<?xml version="1.0" encoding="UTF-8"?>
<structure version="20" html-doctype="HTML4 Transitional" compatibility-view="IE9" html-outputextent="Complete" relativeto="*SPS" encodinghtml="UTF-8" encodingrtf="ISO-8859-1" encodingpdf="UTF-8" useimportschema="1" embed-images="1" ShowDesignMarkups="2" enable-authentic-scripts="1" authentic-scripts-in-debug-mode-external="0" generated-file-location="DEFAULT">
	<parameters>
		<parameter name="USE_PDF_FORM" default="yes"/>
	</parameters>
	<schemasources>
		<namespaces/>
		<schemasources>
			<xsdschemasource name="XML" main="1" schemafile="Patient Registration Form.xsd" workingxmlfile="Patient Registration Form.xml"/>
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	<flags>
		<scripts/>
		<mainparts/>
		<globalparts/>
		<designfragments/>
		<pagelayouts/>
		<xpath-functions/>
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	<scripts>
		<script language="javascript"/>
	</scripts>
	<script-project>
		<Project version="4" app="AuthenticView"/>
	</script-project>
	<importedxslt/>
	<globalstyles/>
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			<globaltemplate subtype="main" match="/">
				<document-properties/>
				<children>
					<documentsection>
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						<watermark>
							<image transparency="50" fill-page="1" center-if-not-fill="1"/>
							<text transparency="50"/>
						</watermark>
					</documentsection>
					<template subtype="source" match="XML">
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							<template subtype="element" match="patient-registration-form">
								<children>
									<layout-container locksize="1">
										<styles height="3.50in" overflow="hidden" position="relative" width="5in"/>
										<children>
											<textbox additional-width="4.79in" additional-height="0.02in">
												<styles background-color="#b4b4b4" height="0.21in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="center" top="0.32in" width="7.03in"/>
												<children>
													<text fixtext="REGISTRATION FORM">
														<styles font-family="Arial" font-size="10pt" font-weight="bold"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="5.25in" overflow="hidden" padding="2px" position="absolute" top="0.56in" width="0.83in"/>
												<children>
													<text fixtext="Admission date:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="4.89in" additional-height="-0.03in">
												<styles background-color="#e1e1e1" height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="center" top="0.79in" width="7.03in"/>
												<children>
													<text fixtext="PATIENT INFORMATION">
														<styles font-family="Arial" font-size="8pt" font-weight="bold"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="-0.18in" additional-height="-0.05in">
												<styles height="0.187in" left="6.12in" overflow="hidden" padding="2px" position="absolute" top="0.56in" width="0.91in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="data">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;date&quot;"/>
																		</parameters>
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																<variables/>
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														</children>
														<variables/>
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											</textbox>
											<textbox additional-width="0.12in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="0.99in" width="0.57in"/>
												<children>
													<text fixtext="Last name:">
														<properties id="ddd"/>
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.12in" additional-height="-0.03in">
												<styles height="0.16in" left="2.48in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="0.99in" width="0.28in"/>
												<children>
													<text fixtext="First:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="-0.19in" additional-height="-0.05in">
												<styles height="0.187in" left="0.6in" overflow="hidden" padding="2px" position="absolute" top="1in" width="1.63in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="lastname">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;patientLastName&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
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											</textbox>
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												<properties color="#b4b4b4" width="1px"/>
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											<textbox additional-width="0.01in" additional-height="-0.03in">
												<styles height="0.16in" left="4.30in" overflow="hidden" padding="2px" position="absolute" text-align="right" top="0.99in" width="0.36in"/>
												<children>
													<text fixtext="Middle:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="-0.16in" additional-height="-0.05in">
												<styles height="0.187in" left="2.80in" overflow="hidden" padding="2px" position="absolute" top="1in" width="1.2in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="firstname">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;patientFirstName&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="-16px" additional-height="-4px">
												<styles height="0.187in" left="4.70in" overflow="hidden" padding="2px" position="absolute" top="1in" width="1.1in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="middlename">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;patientMiddleName&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
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											</textbox>
											<shape subtype="line" from-x="6in" from-y="0.96in" to-x="6in" to-y="1.23in">
												<properties color="#b4b4b4" width="1px"/>
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											<textbox additional-width="0.07in" additional-height="-0.03in">
												<styles height="0.16in" left="6.1in" overflow="hidden" padding="2px" position="absolute" text-align="right" top="0.99in" width="0.46in"/>
												<children>
													<text fixtext="Married:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="-0.11in" additional-height="-0.05in">
