{"id":1505,"date":"2019-06-13T10:20:53","date_gmt":"2019-06-13T16:20:53","guid":{"rendered":"https:\/\/clear-dental.ca\/?page_id=1505"},"modified":"2022-02-05T14:40:24","modified_gmt":"2022-02-05T21:40:24","slug":"information-form","status":"publish","type":"page","link":"https:\/\/clear-dental.ca\/patient-forms\/information-form\/","title":{"rendered":"Patient Information Form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;margin-bottom: 0px;margin-top: 0px;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"margin-top:0px;margin-bottom:20px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-1\"><\/div><div class=\"forminator-ui forminator-custom-form forminator-custom-form-3392 forminator-design--material  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-3392\" data-uid=\"662d7c2633fe1\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-3392\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-3392 forminator-design--material  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"3392\"\n\t\t\t\t\n\t\t\t\tdata-design=\"material\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"662d7c2633fe1\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div role=\"tablist\" class=\"forminator-pagination-steps\" aria-label=\"Pagination\"><\/div><div tabindex=\"0\" role=\"tabpanel\" id=\"forminator-custom-form-3392--page-0\" class=\"forminator-pagination forminator-pagination-start\" aria-labelledby=\"forminator-custom-form-3392--page-0-label\" data-step=\"0\" data-label=\"Finish\" data-name=\"page-break-1\"><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_662d7c2633fe1\" id=\"forminator-field-name-1_662d7c2633fe1-label\" class=\"forminator-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_662d7c2633fe1\" id=\"forminator-field-name-2_662d7c2633fe1-label\" class=\"forminator-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_662d7c2633fe1\" id=\"forminator-field-name-3_662d7c2633fe1-label\" class=\"forminator-label\">Preferred Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-3392__field--select-2_662d7c2633fe1\" id=\"forminator-form-3392__field--select-2_662d7c2633fe1-label\" class=\"forminator-label\">Title <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-3392__field--select-2_662d7c2633fe1\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-2\" data-default-value=\"\" data-placeholder=\"Please select an option\" data-search=\"false\" aria-labelledby=\"forminator-form-3392__field--select-2_662d7c2633fe1-label\" aria-describedby=\"forminator-form-3392__field--select-2_662d7c2633fe1-description\"><option value=\"\">Please select an option<\/option><option value=\"mr\"  data-calculation=\"0\">Mr.<\/option><option value=\"mrs\"  data-calculation=\"0\">Mrs.<\/option><option value=\"ms\"  data-calculation=\"0\">Ms.<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-3392__field--select-3_662d7c2633fe1\" id=\"forminator-form-3392__field--select-3_662d7c2633fe1-label\" class=\"forminator-label\">Gender <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-3392__field--select-3_662d7c2633fe1\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-3\" data-default-value=\"\" data-placeholder=\"Please select an option\" data-search=\"false\" aria-labelledby=\"forminator-form-3392__field--select-3_662d7c2633fe1-label\" aria-describedby=\"forminator-form-3392__field--select-3_662d7c2633fe1-description\"><option value=\"\">Please select an option<\/option><option value=\"male\"  data-calculation=\"0\">Male<\/option><option value=\"female\"  data-calculation=\"0\">Female<\/option><\/select><\/div><\/div><div id=\"select-4\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-3392__field--select-4_662d7c2633fe1\" id=\"forminator-form-3392__field--select-4_662d7c2633fe1-label\" class=\"forminator-label\">Status <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-3392__field--select-4_662d7c2633fe1\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-4\" data-default-value=\"\" data-placeholder=\"Please select an option\" data-search=\"false\" aria-labelledby=\"forminator-form-3392__field--select-4_662d7c2633fe1-label\" aria-describedby=\"forminator-form-3392__field--select-4_662d7c2633fe1-description\"><option value=\"\">Please select an option<\/option><option value=\"married\"  data-calculation=\"0\">Married<\/option><option value=\"single\"  data-calculation=\"0\">Single<\/option><option value=\"child\"  data-calculation=\"0\">Child<\/option><option value=\"other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_662d7c2633fe1\" id=\"forminator-field-date-1-picker_662d7c2633fe1-label\" class=\"forminator-label\">Birth Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-1-picker_662d7c2633fe1\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_662d7c2633fe1\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1924\" data-end-year=\"2124\" data-past-dates=\"enable\" data-start-of-week=\"0\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_662d7c2633fe1\" id=\"forminator-field-email-1_662d7c2633fe1-label\" class=\"forminator-label\">Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_662d7c2633fe1\" class=\"forminator-input