u064a\u0646\u064a\u0633\u064a\u0633 \u0644\u0644\u0623\u0633\u0646\u0627\u0646<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-83562d3 elementor-widget elementor-widget-text-editor\" data-id=\"83562d3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>\u0646\u062d\u0646 \u0633\u0639\u062f\u0627\u0621 \u0628\u062a\u0631\u062d\u064a\u0628 \u0627\u0644\u0645\u0631\u0636\u0649 \u0627\u0644\u062c\u062f\u062f \u0641\u064a \u0639\u064a\u0627\u062f\u0629 \u0627\u0644\u0623\u0633\u0646\u0627\u0646 \u0641\u064a \u0631\u064a\u062a\u0634\u0645\u0648\u0646\u062f \u0647\u064a\u0644. \u0623\u0643\u0645\u0644 \u0646\u0645\u0648\u0630\u062c \u0627\u0644\u0645\u0631\u064a\u0636 \u0627\u0644\u062c\u062f\u064a\u062f \u0639\u0628\u0631 \u0627\u0644\u0625\u0646\u062a\u0631\u0646\u062a \u0642\u0628\u0644 \u0632\u064a\u0627\u0631\u062a\u0643 \u0627\u0644\u0623\u0648\u0644\u0649 \u0644\u062a\u0633\u0647\u064a\u0644 \u0639\u0645\u0644\u064a\u0629 \u0627\u0644\u062a\u0633\u062c\u064a\u0644 \u0648\u062c\u0639\u0644\u0647\u0627 \u0645\u0631\u064a\u062d\u0629.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-4220b89 e-flex e-con-boxed e-con e-parent\" data-id=\"4220b89\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e471c35 elementor-widget elementor-widget-heading\" data-id=\"e471c35\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">\u0623\u0643\u0645\u0644 \u0646\u0645\u0648\u0630\u062c \u0627\u0644\u0645\u0631\u064a\u0636 \u0627\u0644\u062c\u062f\u064a\u062f<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bfccb55 elementor-widget__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"bfccb55\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0647\u0630\u0647 \u0632\u064a\u0627\u0631\u062a\u0643 \u0627\u0644\u0623\u0648\u0644\u0649 \u0625\u0644\u0649 \u0639\u064a\u0627\u062f\u0629 \u062c\u0631\u0627\u0646\u062f \u062c\u064a\u0646\u064a\u0633\u064a\u0633 \u0644\u0644\u0623\u0633\u0646\u0627\u0646\u060c \u064a\u0631\u062c\u0649 \u0625\u0643\u0645\u0627\u0644 \u0627\u0644\u0646\u0645\u0648\u0630\u062c \u0623\u062f\u0646\u0627\u0647 \u0642\u0628\u0644 \u0645\u0648\u0639\u062f\u0643. \u0633\u064a\u0633\u0627\u0639\u062f\u0646\u0627 \u0645\u0639\u0644\u0648\u0645\u0627\u062a\u0643 \u0641\u064a \u062a\u062d\u0636\u064a\u0631 \u0641\u0631\u064a\u0642\u0646\u0627 \u0644\u0632\u064a\u0627\u0631\u062a\u0643 \u0648\u062a\u0633\u0647\u064a\u0644 \u0639\u0645\u0644\u064a\u0629 \u0627\u0644\u062a\u0633\u062c\u064a\u0644 \u0639\u0646\u062f \u0648\u0635\u0648\u0644\u0643.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-ccda2f1 elementor-widget elementor-widget-formidable\" data-id=\"ccda2f1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"formidable.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_4_container\" data-token=\"3cab5a89202e2267ac1757e01f003f5d\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form \" id=\"form_new-patient-registration-form\" data-frm-error-config='{\"includeAlertRole\":false,\"focusFirstError\":false,\"focusErrorSummary\":true}' data-token=\"3cab5a89202e2267ac1757e01f003f5d\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">\u0646\u0645\u0648\u0630\u062c \u062a\u0633\u062c\u064a\u0644 \u0645\u0631\u064a\u0636 \u062c\u062f\u064a\u062f<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\">\n<input type=\"hidden\" name=\"form_id\" value=\"4\">\n<input type=\"hidden\" name=\"frm_hide_fields_4\" id=\"frm_hide_fields_4\" value=\"\">\n<input type=\"hidden\" name=\"form_key\" value=\"new-patient-registration-form\">\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\">\n<input type=\"hidden\" id=\"frm_submit_entry_4\" name=\"frm_submit_entry_4\" value=\"63e74166d1\"><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/3439\"><div id=\"frm_field_66_container\" class=\"frm_form_field  frm_html_container form-field\">\n<div style=\"border-bottom:2px solid #C8102E; padding-bottom:10px; margin:15px 0 25px 0;\">\n<h3 style=\"margin:0; color:#111111; font-size:22px; font-weight:600;\">\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0645\u0631\u064a\u0636<\/h3>\n<\/div>\n<\/div>\n<div id=\"frm_field_22_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div id=\"field_sgrfb_label\" class=\"frm_primary_label\">\u0627\u0644\u0627\u0633\u0645\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_sgrfb_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\t\u0627\u0644\u0627\u0633\u0645\t<\/legend>\n\n\t<div class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_22\" data-reqmsg=\"Name cannot be blank.\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div id=\"frm_field_22-first_container\" class=\"frm_form_field form-field frm_form_subfield-first  frm6\" data-sub-field-name=\"first\">\n\t\t\t\t<label for=\"field_sgrfb_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\t\u0627\u0644\u0627\u0633\u0645 \u0627\u0644\u0623\u0648\u0644\t\t\t\t<\/label>\n\n\t\t\t\t<input type=\"text\" id=\"field_sgrfb_first\" value=\"\" name=\"item_meta[22][first]\" autocomplete=\"given-name\" data-reqmsg=\"First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"><div class=\"frm_description\" id=\"frm_field_22_first_desc\">\u0627\u0644\u0627\u0633\u0645 \u0627\u0644\u0623\u0648\u0644<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div id=\"frm_field_22-last_container\" class=\"frm_form_field form-field frm_form_subfield-last  frm6\" data-sub-field-name=\"last\">\n\t\t\t\t<label for=\"field_sgrfb_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\t\u0627\u0633\u0645 \u0627\u0644\u0639\u0627\u0626\u0644\u0629\t\t\t\t<\/label>\n\n\t\t\t\t<input type=\"text\" id=\"field_sgrfb_last\" value=\"\" name=\"item_meta[22][last]\" autocomplete=\"family-name\" data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"><div class=\"frm_description\" id=\"frm_field_22_last_desc\">\u0627\u0633\u0645 \u0627\u0644\u0639\u0627\u0626\u0644\u0629<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_krvmz\" id=\"field_krvmz_label\" class=\"frm_primary_label\">\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0645\u064a\u0644\u0627\u062f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_krvmz\" name=\"item_meta[23]\" value=\"\" data-reqmsg=\"Date of Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date of Birth is invalid\" aria-invalid=\"false\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_24_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_x32y1\" id=\"field_x32y1_label\" class=\"frm_primary_label\">\u0631\u0642\u0645 \u0627\u0644\u0647\u0627\u062a\u0641\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_x32y1\" name=\"item_meta[24]\" value=\"\" data-reqmsg=\"Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone Number is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_25_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_nfil2\" id=\"field_nfil2_label\" class=\"frm_primary_label\">\u0639\u0646\u0648\u0627\u0646 \u0627\u0644\u0628\u0631\u064a\u062f \u0627\u0644\u0625\u0644\u0643\u062a\u0631\u0648\u0646\u064a\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"email\" id=\"field_nfil2\" name=\"item_meta[25]\" value=\"\" data-reqmsg=\"Email Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email Address is invalid\" aria-invalid=\"false\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_mlbf1\" id=\"field_mlbf1_label\" class=\"frm_primary_label\">\u0627\u0644\u0639\u0646\u0648\u0627\u0646 \u0627\u0644\u0645\u0646\u0632\u0644\u064a\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_mlbf1\" name=\"item_meta[26]\" value=\"\" data-reqmsg=\"Home Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Home Address is invalid\" aria-invalid=\"false\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_27_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_xk5go_label\" class=\"frm_primary_label\">\u0637\u0631\u064a\u0642\u0629 \u0627\u0644\u0627\u062a\u0635\u0627\u0644 \u0627\u0644\u0645\u0641\u0636\u0644\u0629\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_xk5go_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_27-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[27]\" id=\"field_xk5go-0\" value=\"Phone\" data-reqmsg=\"Preferred Method of Contact cannot be blank.