												<styles height="0.16in" left="6.65in" overflow="hidden" padding="2px" position="absolute" top="1.01in" width="0.34in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="married">
																<children>
																	<checkbox checkedvalue="Yes">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="married"/>
																		<styles font-size="8pt"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</checkbox>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
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											</textbox>
											<shape subtype="line" from-x="0.02in" from-y="1.23in" to-x="7.07in" to-y="1.23in">
												<properties color="#b4b4b4" width="1px"/>
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											<shape subtype="line" from-x="0in" from-y="1.74in" to-x="7.05in" to-y="1.74in">
												<properties color="#b4b4b4" width="1px"/>
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											<textbox additional-width="0.12in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="1.25in" width="1.18in"/>
												<children>
													<text fixtext="Is this your legal name?">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.01in" additional-height="-0.03in">
												<styles height="0.16in" left="0.32in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="1.48in" width="0.19in"/>
												<children>
													<text fixtext="Yes">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.02in" additional-height="-0.03in">
												<styles height="0.16in" left="0.97in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="1.48in" width="0.16in"/>
												<children>
													<text fixtext="No">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="1.30in" from-y="1.74in" to-x="1.30in" to-y="1.23in">
												<properties color="#b4b4b4" width="1px"/>
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											<textbox additional-width="0.15in" additional-height="-0.03in">
												<styles height="0.16in" left="1.40in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="1.25in" width="1.56in"/>
												<children>
													<text fixtext="If not, what is your legal name?">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="-6px" additional-height="-4px">
												<styles height="0.187in" left="1.40in" overflow="hidden" padding="2px" position="absolute" top="1.49in" width="1.67in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="legalname">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;legalName1&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
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											<shape subtype="line" from-x="3.25in" from-y="1.74in" to-x="3.25in" to-y="1.23in">
												<properties color="#b4b4b4" width="1px"/>
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											<textbox additional-width="0.14in" additional-height="-0.03in">
												<styles height="0.16in" left="3.35in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="1.25in" width="0.76in"/>
												<children>
													<text fixtext="Former name:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="-0.03in" additional-height="-4px">
												<styles height="0.187in" left="3.35in" overflow="hidden" padding="2px" position="absolute" top="1.49in" width="0.96in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="formername">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;formerName&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
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											<shape subtype="line" from-x="4.50in" from-y="1.74in" to-x="4.50in" to-y="1.23in">
												<properties color="#b4b4b4" width="1px"/>
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											<textbox additional-width="0.06in" additional-height="-0.03in">
												<styles height="0.16in" left="4.60in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="1.25in" width="0.53in"/>
												<children>
													<text fixtext="Birth date:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="-0.12in" additional-height="-4px">
												<styles height="0.187in" left="4.60in" overflow="hidden" padding="2px" position="absolute" top="1.49in" width="0.65in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="birthday">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;birthday&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
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														</children>
														<variables/>
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											<shape subtype="line" from-x="5.40in" from-y="1.74in" to-x="5.40in" to-y="1.23in">
												<properties color="#b4b4b4" width="1px"/>
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											<textbox additional-width="0.05in" additional-height="-0.03in">
												<styles height="0.16in" left="5.50in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="1.25in" width="0.27in"/>
												<children>
													<text fixtext="Age:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
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											<shape subtype="line" from-x="6in" from-y="1.74in" to-x="6in" to-y="1.23in">
												<properties color="#b4b4b4" width="1px"/>
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											<textbox additional-width="-0.30in" additional-height="-4px">
												<styles height="0.187in" left="5.50in" overflow="hidden" padding="2px" position="absolute" top="1.49in" width="0.31in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="age">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;age&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.07in" additional-height="-0.03in">
												<styles height="0.16in" left="6.20in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="1.25in" width="0.27in"/>
												<children>
													<text fixtext="Sex:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.04in" additional-height="-0.03in">
												<styles height="0.16in" left="6.40in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="1.48in" width="0.13in"/>
												<children>
													<text fixtext="M">
														<styles font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.07in" additional-height="-0.03in">