forminator-email--field\" data-required=\"true\" aria-required=\"true\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_662d7c2633fe1\" id=\"forminator-field-phone-1_662d7c2633fe1-label\" class=\"forminator-label\">Phone Number (Home) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"E.g. +1 3004005000\" id=\"forminator-field-phone-1_662d7c2633fe1\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" data-validation=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_662d7c2633fe1\" id=\"forminator-field-phone-2_662d7c2633fe1-label\" class=\"forminator-label\">Phone Number (Cell)<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"E.g. +1 3004005000\" id=\"forminator-field-phone-2_662d7c2633fe1\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-validation=\"1\" \/><\/div><\/div><div id=\"phone-3\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-3_662d7c2633fe1\" id=\"forminator-field-phone-3_662d7c2633fe1-label\" class=\"forminator-label\">Phone Number (Work)<\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"E.g. +1 3004005000\" id=\"forminator-field-phone-3_662d7c2633fe1\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-validation=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-3392__field--select-1_662d7c2633fe1\" id=\"forminator-form-3392__field--select-1_662d7c2633fe1-label\" class=\"forminator-label\">Preferred Time of Contact <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-3392__field--select-1_662d7c2633fe1\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-1\" data-default-value=\"\" data-placeholder=\"Please select\" data-search=\"false\" aria-labelledby=\"forminator-form-3392__field--select-1_662d7c2633fe1-label\" aria-describedby=\"forminator-form-3392__field--select-1_662d7c2633fe1-description\"><option value=\"\">Please select<\/option><option value=\"morning\"  data-calculation=\"0\">Morning<\/option><option value=\"afternoon\"  data-calculation=\"0\">Afternoon<\/option><option value=\"late-afternoon\"  data-calculation=\"0\">Late Afternoon<\/option><\/select><\/div><\/div><div id=\"select-6\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-3392__field--select-6_662d7c2633fe1\" id=\"forminator-form-3392__field--select-6_662d7c2633fe1-label\" class=\"forminator-label\">Preferred Method of Contact <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-3392__field--select-6_662d7c2633fe1\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-6\" data-default-value=\"\" data-placeholder=\"Please select\" data-search=\"false\" aria-labelledby=\"forminator-form-3392__field--select-6_662d7c2633fe1-label\" aria-describedby=\"forminator-form-3392__field--select-6_662d7c2633fe1-description\"><option value=\"\">Please select<\/option><option value=\"email\"  data-calculation=\"0\">Email<\/option><option value=\"phone-home\"  data-calculation=\"0\">Phone (Home)<\/option><option value=\"phone-cell\"  data-calculation=\"0\">Phone (Cell)<\/option><option value=\"phone-work\"  data-calculation=\"0\">Phone (Work)<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-10\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-10_662d7c2633fe1\" id=\"forminator-field-text-10_662d7c2633fe1-label\" class=\"forminator-label\">Address Line 1 <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-10\" value=\"\" placeholder=\"\" id=\"forminator-field-text-10_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-11\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-11_662d7c2633fe1\" id=\"forminator-field-text-11_662d7c2633fe1-label\" class=\"forminator-label\">Address Line 2 <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-11\" value=\"\" placeholder=\"\" id=\"forminator-field-text-11_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-12\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-12_662d7c2633fe1\" id=\"forminator-field-text-12_662d7c2633fe1-label\" class=\"forminator-label\">City <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-12\" value=\"\" placeholder=\"\" id=\"forminator-field-text-12_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-13\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-13_662d7c2633fe1\" id=\"forminator-field-text-13_662d7c2633fe1-label\" class=\"forminator-label\">Province <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-13\" value=\"\" placeholder=\"\" id=\"forminator-field-text-13_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-14\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-14_662d7c2633fe1\" id=\"forminator-field-text-14_662d7c2633fe1-label\" class=\"forminator-label\">Postal Code <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-14\" value=\"\" placeholder=\"\" id=\"forminator-field-text-14_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><\/div><\/div><div tabindex=\"0\" role=\"tabpanel\" id=\"forminator-custom-form-3392--page-1\" class=\"forminator-pagination\" aria-labelledby=\"forminator-custom-form-3392--page-1-label\" aria-hidden=\"true\" data-step=\"1\" data-label=\"Page  