\" data-invmsg=\"Preferred Method of Contact is invalid\"> \u0647\u0627\u062a\u0641<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_27-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[27]\" id=\"field_xk5go-1\" value=\"Email\" data-reqmsg=\"Preferred Method of Contact cannot be blank.\" data-invmsg=\"Preferred Method of Contact is invalid\"> \u0627\u0644\u0628\u0631\u064a\u062f \u0627\u0644\u0625\u0644\u0643\u062a\u0631\u0648\u0646\u064a<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_28_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ncnjn\" id=\"field_ncnjn_label\" class=\"frm_primary_label\">\u0627\u0633\u0645 \u062c\u0647\u0629 \u0627\u0644\u0627\u062a\u0635\u0627\u0644 \u0627\u0644\u0637\u0627\u0631\u0626\u0629\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_ncnjn\" name=\"item_meta[28]\" value=\"\" data-reqmsg=\"Emergency Contact Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Emergency Contact Name is invalid\" aria-invalid=\"false\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_29_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_zv9vf\" id=\"field_zv9vf_label\" class=\"frm_primary_label\">\u0647\u0627\u062a\u0641 \u062c\u0647\u0629 \u0627\u0644\u0627\u062a\u0635\u0627\u0644 \u0627\u0644\u0637\u0627\u0631\u0626\u0629\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_zv9vf\" name=\"item_meta[29]\" value=\"\" data-reqmsg=\"Emergency Contact Phone cannot be blank.\" aria-required=\"true\" data-invmsg=\"Emergency Contact Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_67_container\" class=\"frm_form_field  frm_html_container form-field\">\n<div style=\"border-bottom:2px solid #C8102E; padding-bottom:10px; margin:15px 0 25px 0;\">\n<h3 style=\"margin:0; color:#111111; font-size:22px; font-weight:600;\">\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u062a\u0623\u0645\u064a\u0646<\/h3>\n<\/div>\n<\/div>\n<div id=\"frm_field_30_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_hpaeo_label\" class=\"frm_primary_label\">\u0647\u0644 \u0644\u062f\u064a\u0643 \u062a\u0623\u0645\u064a\u0646 \u0623\u0633\u0646\u0627\u0646\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_hpaeo_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_30-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[30]\" id=\"field_hpaeo-0\" value=\"Yes\" data-reqmsg=\"Do you have dental insurance? cannot be blank.\" data-invmsg=\"Do you have dental insurance? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_30-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[30]\" id=\"field_hpaeo-1\" value=\"No\" data-reqmsg=\"Do you have dental insurance? cannot be blank.\" data-invmsg=\"Do you have dental insurance? is invalid\"> \u0644\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_31_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_kikkd\" id=\"field_kikkd_label\" class=\"frm_primary_label\">\u0634\u0631\u0643\u0629 \u0627\u0644\u062a\u0623\u0645\u064a\u0646\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_kikkd\" name=\"item_meta[31]\" value=\"\" data-invmsg=\"Insurance Company is invalid\" aria-invalid=\"false\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_32_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_cs06p\" id=\"field_cs06p_label\" class=\"frm_primary_label\">\u0631\u0642\u0645 \u0627\u0644\u0633\u064a\u0627\u0633\u0629 \/ \u0627\u0644\u062e\u0637\u0629\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_cs06p\" name=\"item_meta[32]\" value=\"\" data-invmsg=\"Policy \/ Plan Number is invalid\" aria-invalid=\"false\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_33_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_llwc7\" id=\"field_llwc7_label\" class=\"frm_primary_label\">\u0631\u0642\u0645 \u0627\u0644\u0639\u0636\u0648 \/ \u0627\u0644\u0634\u0647\u0627\u062f\u0629\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_llwc7\" name=\"item_meta[33]\" value=\"\" data-invmsg=\"Member \/ Certificate ID is invalid\" aria-invalid=\"false\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_34_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_9oq3o\" id=\"field_9oq3o_label\" class=\"frm_primary_label\">\u0627\u0633\u0645 \u0635\u0627\u062d\u0628 \u0627\u0644\u0648\u062b\u064a\u0642\u0629 \u0627\u0644\u0631\u0626\u064a\u0633\u064a\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_9oq3o\" name=\"item_meta[34]\" value=\"\" data-invmsg=\"Primary Policy Holder Name is invalid\" aria-invalid=\"false\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_35_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_w37dl\" id=\"field_w37dl_label\" class=\"frm_primary_label\">\u0627\u0644\u0639\u0644\u0627\u0642\u0629 \u0628\u0635\u0627\u062d\u0628 \u0627\u0644\u0648\u062b\u064a\u0642\u0629\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[35]\" id=\"field_w37dl\" data-invmsg=\"Relationship to Policy Holder is invalid\" aria-invalid=\"false\">\n\t\t<option value=\"\" selected> <\/option><option value=\"Self\">\u0623\u0646\u0627<\/option><option value=\"Spouse\">\u0627\u0644\u0632\u0648\u062c\/\u0627\u0644\u0632\u0648\u062c\u0629<\/option><option value=\"Child \/ Dependent\">\u0637\u0641\u0644 \/ \u062a\u0627\u0628\u0639<\/option><option value=\"Other\">\u0623\u062e\u0631\u0649<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_68_container\" class=\"frm_form_field  frm_html_container form-field\">\n<div style=\"border-bottom:2px solid #C8102E; padding-bottom:10px; margin:15px 0 25px 0;\">\n<h3 style=\"margin:0; color:#111111; font-size:22px; font-weight:600;\">\u0627\u0644\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0637\u0628\u064a<\/h3>\n<\/div>\n<\/div>\n<div id=\"frm_field_36_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_gxube_label\" class=\"frm_primary_label\">\u0647\u0644 \u0644\u062f\u064a\u0643 \u0623\u064a \u0645\u0646 \u0627\u0644\u062d\u0627\u0644\u0627\u062a \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644\u062a\u0627\u0644\u064a\u0629\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_gxube_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-0\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-0\" value=\"Heart Disease \/ Heart Problems\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\" aria-required=\"true\"> \u0623\u0645\u0631\u0627\u0636 \u0627\u0644\u0642\u0644\u0628 \/ \u0645\u0634\u0627\u0643\u0644 \u0627\u0644\u0642\u0644\u0628<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-1\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-1\" value=\"High Blood Pressure\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0627\u0631\u062a\u0641\u0627\u0639 \u0636\u063a\u0637 \u0627\u0644\u062f\u0645<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-2\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-2\" value=\"Low Blood Pressure\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0627\u0646\u062e\u0641\u0627\u0636 \u0636\u063a\u0637 \u0627\u0644\u062f\u0645<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-3\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-3\" value=\"Stroke\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0633\u0643\u062a\u0629 \u062f\u0645\u0627\u063a\u064a\u0629<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-4\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-4\" value=\"Diabetes\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0633\u0643\u0631\u064a<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-5\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-5\" value=\"Thyroid Problems\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0645\u0634\u0627\u0643\u0644 \u0627\u0644\u063a\u062f\u0629 \u0627\u0644\u062f\u0631\u0642\u064a\u0629<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-6\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-6\" value=\"Asthma\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0627\u0644\u0631\u0628\u0648<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-7\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-7\" value=\"Lung Disease \/ Breathing Problems\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0623\u0645\u0631\u0627\u0636 \u0627\u0644\u0631\u0626\u0629 \/ \u0645\u0634\u0627\u0643\u0644 \u0627\u0644\u062a\u0646\u0641\u0633<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-8\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-8\" value=\"Kidney Disease\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0623\u0645\u0631\u0627\u0636 \u0627\u0644\u0643\u0644\u0649<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-9\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-9\" value=\"Liver Disease \/ Hepatitis\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0623\u0645\u0631\u0627\u0636 \u0627\u0644\u0643\u0628\u062f \/ \u0627\u0644\u062a\u0647\u0627\u0628 \u0627\u0644\u0643\u0628\u062f<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-10\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-10\" value=\"Epilepsy \/ Seizures\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0627\u0644\u0635\u0631\u0639 \/ \u0627\u0644\u0646\u0648\u0628\u0627\u062a<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-11\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-11\" value=\"Blood Disease \/ Bleeding Problems\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0623\u0645\u0631\u0627\u0636 \u0627\u0644\u062f\u0645 \/ \u0645\u0634\u0627\u0643\u0644 \u0627\u0644\u0646\u0632\u064a\u0641<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-12\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-12\" value=\"Cancer\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0627\u0644\u0633\u0631\u0637\u0627\u0646<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-13\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-13\" value=\"Tuberculosis\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0627\u0644\u0633\u0644<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-14\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-14\" value=\"Arthritis \/ Rheumatism\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0627\u0644\u062a\u0647\u0627\u0628 \u0627\u0644\u0645\u0641\u0627\u0635\u0644 \/ \u0627\u0644\u0631\u0648\u0645\u0627\u062a\u064a\u0632\u0645<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-15\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-15\" value=\"HIV \/ AIDS\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0641\u064a\u0631\u0648\u0633 \u0646\u0642\u0635 \u0627\u0644\u0645\u0646\u0627\u0639\u0629 \u0627\u0644\u0628\u0634\u0631\u064a\u0629 \/ \u0627\u0644\u0625\u064a\u062f\u0632<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-16\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-16\" value=\"Other\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0623\u062e\u0631\u0649<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-17\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_gxube-17\" value=\"None of the Above\" data-reqmsg=\"Do you have any of the following medical conditions? cannot be blank.\" data-invmsg=\"Do you have any of the following medical conditions? is invalid\"> \u0644\u0627 \u0634\u064a\u0621 \u0645\u0645\u0627 \u0633\u0628\u0642<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_37_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_yd3sf_label\" class=\"frm_primary_label\">\u0647\u0644 \u0623\u0646\u062a \u0628\u0635\u062d\u0629 \u062c\u064a\u062f\u0629\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_yd3sf_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_37-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[37]\" id=\"field_yd3sf-0\" value=\"Yes\" data-reqmsg=\"Are you in good health? cannot be blank.\" data-invmsg=\"Are you in good health? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_37-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[37]\" id=\"field_yd3sf-1\" value=\"No\" data-reqmsg=\"Are you in good health? cannot be blank.\" data-invmsg=\"Are you in good health? is invalid\"> \u0644\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_38_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_arqix_label\" class=\"frm_primary_label\">\u0647\u0644 \u062d\u062f\u062b \u0623\u064a \u062a\u063a\u064a\u064a\u0631 \u0641\u064a \u0635\u062d\u062a\u0643 \u0627\u0644\u0639\u0627\u0645\u0629 \u062e\u0644\u0627\u0644 \u0627\u0644\u0639\u0627\u0645 \u0627\u0644\u0645\u0627\u0636\u064a\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_arqix_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_38-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[38]\" id=\"field_arqix-0\" value=\"Yes\" data-reqmsg=\"Has there been any change in your general health in the past year? cannot be blank.\" data-invmsg=\"Has there been any change in your general health in the past year? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_38-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[38]\" id=\"field_arqix-1\" value=\"No\" data-reqmsg=\"Has there been any change in your general health in the past year? cannot be blank.\" data-invmsg=\"Has there been any change in your general health in the past year? is invalid\"> \u0644\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_39_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_dvayx\" id=\"field_dvayx_label\" class=\"frm_primary_label\">\u0625\u0630\u0627 \u0643\u0627\u0646 \u0627\u0644\u062c\u0648\u0627\u0628 \u0646\u0639\u0645\u060c \u064a\u0631\u062c\u0649 \u0627\u0644\u0634\u0631\u062d\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[39]\" id=\"field_dvayx\" rows=\"5\" data-invmsg=\"If yes, please explain is invalid\" aria-invalid=\"false\"><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_40_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_rsfe8_label\" class=\"frm_primary_label\">\u0647\u0644 \u062a\u062a\u0646\u0627\u0648\u0644 \u062d\u0627\u0644\u064a\u0627\u064b \u0623\u064a \u062f\u0648\u0627\u0621 \u0623\u0648 \u0623\u062f\u0648\u064a\u0629 \u063a\u064a\u0631 \u0628\u0648\u0635\u0641\u0629 \u0637\u0628\u064a\u0629 \u0623\u0648 \u0645\u0643\u0645\u0644\u0627\u062a \u0639\u0634\u0628\u064a\u0629 \u0645\u0646 \u0623\u064a \u0646\u0648\u0639\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_rsfe8_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_40-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[40]\" id=\"field_rsfe8-0\" value=\"Yes\" data-reqmsg=\"Are you currently taking any medication, non-prescription drugs, or herbal supplements of any kind? cannot be blank.