												<styles height="0.16in" left="6.80in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="1.48in" width="0.13in"/>
												<children>
													<text fixtext="F">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
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											<shape subtype="line" from-x="0in" from-y="2.03in" to-x="7.05in" to-y="2.03in">
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											<textbox additional-width="0.02in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="1.79in" width="0.42in"/>
												<children>
													<text fixtext="Address:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.03in" additional-height="-4px">
												<properties id="address"/>
												<styles height="0.187in" left="0.47in" overflow="hidden" padding="2px" position="absolute" top="1.79in" width="5.69in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="address">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;patientAddress&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.03in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="2.05in" width="0.96in"/>
												<children>
													<text fixtext="Social Security no.:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="3in" from-y="3in" to-x="3in" to-y="2.03in">
												<properties color="#b4b4b4" width="1px"/>
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											<textbox additional-width="0.05in" additional-height="-4px">
												<styles height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" top="2.27in" width="2.76in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="social.security.no">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;socialSecurityNo&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
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											<shape subtype="line" from-x="5in" from-y="3in" to-x="5in" to-y="2.03in">
												<properties color="#b4b4b4" width="1px"/>
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											<shape subtype="line" from-x="0in" from-y="2.52in" to-x="7.05in" to-y="2.52in">
												<properties color="#b4b4b4" width="1px"/>
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											<textbox additional-width="0.13in" additional-height="-0.03in">
												<styles height="0.16in" left="3.20in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="2.05in" width="0.87in"/>
												<children>
													<text fixtext="Home phone no.">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.19in" additional-height="-0.03in">
												<styles height="0.16in" left="5.20in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="2.05in" width="0.96in"/>
												<children>
													<text fixtext="Mobile phone no.:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.03in" additional-height="-4px">
												<styles height="0.187in" left="3.20in" overflow="hidden" padding="2px" position="absolute" top="2.27in" width="1.56in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="home.phone">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;homePhone&quot;"/>
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																	</calltemplate>
																</children>
																<variables/>
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														<variables/>
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												<properties color="#b4b4b4" width="1px"/>
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											<textbox additional-width="0.09in" additional-height="-4px">
												<styles height="0.187in" left="5.20in" overflow="hidden" padding="2px" position="absolute" top="2.27in" width="1.71in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="cell.phone">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;cellPhone&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="2.54in" width="0.90in"/>
												<children>
													<text fixtext="Occupation:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.09in" additional-height="-0.03in">
												<styles height="0.16in" left="3.20in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="2.54in" width="0.56in"/>
												<children>
													<text fixtext="Employer:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.08in" additional-height="-4px">
												<styles height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" top="2.76in" width="2.76in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="occupation">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;occupation&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.17in" additional-height="-0.03in">
												<styles height="0.16in" left="5.20in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="2.54in" width="1.11in"/>
												<children>
													<text fixtext="Employer phone no.:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.10in" additional-height="-4px">
												<styles height="0.187in" left="3.20in" overflow="hidden" padding="2px" position="absolute" top="2.76in" width="1.56in"/>
												<children>
													<template subtype="element" match="employer">
														<children>
															<template subtype="element" match="name">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;employer&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="3.05in" width="3.5in"/>
												<children>
													<text fixtext="Clinic chosen because, or referred by (Please choose one option):">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.04in" additional-height="-4px">
												<styles height="0.187in" left="5.20in" overflow="hidden" padding="2px" position="absolute" top="2.76in" width="1.71in"/>
												<children>
													<template subtype="element" match="employer">
														<children>
															<template subtype="element" match="phone">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;employerPhone&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="3.85in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="3.05in" width="0.75in"/>
												<children>