1\" data-name=\"page-break-2\" hidden><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Employment Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_662d7c2633fe1\" id=\"forminator-field-text-1_662d7c2633fe1-label\" class=\"forminator-label\">Employer Name<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"phone-4\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-4_662d7c2633fe1\" id=\"forminator-field-phone-4_662d7c2633fe1-label\" class=\"forminator-label\">Employer Phone<\/label><input type=\"text\" name=\"phone-4\" value=\"\" placeholder=\"E.g. +1 3004005000\" id=\"forminator-field-phone-4_662d7c2633fe1\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-validation=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-15\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-15_662d7c2633fe1\" id=\"forminator-field-text-15_662d7c2633fe1-label\" class=\"forminator-label\">Address Line 1<\/label><input type=\"text\" name=\"text-15\" value=\"\" placeholder=\"\" id=\"forminator-field-text-15_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-16\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-16_662d7c2633fe1\" id=\"forminator-field-text-16_662d7c2633fe1-label\" class=\"forminator-label\">Address Line 2<\/label><input type=\"text\" name=\"text-16\" value=\"\" placeholder=\"\" id=\"forminator-field-text-16_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-17\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-17_662d7c2633fe1\" id=\"forminator-field-text-17_662d7c2633fe1-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"text-17\" value=\"\" placeholder=\"\" id=\"forminator-field-text-17_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-18\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-18_662d7c2633fe1\" id=\"forminator-field-text-18_662d7c2633fe1-label\" class=\"forminator-label\">Province<\/label><input type=\"text\" name=\"text-18\" value=\"\" placeholder=\"\" id=\"forminator-field-text-18_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-19\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-19_662d7c2633fe1\" id=\"forminator-field-text-19_662d7c2633fe1-label\" class=\"forminator-label\">Postal Code<\/label><input type=\"text\" name=\"text-19\" value=\"\" placeholder=\"\" id=\"forminator-field-text-19_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><div tabindex=\"0\" role=\"tabpanel\" id=\"forminator-custom-form-3392--page-2\" class=\"forminator-pagination\" aria-labelledby=\"forminator-custom-form-3392--page-2-label\" aria-hidden=\"true\" data-step=\"2\" data-label=\"Page  2\" data-name=\"\" hidden><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Insurance Information<\/h2><h3 class=\"forminator-subtitle\">Primary Dental Insurance<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_662d7c2633fe1\" id=\"forminator-field-name-4_662d7c2633fe1-label\" class=\"forminator-label\">First Name of Insured<\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-5_662d7c2633fe1\" id=\"forminator-field-name-5_662d7c2633fe1-label\" class=\"forminator-label\">Last Name of Insured<\/label><input type=\"text\" name=\"name-5\" value=\"\" placeholder=\"\" id=\"forminator-field-name-5_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_662d7c2633fe1\" id=\"forminator-field-date-3-picker_662d7c2633fe1-label\" class=\"forminator-label\">Birth Date<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-3-picker_662d7c2633fe1\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-3-picker_662d7c2633fe1\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1924\" data-end-year=\"2124\" data-past-dates=\"enable\" data-start-of-week=\"0\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"select-7\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-3392__field--select-7_662d7c2633fe1\" id=\"forminator-form-3392__field--select-7_662d7c2633fe1-label\" class=\"forminator-label\">Patient&#039;s Relationship to Insured<\/label><select id=\"forminator-form-3392__field--select-7_662d7c2633fe1\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-7\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-3392__field--select-7_662d7c2633fe1-label\" aria-describedby=\"forminator-form-3392__field--select-7_662d7c2633fe1-description\"><option value=\"self\"  data-calculation=\"0\">Self<\/option><option value=\"spouse\"  data-calculation=\"0\">Spouse<\/option><option value=\"child\"  data-calculation=\"0\">Child<\/option><option value=\"other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_662d7c2633fe1\" id=\"forminator-field-text-2_662d7c2633fe1-label\" class=\"forminator-label\">Insurance Plan Name<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-5\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-5_662d7c2633fe1\" id=\"forminator-field-phone-5_662d7c2633fe1-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-5\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-5_662d7c2633fe1\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_662d7c2633fe1\" id=\"forminator-field-text-3_662d7c2633fe1-label\" class=\"forminator-label\">I.D. #<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_662d7c2633fe1\" id=\"forminator-field-text-4_662d7c2633fe1-label\" class=\"forminator-label\">Group