\" data-invmsg=\"Are you currently taking any medication, non-prescription drugs, or herbal supplements of any kind? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_40-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[40]\" id=\"field_rsfe8-1\" value=\"No\" data-reqmsg=\"Are you currently taking any medication, non-prescription drugs, or herbal supplements of any kind? cannot be blank.\" data-invmsg=\"Are you currently taking any medication, non-prescription drugs, or herbal supplements of any kind? is invalid\"> \u0644\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_fqdfi\" id=\"field_fqdfi_label\" class=\"frm_primary_label\">\u064a\u0631\u062c\u0649 \u062a\u062d\u062f\u064a\u062f \u0627\u0644\u0623\u062f\u0648\u064a\u0629\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[41]\" id=\"field_fqdfi\" rows=\"5\" data-invmsg=\"Please specify medications is invalid\" aria-invalid=\"false\"><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_42_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_dhqlb_label\" class=\"frm_primary_label\">\u0647\u0644 \u0644\u062f\u064a\u0643 \u0623\u064a \u062d\u0633\u0627\u0633\u064a\u0629\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_dhqlb_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_42-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[42]\" id=\"field_dhqlb-0\" value=\"Yes\" data-reqmsg=\"Do you have any allergies? cannot be blank.\" data-invmsg=\"Do you have any allergies? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_42-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[42]\" id=\"field_dhqlb-1\" value=\"No\" data-reqmsg=\"Do you have any allergies? cannot be blank.\" data-invmsg=\"Do you have any allergies? is invalid\"> \u0644\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_43_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_czx50\" id=\"field_czx50_label\" class=\"frm_primary_label\">\u064a\u0631\u062c\u0649 \u062a\u062d\u062f\u064a\u062f \u0627\u0644\u062d\u0633\u0627\u0633\u064a\u0629\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[43]\" id=\"field_czx50\" rows=\"5\" data-invmsg=\"Please specify allergies is invalid\" aria-invalid=\"false\"><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_44_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_me0er_label\" class=\"frm_primary_label\">\u0647\u0644 \u062a\u0645 \u0625\u062f\u062e\u0627\u0644\u0643 \u0625\u0644\u0649 \u0627\u0644\u0645\u0633\u062a\u0634\u0641\u0649 \u0645\u0646 \u0642\u0628\u0644 \u0644\u0623\u064a \u0645\u0631\u0636 \u0623\u0648 \u0639\u0645\u0644\u064a\u0629\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_me0er_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_44-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[44]\" id=\"field_me0er-0\" value=\"Yes\" data-reqmsg=\"Have you ever been hospitalized for any illness or operation? cannot be blank.\" data-invmsg=\"Have you ever been hospitalized for any illness or operation? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_44-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[44]\" id=\"field_me0er-1\" value=\"No\" data-reqmsg=\"Have you ever been hospitalized for any illness or operation? cannot be blank.\" data-invmsg=\"Have you ever been hospitalized for any illness or operation? is invalid\"> \u0644\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_45_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_rbajf_label\" class=\"frm_primary_label\">\u0647\u0644 \u0623\u0635\u0628\u062a \u0628\u0645\u0631\u0636 \u062e\u0637\u064a\u0631 \u0623\u0648 \u062d\u0627\u0644\u0629 \u0637\u0628\u064a\u0629 \u062c\u062f\u064a\u0629 \u0645\u0646 \u0642\u0628\u0644\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_rbajf_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_45-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[45]\" id=\"field_rbajf-0\" value=\"Yes\" data-reqmsg=\"Have you ever had a major illness or serious medical condition? cannot be blank.\" data-invmsg=\"Have you ever had a major illness or serious medical condition? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_45-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[45]\" id=\"field_rbajf-1\" value=\"No\" data-reqmsg=\"Have you ever had a major illness or serious medical condition? cannot be blank.\" data-invmsg=\"Have you ever had a major illness or serious medical condition? is invalid\"> \u0644\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_46_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_naskt\" id=\"field_naskt_label\" class=\"frm_primary_label\">\u0625\u0630\u0627 \u0643\u0627\u0646 \u0627\u0644\u062c\u0648\u0627\u0628 \u0646\u0639\u0645\u060c \u064a\u0631\u062c\u0649 \u0627\u0644\u0634\u0631\u062d\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[46]\" id=\"field_naskt\" rows=\"5\" data-invmsg=\"If yes, please explain is invalid\" aria-invalid=\"false\"><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_47_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_l6fau_label\" class=\"frm_primary_label\">\u0647\u0644 \u0623\u0646\u062a \u062d\u0627\u0645\u0644 \u0623\u0645 \u0647\u0646\u0627\u0643 \u0627\u062d\u062a\u0645\u0627\u0644 \u0623\u0646\u0643 \u0642\u062f \u062a\u0643\u0648\u0646\u064a\u0646 \u062d\u0627\u0645\u0644\u064b\u0627\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_l6fau_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_47-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[47]\" id=\"field_l6fau-0\" value=\"Yes\" data-reqmsg=\"Are you pregnant or is there a possibility that you may be pregnant? cannot be blank.\" data-invmsg=\"Are you pregnant or is there a possibility that you may be pregnant? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_47-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[47]\" id=\"field_l6fau-1\" value=\"No\" data-reqmsg=\"Are you pregnant or is there a possibility that you may be pregnant? cannot be blank.\" data-invmsg=\"Are you pregnant or is there a possibility that you may be pregnant? is invalid\"> \u0644\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_69_container\" class=\"frm_form_field  frm_html_container form-field\">\n<div style=\"border-bottom:2px solid #C8102E; padding-bottom:10px; margin:15px 0 25px 0;\">\n<h3 style=\"margin:0; color:#111111; font-size:22px; font-weight:600;\">\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0623\u0633\u0646\u0627\u0646<\/h3>\n<\/div>\n<\/div>\n<div id=\"frm_field_48_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_r5rx3_label\" class=\"frm_primary_label\">\u0647\u0644 \u0648\u0627\u062c\u0647\u062a \u0623\u064a \u0645\u0636\u0627\u0639\u0641\u0627\u062a \u0623\u0648 \u0645\u0634\u0627\u0643\u0644 \u0645\u0639 \u0639\u0644\u0627\u062c \u0627\u0644\u0623\u0633\u0646\u0627\u0646 \u0627\u0644\u0633\u0627\u0628\u0642\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_r5rx3_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_48-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[48]\" id=\"field_r5rx3-0\" value=\"Yes\" data-reqmsg=\"Have you ever had any complications or problems with previous dental treatment? cannot be blank.\" data-invmsg=\"Have you ever had any complications or problems with previous dental treatment? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_48-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[48]\" id=\"field_r5rx3-1\" value=\"No\" data-reqmsg=\"Have you ever had any complications or problems with previous dental treatment? cannot be blank.