													<text fixtext="Doctor&apos;s name:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="4.7in" overflow="hidden" padding="2px" position="absolute" top="3.05in" width="1.46in"/>
												<children>
													<template subtype="element" match="clinicselection">
														<children>
															<template subtype="element" match="doctorname">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;doctorNameField&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="3.80in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="3.30in" width="0.76in"/>
												<children>
													<text fixtext="Insurance plan">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="2.60in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="3.30in" width="0.45in"/>
												<children>
													<text fixtext="Hospital">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="3.80in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="3.50in" width="1in"/>
												<children>
													<text fixtext="Close to home/work">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="5.40in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="3.30in" width="0.36in"/>
												<children>
													<text fixtext="Friend">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="2.60in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="3.50in" width="0.76in"/>
												<children>
													<text fixtext="Yellow pages">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="5.40in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="3.50in" width="0.36in"/>
												<children>
													<text fixtext="Other">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="0in" from-y="3.73in" to-x="7.05in" to-y="3.73in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="3.78in" width="2.56in"/>
												<children>
													<text fixtext="Other family members seen at this clinic (list all):">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="4.89in" additional-height="-0.03in">
												<styles background-color="#e1e1e1" height="0.36in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="center" top="4in" width="7.03in"/>
												<children>
													<text fixtext="INSURANCE INFORMATION">
														<styles font-family="Arial" font-size="8pt" font-weight="bold"/>
													</text>
													<newline/>
													<text fixtext="( Please give your insurance card to the receptionist )">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
													<newline/>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="2.64in" overflow="hidden" padding="2px" position="absolute" top="3.78in" width="4.39in"/>
												<children>
													<template subtype="element" match="clinicselection">
														<children>
															<template subtype="element" match="familymembers">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;familyMembers&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="4.40in" width="1.34in"/>
												<children>
													<text fixtext="Insurance subscriber:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="1.7in" from-y="4.90in" to-x="1.7in" to-y="4.38in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" top="4.65in" width="1.56in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="owner">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;insuranceOwner&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.06in" additional-height="-0.03in">
												<styles height="0.16in" left="1.80in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="4.40in" width="0.53in"/>
												<children>
													<text fixtext="Birth date:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="2.90in" from-y="4.90in" to-x="2.90in" to-y="4.38in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="0.02in" additional-height="-0.03in">
												<styles height="0.16in" left="3in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="4.40in" width="2.36in"/>
												<children>
													<text fixtext="Address (if different from above):">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="5.70in" from-y="4.90in" to-x="5.70in" to-y="4.38in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="0.13in" additional-height="-0.03in">
												<styles height="0.16in" left="5.80in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="4.40in" width="0.87in"/>
												<children>
													<text fixtext="Home phone no.">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="1.80in" overflow="hidden" padding="2px" position="absolute" top="4.65in" width="0.76in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="birthday">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;insuranceBirthDate&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="3in" overflow="hidden" padding="2px" position="absolute" top="4.65in" width="2.56in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="address">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;insuranceAddressIfDifferent&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<shape subtype="line" from-x="0in" from-y="4.9in" to-x="7.05in" to-y="4.9in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="5.80in" overflow="hidden" padding="2px" position="absolute" top="4.65in" width="1.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="homephone">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;insuranceHomePhone&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<shape subtype="line" from-x="0in" from-y="5.25in" to-x="7.05in" to-y="5.25in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="4.98in" width="1.45in"/>
												<children>
													<text fixtext="Is subscriber a patient here?">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="2.90in" from-y="5.25in" to-x="2.90in" to-y="4.90in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="0.01in" additional-height="-0.03in">
												<styles height="0.16in" left="1.83in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="4.98in" width="0.19in"/>
												<children>
													<text fixtext="Yes">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.02in" additional-height="-0.03in">
												<styles height="0.16in" left="2.43in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="4.98in" width="0.16in"/>
												<children>