Name<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_662d7c2633fe1\" id=\"forminator-field-text-5_662d7c2633fe1-label\" class=\"forminator-label\">Group Number<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h3 class=\"forminator-subtitle\">Secondary Dental Insurance<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-6\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-6_662d7c2633fe1\" id=\"forminator-field-name-6_662d7c2633fe1-label\" class=\"forminator-label\">First Name of Insured<\/label><input type=\"text\" name=\"name-6\" value=\"\" placeholder=\"\" id=\"forminator-field-name-6_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"name-7\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-7_662d7c2633fe1\" id=\"forminator-field-name-7_662d7c2633fe1-label\" class=\"forminator-label\">Last Name of Insured<\/label><input type=\"text\" name=\"name-7\" value=\"\" placeholder=\"\" id=\"forminator-field-name-7_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_662d7c2633fe1\" id=\"forminator-field-date-4-picker_662d7c2633fe1-label\" class=\"forminator-label\">Birth Date<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-4-picker_662d7c2633fe1\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-4-picker_662d7c2633fe1\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1924\" data-end-year=\"2124\" data-past-dates=\"enable\" data-start-of-week=\"0\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"select-8\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-3392__field--select-8_662d7c2633fe1\" id=\"forminator-form-3392__field--select-8_662d7c2633fe1-label\" class=\"forminator-label\">Patient&#039;s Relationship to Insured<\/label><select id=\"forminator-form-3392__field--select-8_662d7c2633fe1\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-8\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-3392__field--select-8_662d7c2633fe1-label\" aria-describedby=\"forminator-form-3392__field--select-8_662d7c2633fe1-description\"><option value=\"self\"  data-calculation=\"0\">Self<\/option><option value=\"spouse\"  data-calculation=\"0\">Spouse<\/option><option value=\"child\"  data-calculation=\"0\">Child<\/option><option value=\"other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_662d7c2633fe1\" id=\"forminator-field-text-6_662d7c2633fe1-label\" class=\"forminator-label\">Insurance Plan Name<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-6\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-6_662d7c2633fe1\" id=\"forminator-field-phone-6_662d7c2633fe1-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-6\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-6_662d7c2633fe1\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_662d7c2633fe1\" id=\"forminator-field-text-7_662d7c2633fe1-label\" class=\"forminator-label\">I.D. #<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_662d7c2633fe1\" id=\"forminator-field-text-8_662d7c2633fe1-label\" class=\"forminator-label\">Group Name<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_662d7c2633fe1\" id=\"forminator-field-text-9_662d7c2633fe1-label\" class=\"forminator-label\">Group Number<\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_662d7c2633fe1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"captcha-1\" class=\"forminator-field-captcha forminator-col forminator-col-12 \"><div class=\"forminator-g-recaptcha recaptcha-invisible\" data-theme=\"light\" data-badge=\"inline\" data-sitekey=\"6LdW4OwUAAAAAI7AhLGi1Bat4xrmFr2DRk-kwTC6\" data-size=\"invisible\"><\/div> <\/div><\/div><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled><span class=\"forminator-button--mask\" aria-label=\"hidden\"><\/span><span class=\"forminator-button--text\">SUBMIT<\/span><\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"983675cb6c\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/1505\" \/><input type=\"hidden\" name=\"form_id\" value=\"3392\"><input type=\"hidden\" name=\"page_id\" value=\"1505\"><input type=\"hidden\" name=\"form_type\" value=\"\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/clear-dental.ca\/patient-forms\/information-form\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><label for=\"input_44\" class=\"forminator-hidden\" aria-hidden=\"true\">Please do not fill in this field. <input id=\"input_44\" type=\"text\" name=\"input_44\" value=\"\" autocomplete=\"off\"><\/label><\/form><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":622,"menu_order":1,"comment_status":"closed","ping_status":"closed","template":"","meta":{"ngg_post_thumbnail":0,"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Patient Information Form - Clear Dental<\/title>\n<meta name=\"description\" content=\"Our Patient Information Form can be completed online or for download to print and bring into your initial appointment with us.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/clear-dental.ca\/patient-forms\/information-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" 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