\" data-invmsg=\"Have you ever had any complications or problems with previous dental treatment? is invalid\"> \u0644\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_49_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_bpnou\" id=\"field_bpnou_label\" class=\"frm_primary_label\">\u0625\u0630\u0627 \u0643\u0627\u0646 \u0627\u0644\u062c\u0648\u0627\u0628 \u0646\u0639\u0645\u060c \u064a\u0631\u062c\u0649 \u0627\u0644\u0634\u0631\u062d\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[49]\" id=\"field_bpnou\" rows=\"5\" data-invmsg=\"If yes, please explain is invalid\" aria-invalid=\"false\"><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_50_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_x5rxz_label\" class=\"frm_primary_label\">\u0647\u0644 \u062e\u0636\u0639\u062a \u0644\u0623\u0634\u0639\u0629 \u0633\u064a\u0646\u064a\u0629 \u0644\u0644\u0623\u0633\u0646\u0627\u0646 \u062e\u0644\u0627\u0644 \u0627\u0644\u0639\u0627\u0645 \u0627\u0644\u0645\u0627\u0636\u064a\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_x5rxz_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_50-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[50]\" id=\"field_x5rxz-0\" value=\"Yes\" data-reqmsg=\"Have you had dental X-rays taken within the past year? cannot be blank.\" data-invmsg=\"Have you had dental X-rays taken within the past year? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_50-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[50]\" id=\"field_x5rxz-1\" value=\"No\" data-reqmsg=\"Have you had dental X-rays taken within the past year? cannot be blank.\" data-invmsg=\"Have you had dental X-rays taken within the past year? is invalid\"> \u0644\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_51_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_v3aaf\" id=\"field_v3aaf_label\" class=\"frm_primary_label\">\u0645\u062a\u0649 \u0643\u0627\u0646\u062a \u0622\u062e\u0631 \u0632\u064a\u0627\u0631\u0629 \u0644\u0643 \u0644\u0637\u0628 \u0627\u0644\u0623\u0633\u0646\u0627\u0646\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_v3aaf\" name=\"item_meta[51]\" value=\"\" data-invmsg=\"When was your last dental visit? is invalid\" aria-invalid=\"false\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_52_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_nvq3s\" id=\"field_nvq3s_label\" class=\"frm_primary_label\">\u0645\u0627 \u0647\u0648 \u0627\u0644\u0633\u0628\u0628 \u0627\u0644\u0631\u0626\u064a\u0633\u064a \u0644\u0632\u064a\u0627\u0631\u062a\u0643 \u0644\u0637\u0628 \u0627\u0644\u0623\u0633\u0646\u0627\u0646\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[52]\" id=\"field_nvq3s\" rows=\"5\" data-reqmsg=\"What is the main reason for your dental visit? cannot be blank.\" aria-required=\"true\" data-invmsg=\"What is the main reason for your dental visit? is invalid\" aria-invalid=\"false\"><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_53_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n\t<div id=\"field_banr4_label\" class=\"frm_primary_label\">\u0647\u0644 \u062a\u0639\u0627\u0646\u064a \u062d\u0627\u0644\u064a\u064b\u0627 \u0645\u0646 \u0623\u064a \u0645\u0645\u0627 \u064a\u0644\u064a\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_banr4_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-0\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_banr4-0\" value=\"Tooth Pain or Sensitivity\" data-invmsg=\"Are you currently experiencing any of the following? is invalid\"> \u0623\u0644\u0645 \u0623\u0648 \u062d\u0633\u0627\u0633\u064a\u0629 \u0627\u0644\u0623\u0633\u0646\u0627\u0646<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-1\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_banr4-1\" value=\"Bleeding Gums\" data-invmsg=\"Are you currently experiencing any of the following? is invalid\"> \u0646\u0632\u064a\u0641 \u0627\u0644\u0644\u062b\u0629<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-2\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_banr4-2\" value=\"Swollen or Tender Gums\" data-invmsg=\"Are you currently experiencing any of the following? is invalid\"> \u062a\u0648\u0631\u0645 \u0623\u0648 \u062d\u0633\u0627\u0633\u064a\u0629 \u0627\u0644\u0644\u062b\u0629<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-3\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_banr4-3\" value=\"Loose Teeth\" data-invmsg=\"Are you currently experiencing any of the following? is invalid\"> \u0623\u0633\u0646\u0627\u0646 \u0645\u0631\u062a\u062e\u064a\u0629<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-4\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_banr4-4\" value=\"Jaw Pain \/ TMJ Problems\" data-invmsg=\"Are you currently experiencing any of the following? is invalid\"> \u0623\u0644\u0645 \u0627\u0644\u0641\u0643 \/ \u0645\u0634\u0627\u0643\u0644 \u0627\u0644\u0645\u0641\u0635\u0644 \u0627\u0644\u0635\u062f\u063a\u064a \u0627\u0644\u0641\u0643\u064a<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-5\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_banr4-5\" value=\"Clicking or Popping of the Jaw\" data-invmsg=\"Are you currently experiencing any of the following? is invalid\"> \u0635\u0648\u062a \u0637\u0642\u0637\u0642\u0629 \u0623\u0648 \u0641\u0631\u0642\u0639\u0629 \u0641\u064a \u0627\u0644\u0641\u0643<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-6\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_banr4-6\" value=\"Difficulty Chewing\" data-invmsg=\"Are you currently experiencing any of the following? is invalid\"> \u0635\u0639\u0648\u0628\u0629 \u0641\u064a \u0627\u0644\u0645\u0636\u063a<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-7\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_banr4-7\" value=\"Teeth Grinding or Clenching\" data-invmsg=\"Are you currently experiencing any of the following? is invalid\"> \u0637\u062d\u0646 \u0623\u0648 \u0636\u063a\u0637 \u0627\u0644\u0623\u0633\u0646\u0627\u0646<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-8\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_banr4-8\" value=\"Bad Breath\" data-invmsg=\"Are you currently experiencing any of the following? is invalid\"> \u0631\u0627\u0626\u062d\u0629 \u0641\u0645 \u0643\u0631\u064a\u0647\u0629<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-9\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_banr4-9\" value=\"Broken or Chipped Tooth\" data-invmsg=\"Are you currently experiencing any of the following? is invalid\"> \u0633\u0646 \u0645\u0643\u0633\u0648\u0631 \u0623\u0648 \u0645\u062a\u0634\u0642\u0642<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-10\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_banr4-10\" value=\"Other\" data-invmsg=\"Are you currently experiencing any of the following? is invalid\"> \u0623\u062e\u0631\u0649<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-11\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_banr4-11\" value=\"None of the Above\" data-invmsg=\"Are you currently experiencing any of the following? is invalid\"> \u0644\u0627 \u0634\u064a\u0621 \u0645\u0645\u0627 \u0633\u0628\u0642<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_54_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_ta5e8_label\" class=\"frm_primary_label\">\u0647\u0644 \u062a\u062f\u062e\u0651\u0646 \u062d\u0627\u0644\u064a\u0627\u064b \u0623\u0648 \u062a\u0633\u062a\u062e\u062f\u0645 \u0645\u0646\u062a\u062c\u0627\u062a \u0627\u0644\u062a\u0628\u063a\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_ta5e8_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_54-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[54]\" id=\"field_ta5e8-0\" value=\"Yes\" data-reqmsg=\"Do you currently smoke or use tobacco products? cannot be blank.