													<text fixtext="No">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="3.05in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="4.98in" width="1.86in"/>
												<children>
													<text fixtext="Is the patient covered by insurance?">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.01in" additional-height="-0.03in">
												<styles height="0.16in" left="5.23in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="4.98in" width="0.19in"/>
												<children>
													<text fixtext="Yes">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.02in" additional-height="-0.03in">
												<styles height="0.16in" left="5.82in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="4.98in" width="0.16in"/>
												<children>
													<text fixtext="No">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="0in" from-y="5.80in" to-x="7.05in" to-y="5.80in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="5.30in" width="1.56in"/>
												<children>
													<text fixtext="Subscriber&apos;s occupation:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="1.7in" from-y="5.80in" to-x="1.7in" to-y="5.25in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" top="5.53in" width="1.56in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="occupation">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;insuranceOccupation&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<shape subtype="line" from-x="5.70in" from-y="5.80in" to-x="5.70in" to-y="5.25in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<shape subtype="line" from-x="2.90in" from-y="5.80in" to-x="2.90in" to-y="5.25in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="0.17in" additional-height="-0.03in">
												<styles height="0.16in" left="5.80in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="5.30in" width="1.11in"/>
												<children>
													<text fixtext="Employer phone no.:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.09in" additional-height="-0.03in">
												<styles height="0.16in" left="1.80in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="5.30in" width="0.56in"/>
												<children>
													<text fixtext="Employer:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.04in" additional-height="-4px">
												<styles height="0.187in" left="5.80in" overflow="hidden" padding="2px" position="absolute" top="5.53in" width="1.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="employer">
																<children>
																	<template subtype="element" match="phone">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insuranceEmployerPhone&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.09in" additional-height="-0.03in">
												<styles height="0.16in" left="3in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="5.30in" width="0.96in"/>
												<children>
													<text fixtext="Employer address:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.10in" additional-height="-4px">
												<styles height="0.187in" left="1.80in" overflow="hidden" padding="2px" position="absolute" top="5.53in" width="0.96in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="employer">
																<children>
																	<template subtype="element" match="name">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insuranceEmployer&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="5.85in" width="0.96in"/>
												<children>
													<text fixtext="Primary insurance:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="0in" from-y="6.10in" to-x="7.05in" to-y="6.10in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="1in" overflow="hidden" padding="2px" position="absolute" top="5.865in" width="6.03in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="primary_insurance">
																<children>
																	<template subtype="element" match="insurance_type">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insurancePrimary&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="6.15in" width="0.96in"/>
												<children>
													<text fixtext="Subscriber&apos;s name:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="1.60in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="6.15in" width="1.05in"/>
												<children>
													<text fixtext="Subscriber&apos;s SS no:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="2.97in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="6.15in" width="0.56in"/>
												<children>
													<text fixtext="Birthday:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="3.83in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="6.15in" width="0.56in"/>
												<children>
													<text fixtext="Group no.:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="4.95in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="6.15in" width="0.56in"/>
												<children>
													<text fixtext="Policy no.:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="6.14in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="6.15in" width="0.85in"/>
												<children>
													<text fixtext="Co-payment ($):">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="1.51in" from-y="6.65in" to-x="1.51in" to-y="6.10in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<shape subtype="line" from-x="2.87in" from-y="6.65in" to-x="2.87in" to-y="6.10in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<shape subtype="line" from-x="3.75in" from-y="6.65in" to-x="3.75in" to-y="6.10in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<shape subtype="line" from-x="4.85in" from-y="6.65in" to-x="4.85in" to-y="6.10in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<shape subtype="line" from-x="6.05in" from-y="6.65in" to-x="6.05in" to-y="6.10in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" top="6.40in" width="1.37in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="primary_insurance">
																<children>
																	<template subtype="element" match="subscriber">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insurancePrimarySubscriberName&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="1.60in" overflow="hidden" padding="2px" position="absolute" top="6.40in" width="1.15in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="primary_insurance">
																<children>
																	<template subtype="element" match="serial_no">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insurancePrimarySubscriberSSNo&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="2.97in" overflow="hidden" padding="2px" position="absolute" top="6.40in" width="0.65in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="primary_insurance">
																<children>
																	<template subtype="element" match="birthday">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insurancePrimaryBirthDate&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="3.83in" overflow="hidden" padding="2px" position="absolute" top="6.40in" width="0.9in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="primary_insurance">
																<children>
																	<template subtype="element" match="group_no">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insurancePrimaryGroupNo&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="4.95in" overflow="hidden" padding="2px" position="absolute" top="6.40in" width="0.99in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="primary_insurance">
																<children>
																	<template subtype="element" match="policy_no">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insurancePrimaryPolicyNo&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="6.14in" overflow="hidden" padding="2px" position="absolute" top="6.40in" width="0.84in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="primary_insurance">
																<children>
																	<template subtype="element" match="co_payment">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insurancePrimaryCoPayment&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<shape subtype="line" from-x="0in" from-y="6.65in" to-x="7.05in" to-y="6.65in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="6.7in" width="1.76in"/>
												<children>
													<text fixtext="Patient&apos;s relationship to subscriber:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="2.80in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="6.70in" width="0.3in"/>
												<children>
													<text fixtext="Self">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="6.70in" width="0.4in"/>
												<children>
													<text fixtext="Spouse">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="4.40in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="6.70in" width="0.3in"/>
												<children>
													<text fixtext="Child">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="5.20in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="6.70in" width="0.35in"/>
												<children>
													<text fixtext="Other:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="0in" from-y="6.95in" to-x="7.05in" to-y="6.95in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="5.60in" overflow="hidden" padding="2px" position="absolute" top="6.7in" width="0.96in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="primary_insurance">
																<children>
																	<template subtype="element" match="patient_relationship">
																		<children>
																			<template subtype="element" match="otherdesc">
																				<children>
																					<calltemplate subtype="named" match="EditableForm">
																						<parameters>
																							<parameter name="id" value="&quot;insurancePrimaryOtherRelationship&quot;"/>
																						</parameters>
																					</calltemplate>
																				</children>
																				<variables/>
																			</template>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="7in" width="2.26in"/>
												<children>
													<text fixtext="Name of secondary insurance (if applicable):">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="2.48in" from-y="7.50in" to-x="2.48in" to-y="6.95in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<shape subtype="line" from-x="5.80in" from-y="7.50in" to-x="5.80in" to-y="6.95in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<shape subtype="line" from-x="4.35in" from-y="7.50in" to-x="4.35in" to-y="6.95in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="2.57in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="7in" width="0.96in"/>
												<children>
													<text fixtext="Subscriber&apos;s name:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="4.45in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="7in" width="0.56in"/>
												<children>
													<text fixtext="Group no.:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="5.9in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="7in" width="0.56in"/>
												<children>
													<text fixtext="Policy no.:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" top="7.24in" width="2.3in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="secondary_insurance">
																<children>
																	<template subtype="element" match="insurancename">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insuranceSecondName&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="2.57in" overflow="hidden" padding="2px" position="absolute" top="7.25in" width="1.65in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="secondary_insurance">
																<children>
																	<template subtype="element" match="subscriber">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insuranceSecondSubscriberName&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="4.45in" overflow="hidden" padding="2px" position="absolute" top="7.25in" width="1.22in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="secondary_insurance">
																<children>
																	<template subtype="element" match="group_no">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insuranceSecondSubscriberGroupNo&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="5.9in" overflow="hidden" padding="2px" position="absolute" top="7.25in" width="1.04in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="secondary_insurance">
																<children>