\" data-invmsg=\"Do you currently smoke or use tobacco products? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_54-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[54]\" id=\"field_ta5e8-1\" value=\"No\" data-reqmsg=\"Do you currently smoke or use tobacco products? cannot be blank.\" data-invmsg=\"Do you currently smoke or use tobacco products? is invalid\"> \u0644\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_55_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_mndg1_label\" class=\"frm_primary_label\">\u0647\u0644 \u062a\u0633\u062a\u0647\u0644\u0643 \u0627\u0644\u0645\u0634\u0631\u0648\u0628\u0627\u062a \u0627\u0644\u0643\u062d\u0648\u0644\u064a\u0629\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_mndg1_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_55-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[55]\" id=\"field_mndg1-0\" value=\"Yes\" data-reqmsg=\"Do you consume alcoholic beverages? cannot be blank.\" data-invmsg=\"Do you consume alcoholic beverages? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_55-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[55]\" id=\"field_mndg1-1\" value=\"No\" data-reqmsg=\"Do you consume alcoholic beverages? cannot be blank.\" data-invmsg=\"Do you consume alcoholic beverages? is invalid\"> \u0644\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_56_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_6sixv_label\" class=\"frm_primary_label\">\u0647\u0644 \u064a\u0639\u0627\u0646\u064a \u0623\u064a \u0634\u062e\u0635 \u0645\u0646 \u0639\u0627\u0626\u0644\u062a\u0643 \u0627\u0644\u0645\u0628\u0627\u0634\u0631\u0629 \u0645\u0646 \u0627\u0644\u0633\u0643\u0631\u064a \u0623\u0648 \u0623\u0645\u0631\u0627\u0636 \u0627\u0644\u0642\u0644\u0628 \u0623\u0648 \u0627\u0644\u0633\u0631\u0637\u0627\u0646\u061f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_6sixv_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_56-0\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[56]\" id=\"field_6sixv-0\" value=\"Yes\" data-reqmsg=\"Does anyone in your immediate family have diabetes, heart disease, or cancer? cannot be blank.\" data-invmsg=\"Does anyone in your immediate family have diabetes, heart disease, or cancer? is invalid\"> \u0646\u0639\u0645<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_56-1\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[56]\" id=\"field_6sixv-1\" value=\"No\" data-reqmsg=\"Does anyone in your immediate family have diabetes, heart disease, or cancer? cannot be blank.\" data-invmsg=\"Does anyone in your immediate family have diabetes, heart disease, or cancer? is invalid\"> \u0644\u0627<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_56-2\">\t\t\t<label>\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[56]\" id=\"field_6sixv-2\" value=\"Not Sure\" data-reqmsg=\"Does anyone in your immediate family have diabetes, heart disease, or cancer? cannot be blank.\" data-invmsg=\"Does anyone in your immediate family have diabetes, heart disease, or cancer? is invalid\"> \u0644\u0633\u062a \u0645\u062a\u0623\u0643\u062f\u064b\u0627<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_57_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_dha1z\" id=\"field_dha1z_label\" class=\"frm_primary_label\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u0646\u0639\u0645\u060c \u064a\u0631\u062c\u0649 \u0627\u0644\u062a\u062d\u062f\u064a\u062f\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[57]\" id=\"field_dha1z\" rows=\"5\" data-invmsg=\"If yes, please specify is invalid\" aria-invalid=\"false\"><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_58_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_kgaxm\" id=\"field_kgaxm_label\" class=\"frm_primary_label\">\u0627\u0633\u0645 \u0637\u0628\u064a\u0628 \u0627\u0644\u0623\u0633\u0646\u0627\u0646 \u0627\u0644\u0633\u0627\u0628\u0642 \/ \u0639\u064a\u0627\u062f\u0629 \u0627\u0644\u0623\u0633\u0646\u0627\u0646\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_kgaxm\" name=\"item_meta[58]\" value=\"\" data-invmsg=\"Name of Previous Dentist \/ Dental Office is invalid\" aria-invalid=\"false\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_59_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_1syuu\" id=\"field_1syuu_label\" class=\"frm_primary_label\">\u0631\u0642\u0645 \u0647\u0627\u062a\u0641 \u0637\u0628\u064a\u0628 \u0627\u0644\u0623\u0633\u0646\u0627\u0646 \u0627\u0644\u0633\u0627\u0628\u0642\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_1syuu\" name=\"item_meta[59]\" value=\"\" data-invmsg=\"Previous Dentist Phone Number is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_70_container\" class=\"frm_form_field  frm_html_container form-field\">\n<div style=\"border-bottom:2px solid #C8102E; padding-bottom:10px; margin:15px 0 25px 0;\">\n<h3 style=\"margin:0; color:#111111; font-size:22px; font-weight:600;\">\u0627\u0644\u0645\u0648\u0627\u0641\u0642\u0629 \u0648\u0627\u0644\u062a\u0641\u0648\u064a\u0636<\/h3>\n<\/div>\n<\/div>\n<div id=\"frm_field_60_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_rj9xh_label\" class=\"frm_primary_label\">\u062a\u0641\u0648\u064a\u0636 \u0627\u0644\u062a\u0623\u0645\u064a\u0646\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_rj9xh_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_60-0\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[60][]\" id=\"field_rj9xh-0\" value=\"I authorize the release of information necessary to process my dental insurance claims and authorize payment of applicable insurance benefits to Grand Genesis Dental.\" data-reqmsg=\"Insurance Authorization cannot be blank.\" data-invmsg=\"Insurance Authorization is invalid\" aria-required=\"true\"> \u0623\u0641\u0648\u0636 \u0628\u0625\u0641\u0631\u0627\u062c \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0644\u0627\u0632\u0645\u0629 \u0644\u0645\u0639\u0627\u0644\u062c\u0629 \u0645\u0637\u0627\u0644\u0628\u0627\u062a \u062a\u0623\u0645\u064a\u0646 \u0627\u0644\u0623\u0633\u0646\u0627\u0646 \u0627\u0644\u062e\u0627\u0635\u0629 \u0628\u064a \u0648\u0623\u0641\u0648\u0636 \u0628\u062f\u0641\u0639 \u0627\u0644\u0645\u0633\u062a\u062d\u0642\u0627\u062a \u0627\u0644\u062a\u0623\u0645\u064a\u0646\u064a\u0629 \u0627\u0644\u0645\u0646\u0627\u0633\u0628\u0629 \u0625\u0644\u0649 \u0639\u064a\u0627\u062f\u0629 \u062c\u0631\u0627\u0646\u062f \u062c\u064a\u0646\u064a\u0633\u064a\u0633 \u0644\u0644\u0623\u0633\u0646\u0627\u0646.<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_61_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_1rjr1_label\" class=\"frm_primary_label\">\u0625\u0642\u0631\u0627\u0631 \u0627\u0644\u0645\u0631\u064a\u0636\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_1rjr1_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_61-0\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[61][]\" id=\"field_1rjr1-0\" value=\"I confirm that the information provided in this form is complete and accurate to the best of my knowledge. I understand that I should inform Grand Genesis Dental of any changes to my health, medications, or personal information.\" data-reqmsg=\"Patient Acknowledgment cannot be blank.