																	<template subtype="element" match="policy_no">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insuranceSecondSubscriberPolicyNo&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<shape subtype="line" from-x="0in" from-y="7.50in" to-x="7.05in" to-y="7.50in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="7.55in" width="1.76in"/>
												<children>
													<text fixtext="Patient&apos;s relationship to subscriber:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="2.80in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="7.55in" width="0.3in"/>
												<children>
													<text fixtext="Self">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="7.55in" width="0.4in"/>
												<children>
													<text fixtext="Spouse">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="4.40in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="7.55in" width="0.3in"/>
												<children>
													<text fixtext="Child">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.36in" additional-height="-0.03in">
												<styles height="0.16in" left="5.20in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="7.55in" width="0.35in"/>
												<children>
													<text fixtext="Other:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="4.89in" additional-height="-0.03in">
												<styles background-color="#e1e1e1" height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="center" top="7.80in" width="7.03in"/>
												<children>
													<text fixtext="IN CASE OF EMERGENCY">
														<styles font-family="Arial" font-size="8pt" font-weight="bold"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="5.60in" overflow="hidden" padding="2px" position="absolute" top="7.55in" width="0.96in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="secondary_insurance">
																<children>
																	<template subtype="element" match="patient_relationship">
																		<children>
																			<template subtype="element" match="otherdesc">
																				<children>
																					<calltemplate subtype="named" match="EditableForm">
																						<parameters>
																							<parameter name="id" value="&quot;insuranceSecondaryOtherRelationship&quot;"/>
																						</parameters>
																					</calltemplate>
																				</children>
																				<variables/>
																			</template>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="8.05in" width="2.70in"/>
												<children>
													<text fixtext="Name of friend or relative (not living at same address):">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="2.85in" from-y="8.55in" to-x="2.85in" to-y="8in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" top="8.3in" width="2.53in"/>
												<children>
													<template subtype="element" match="emergency_case">
														<children>
															<template subtype="element" match="targetname">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;emergencyTargetName&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="2.97in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="8.05in" width="1.15in"/>
												<children>
													<text fixtext="Relationship to patient:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="4.6in" from-y="8.55in" to-x="4.6in" to-y="8in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="2.97in" overflow="hidden" padding="2px" position="absolute" top="8.30in" width="1.51in"/>
												<children>
													<template subtype="element" match="emergency_case">
														<children>
															<template subtype="element" match="relationship">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;emergencyRelationship&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.13in" additional-height="-0.03in">
												<styles height="0.16in" left="4.7in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="8.05in" width="0.87in"/>
												<children>
													<text fixtext="Home phone no.:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="5.85in" from-y="8.55in" to-x="5.85in" to-y="8in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="4.7in" overflow="hidden" padding="2px" position="absolute" top="8.30in" width="1in"/>
												<children>
													<template subtype="element" match="emergency_case">
														<children>
															<template subtype="element" match="home.phone">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;emergencyHomePhone&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.13in" additional-height="-0.03in">
												<styles height="0.16in" left="5.95in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="8.05in" width="0.87in"/>
												<children>
													<text fixtext="Work phone no.:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="5.95in" overflow="hidden" padding="2px" position="absolute" top="8.30in" width="1in"/>
												<children>
													<template subtype="element" match="emergency_case">
														<children>
															<template subtype="element" match="work.phone">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;emergencyWorkPhone&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="4.89in" additional-height="-0.03in">
												<styles height="0.56in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="8.60in" width="7.03in"/>
												<children>
													<text fixtext="The above information is true to the best of my knowledge. I authorize the amount covered by my insurance to be paid directly to the practice/clinic/physican that provided the service. I understand that I am financially responsible for any balance amount. I also authorize ">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
													<template subtype="element" match="practice.name">
														<children>
															<content subtype="regular">
																<styles border-bottom-color="#787878" border-bottom-style="solid" border-bottom-width="1px" font-family="Arial" font-size="8pt"/>
															</content>
														</children>
														<variables/>
													</template>