\" data-invmsg=\"Patient Acknowledgment is invalid\" aria-required=\"true\"> \u0623\u0624\u0643\u062f \u0623\u0646 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0645\u0642\u062f\u0645\u0629 \u0641\u064a \u0647\u0630\u0627 \u0627\u0644\u0646\u0645\u0648\u0630\u062c \u0643\u0627\u0645\u0644\u0629 \u0648\u062f\u0642\u064a\u0642\u0629 \u062d\u0633\u0628 \u0639\u0644\u0645\u064a. \u0623\u0641\u0647\u0645 \u0623\u0646\u0647 \u064a\u062c\u0628 \u0639\u0644\u064a \u0625\u0628\u0644\u0627\u063a \u0639\u064a\u0627\u062f\u0629 \u062c\u0631\u0627\u0646\u062f \u062c\u064a\u0646\u064a\u0633\u064a\u0633 \u0644\u0644\u0623\u0633\u0646\u0627\u0646 \u0628\u0623\u064a \u062a\u063a\u064a\u064a\u0631\u0627\u062a \u0641\u064a \u0635\u062d\u062a\u064a \u0623\u0648 \u0623\u062f\u0648\u064a\u062a\u064a \u0623\u0648 \u0645\u0639\u0644\u0648\u0645\u0627\u062a\u064a \u0627\u0644\u0634\u062e\u0635\u064a\u0629.<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_62_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_iea7s_label\" class=\"frm_primary_label\">\u0627\u0644\u0645\u0648\u0627\u0641\u0642\u0629 \u0639\u0644\u0649 \u0627\u0644\u0639\u0644\u0627\u062c\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_iea7s_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_62-0\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[62][]\" id=\"field_iea7s-0\" value=\"I consent to the dental examination and treatment considered necessary by the dentist and understand that treatment options, benefits, risks, and alternatives will be discussed with me as appropriate.\" data-reqmsg=\"Consent to Treatment cannot be blank.\" data-invmsg=\"Consent to Treatment is invalid\" aria-required=\"true\"> \u0623\u0648\u0627\u0641\u0642 \u0639\u0644\u0649 \u0627\u0644\u0641\u062d\u0635 \u0627\u0644\u0633\u0646\u064a \u0648\u0627\u0644\u0639\u0644\u0627\u062c \u0627\u0644\u0630\u064a \u064a\u0639\u062a\u0628\u0631\u0647 \u0637\u0628\u064a\u0628 \u0627\u0644\u0623\u0633\u0646\u0627\u0646 \u0636\u0631\u0648\u0631\u064a\u064b\u0627 \u0648\u0623\u0641\u0647\u0645 \u0623\u0646\u0647 \u0633\u064a\u062a\u0645 \u0645\u0646\u0627\u0642\u0634\u0629 \u062e\u064a\u0627\u0631\u0627\u062a \u0627\u0644\u0639\u0644\u0627\u062c \u0648\u0627\u0644\u0641\u0648\u0627\u0626\u062f \u0648\u0627\u0644\u0645\u062e\u0627\u0637\u0631 \u0648\u0627\u0644\u0628\u062f\u0627\u0626\u0644 \u0645\u0639\u064a \u062d\u0633\u0628 \u0627\u0644\u0627\u0642\u062a\u0636\u0627\u0621.<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_63_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_cr9oi\" id=\"field_cr9oi_label\" class=\"frm_primary_label\">\u0627\u0644\u0627\u0633\u0645 \u0627\u0644\u0643\u0627\u0645\u0644 \u0644\u0644\u0645\u0631\u064a\u0636 \/ \u0627\u0644\u0648\u0627\u0644\u062f \u0623\u0648 \u0627\u0644\u0648\u0635\u064a\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_cr9oi\" name=\"item_meta[63]\" value=\"\" data-reqmsg=\"Patient \/ Parent or Guardian Full Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Patient \/ Parent or Guardian Full Name is invalid\" aria-invalid=\"false\">\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_64_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div id=\"field_qyw26_label\" class=\"frm_primary_label\">\u0625\u0642\u0631\u0627\u0631 \u0625\u0644\u0643\u062a\u0631\u0648\u0646\u064a\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_qyw26_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_64-0\">\t\t\t<label>\n\t\t\t<input type=\"checkbox\" name=\"item_meta[64][]\" id=\"field_qyw26-0\" value=\"By submitting this form, I confirm that the name entered above is my own (or that I am the patient\u2019s parent\/legal guardian) and that I am submitting this information electronically to Grand Genesis Dental.\" data-reqmsg=\"Electronic Acknowledgment cannot be blank.\" data-invmsg=\"Electronic Acknowledgment is invalid\" aria-required=\"true\"> \u0628\u0625\u0631\u0633\u0627\u0644 \u0647\u0630\u0627 \u0627\u0644\u0646\u0645\u0648\u0630\u062c\u060c \u0623\u0624\u0643\u062f \u0623\u0646 \u0627\u0644\u0627\u0633\u0645 \u0627\u0644\u0645\u062f\u062e\u0644 \u0623\u0639\u0644\u0627\u0647 \u0647\u0648 \u0627\u0633\u0645\u064a (\u0623\u0648 \u0623\u0646\u0646\u064a \u0648\u0627\u0644\u062f\/\u0627\u0644\u0648\u0635\u064a \u0627\u0644\u0642\u0627\u0646\u0648\u0646\u064a \u0644\u0644\u0645\u0631\u064a\u0636) \u0648\u0623\u0646\u0646\u064a \u0623\u0631\u0633\u0644 \u0647\u0630\u0647 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0625\u0644\u0643\u062a\u0631\u0648\u0646\u064a\u064b\u0627 \u0625\u0644\u0649 \u0639\u064a\u0627\u062f\u0629 \u062c\u0631\u0627\u0646\u062f \u062c\u064a\u0646\u064a\u0633\u064a\u0633 \u0644\u0644\u0623\u0633\u0646\u0627\u0646.<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_65_container\" class=\"frm_form_field form-field  frm_none_container\"><div id=\"field_qw0ei\" class=\"frm-g-recaptcha\" data-sitekey=\"6LdBXSopAAAAAMYO_bgCym0nGajw015YOCE-aSbZ\" data-size=\"normal\" data-theme=\"light\"><\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_21_container\" class=\"frm_form_field form-field \">\r\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit\" type=\"submit\">\u0625\u0631\u0633\u0627\u0644<\/button>\r\n\r\n\r\n\r\n<\/div>\r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\">\n\t\t\t<div id=\"frm_field_83_container\">\n\t\t\t<label for=\"field_2muoe\">\n\t\t\t\t\u0625\u0630\u0627 \u0643\u0646\u062a \u0625\u0646\u0633\u0627\u0646\u064b\u0627\u060c \u0627\u062a\u0631\u0643 \u0647\u0630\u0627 \u0627\u0644\u062d\u0642\u0644 \u0641\u0627\u0631\u063a\u064b\u0627.\t\t\t<\/label>\n\t\t\t<input id=\"field_2muoe\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[83]\" value=\"\">\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"JXEW+jYJz7dojBmpe4HIqWDOiQqFdoTp6pG18o8mBro=\"><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-4db8ed9e e-flex e-con-boxed e-con e-parent\" data-id=\"4db8ed9e\" data-element_type=\"container\" data-e-type=\"container\" data-settings='{\"background_background\":\"classic\"}'>\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-23ccb144 e-con-full e-flex e-con e-child\" data-id=\"23ccb144\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-48be3fe2 elementor-widget elementor-widget-image\" data-id=\"48be3fe2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"1024\" height=\"402\" src=\"https:\/\/grandgenesisdental.com\/wp-content\/uploads\/2026\/09\/aa2-1024x402.png\" class=\"attachment-large size-large wp-image-3460\" alt=\"\" srcset=\"https:\/\/grandgenesisdental.com\/wp-content\/uploads\/2026\/09\/aa2-1024x402.png 1024w, https:\/\/grandgenesisdental.com\/wp-content\/uploads\/2026\/09\/aa2-300x118.png 300w, https:\/\/grandgenesisdental.com\/wp-content\/uploads\/2026\/09\/aa2-768x302.png 768w, https:\/\/grandgenesisdental.com\/wp-content\/uploads\/2026\/09\/aa2-1536x603.png 1536w, https:\/\/grandgenesisdental.com\/wp-content\/uploads\/2026\/09\/aa2.png 2001w\" sizes=\"(max-width: 1024px) 100vw, 1024px\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-53702faa elementor-widget elementor-widget-text-editor\" data-id=\"53702faa\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>\u0631\u0639\u0627\u064a\u0629 \u0623\u0633\u0646\u0627\u0646 \u0631\u062d\u064a\u0645\u0629 \u0648\u0639\u0635\u0631\u064a\u0629 \u0644\u0644\u0645\u0631\u0636\u0649 \u0645\u0646 \u062c\u0645\u064a\u0639 \u0627\u0644\u0623\u0639\u0645\u0627\u0631 \u0641\u064a \u0631\u064a\u062a\u0634\u0645\u0648\u0646\u062f \u0647\u064a\u0644.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-23dc0e28 e-con-full e-flex e-con e-child\" data-id=\"23dc0e28\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6f94cb8 elementor-widget elementor-widget-heading\" data-id=\"6f94cb8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">\u0631\u0648\u0627\u0628\u0637 \u0633\u0631\u064a\u0639\u0629<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-25e74901 elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"25e74901\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\/ar\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-check\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u0627\u0644\u0631\u0626\u064a\u0633\u064a\u0629<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\/ar\/about-us\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-times\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u0645\u0646 \u0646\u062d\u0646<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\/ar\/our-services\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-dot-circle\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u062e\u062f\u0645\u0627\u062a\u0646\u0627<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\/ar\/new-patients\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-check\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u0645\u0631\u0636\u0649 \u062c\u062f\u062f<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\/ar\/reviews\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-check\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u0627\u0644\u062a\u0639\u0644\u064a\u0642\u0627\u062a<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\/ar\/contact-us\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-check\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u0627\u062a\u0635\u0644 \u0628\u0646\u0627<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-36710e5f e-con-full e-flex e-con e-child\" data-id=\"36710e5f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3f8f09b0 elementor-widget elementor-widget-heading\" data-id=\"3f8f09b0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0623\u0633\u0646\u0627\u0646<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5452b5f3 elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"5452b5f3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\/ar\/our-services\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-check\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u0637\u0628 \u0623\u0633\u0646\u0627\u0646 \u0627\u0644\u0637\u0648\u0627\u0631\u0626<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\/ar\/our-services\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-times\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u0637\u0628 \u0623\u0633\u0646\u0627\u0646 \u0627\u0644\u0623\u0637\u0641\u0627\u0644<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\/ar\/our-services\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-dot-circle\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u0632\u0631\u0639\u0627\u062a \u0627\u0644\u0623\u0633\u0646\u0627\u0646<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\/ar\/our-services\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-check\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u0637\u0628 \u0623\u0633\u0646\u0627\u0646 \u062a\u062c\u0645\u064a\u0644\u064a<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\/ar\/our-services\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-check\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u062a\u064a\u062c\u0627\u0646 \u0648\u062c\u0633\u0648\u0631<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"\/ar\/our-services\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-check\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u062a\u0642\u0648\u064a\u0645 \u0627\u0644\u0623\u0633\u0646\u0627\u0646<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-5c6f28a5 e-con-full e-flex e-con e-child\" data-id=\"5c6f28a5\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3609e1c9 elementor-widget elementor-widget-heading\" data-id=\"3609e1c9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">\u0627\u062a\u0635\u0644 \u0628\u0646\u0627<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-64d599aa elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"64d599aa\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-check\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">9080 Yonge St, #10 &amp; #11, Richmond Hill, ON L4C 0Y7<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"tel:+19055978700\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-times\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">(905) 597-8700<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"mailto:info@grandgenesisdental.com\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-dot-circle\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">\u0631\u0627\u0633\u0644\u0646\u0627 \u0639\u0628\u0631 \u0627\u0644\u0628\u0631\u064a\u062f \u0627\u0644\u0625\u0644\u0643\u062a\u0631\u0648\u0646\u064a<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-315e0c39 e-flex e-con-boxed e-con e-parent\" data-id=\"315e0c39\" data-element_type=\"container\" data-e-type=\"container\" data-settings='{\"background_background\":\"classic\"}'>\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-141959ea elementor-widget elementor-widget-text-editor\" data-id=\"141959ea\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>\u00a9 2026 Grand Genesis Dental. \u062c\u0645\u064a\u0639 \u0627\u0644\u062d\u0642\u0648\u0642 \u0645\u062d\u0641\u0648\u0638\u0629.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-74807dd4 elementor-widget elementor-widget-text-editor\" data-id=\"74807dd4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><span style=\"font-size: 12px; letter-spacing: 2px;\">\u0635\u0645\u0645 \u0628\u0648\u0627\u0633\u0637\u0629<\/span> <span style=\"font-size: 20px; font-style: italic; font-weight: 600; color: #c8102e;\">A.A<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>9080 Yonge St, #10 &amp; #11, Richmond Hill, ON L4C 0Y7 info@grandgenesisdental.com Facebook Instagram (905) 597-8700 Call Us Today BOOK \u0645\u0631\u062d\u0628\u064b\u0627 \u0628\u0643\u0645 \u0641\u064a Grand Genesis Dental \u0646\u062d\u0646 \u0633\u0639\u062f\u0627\u0621 \u0628\u062a\u0631\u062d\u064a\u0628 \u0627\u0644\u0645\u0631\u0636\u0649 \u0627\u0644\u062c\u062f\u062f \u0641\u064a \u0639\u064a\u0627\u062f\u0629 \u0627\u0644\u0623\u0633\u0646\u0627\u0646 \u0641\u064a \u0631\u064a\u062a\u0634\u0645\u0648\u0646\u062f \u0647\u064a\u0644. \u0623\u0643\u0645\u0644 \u0646\u0645\u0648\u0630\u062c \u0627\u0644\u0645\u0631\u064a\u0636 \u0627\u0644\u062c\u062f\u064a\u062f \u0639\u0628\u0631 \u0627\u0644\u0625\u0646\u062a\u0631\u0646\u062a \u0642\u0628\u0644 \u0632\u064a\u0627\u0631\u062a\u0643 \u0627\u0644\u0623\u0648\u0644\u0649 \u0644\u062a\u0633\u0647\u064a\u0644 \u0639\u0645\u0644\u064a\u0629 \u0627\u0644\u062a\u0633\u062c\u064a\u0644 \u0648\u062c\u0639\u0644\u0647\u0627 \u0645\u0631\u064a\u062d\u0629. \u0623\u0643\u0645\u0644 \u2026<\/p>\n","protected":false},"author":13,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"footnotes":""},"class_list":["post-3439","page","type-page","status-publish","hentry"],"blocksy_meta":{"styles_descriptor":{"styles":{"desktop":"","tablet":"","mobile":""},"google_fonts":[],"version":8}},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>New Patients - Grand Genesis Dental<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/grandgenesisdental.com\/new-patients\/\" \/>\n<meta property=\"og:locale\" content=\"ar_AR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"New Patients - Grand Genesis Dental\" \/>\n<meta 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