													<text fixtext=" or insurance company to relase any information required to process my claims.">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="0in" from-y="8.55in" to-x="7.05in" to-y="8.55in">
												<properties color="#b4b4b4" width="1px"/>
											</shape>
											<shape subtype="line" from-x="1.05in" from-y="9.60in" to-x="3.70in" to-y="9.60in">
												<properties color="#1e1e1e" width="1px"/>
											</shape>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="9.40in" width="0.95in"/>
												<children>
													<text fixtext="Patient signature:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="4.20in" overflow="hidden" padding="2px" position="absolute" text-align="left" top="9.40in" width="0.3in"/>
												<children>
													<text fixtext="Date:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="4.60in" from-y="9.60in" to-x="6.10in" to-y="9.60in">
												<properties color="black" width="1px"/>
											</shape>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="6.20in" overflow="hidden" padding="2px" position="absolute" top="1.50in" width="0.16in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="sex">
																<children>
																	<radiobutton checkedvalue="male">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="male" name="sex"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="6.60in" overflow="hidden" padding="2px" position="absolute" top="1.50in" width="0.16in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="sex">
																<children>
																	<radiobutton checkedvalue="female">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="female" name="sex"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.26in" left="2.38in" overflow="hidden" padding="2px" position="absolute" top="0in" width="1.1in"/>
												<children>
													<condition>
														<children>
															<conditionbranch xpath="$SV_OutputFormat = &apos;PDF&apos; and $USE_PDF_FORM = &apos;yes&apos;">
																<children>
																	<button>
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<children>
																			<text fixtext="Reset"/>
																		</children>
																		<action>
																			<none/>
																		</action>
																		<hyperlink/>
																	</button>
																</children>
															</conditionbranch>
														</children>
													</condition>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.26in" left="1.19in" overflow="hidden" padding="2px" position="absolute" top="0in" width="1.1in"/>
												<children>
													<condition>
														<children>
															<conditionbranch xpath="$SV_OutputFormat = &apos;PDF&apos; and $USE_PDF_FORM = &apos;yes&apos;">
																<children>
																	<button pdfform-type="Print-pdfform">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<children>
																			<text fixtext="Print"/>
																		</children>
																		<action>
																			<none/>
																		</action>
																		<hyperlink/>
																	</button>
																</children>
															</conditionbranch>
														</children>
													</condition>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.26in" left="0in" overflow="hidden" padding="2px" position="absolute" top="0in" width="1.1in"/>
												<children>
													<condition>
														<children>
															<conditionbranch xpath="$SV_OutputFormat = &apos;PDF&apos; and $USE_PDF_FORM = &apos;yes&apos;">
																<children>
																	<button pdfform-type="Submit-pdfform">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<children>
																			<text fixtext="Submit"/>
																		</children>
																		<action>
																			<none/>
																		</action>
																		<hyperlink/>
																	</button>
																</children>
															</conditionbranch>
														</children>
													</condition>
												</children>
											</textbox>
											<textbox autoresize="1" additional-width="29px" additional-height="10%">
												<styles height="0.26in" left="5.46in" overflow="hidden" padding="2px" position="absolute" text-align="right" top="0in" width="1.57in"/>
												<children>
													<condition>
														<children>
															<conditionbranch xpath="$SV_OutputFormat = &apos;PDF&apos; and $USE_PDF_FORM = &apos;yes&apos;">
																<children>
																	<button pdfform-type="NextPage-pdfform">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<children>
																			<text fixtext="Next page"/>
																		</children>
																		<action>
																			<none/>
																		</action>
																		<hyperlink/>
																	</button>
																</children>
															</conditionbranch>
														</children>
													</condition>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" top="0.56in" width="1.16in"/>
												<children>
													<text fixtext="Name of practice/clinic:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="-0.18in" additional-height="-0.05in">
												<styles height="0.187in" left="1.20in" overflow="hidden" padding="2px" position="absolute" top="0.56in" width="1.61in"/>
												<children>
													<template subtype="element" match="practice.name">
														<children>
															<calltemplate subtype="named" match="EditableForm">
																<parameters>
																	<parameter name="id" value="&quot;practiceName&quot;"/>
																</parameters>
															</calltemplate>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="1.6in" overflow="hidden" padding="2px" position="absolute" top="5in" width="0.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="patient">
																<children>
																	<radiobutton checkedvalue="yes">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="yes1" name="insurancePatient"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="2.20in" overflow="hidden" padding="2px" position="absolute" top="5in" width="0.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="patient">
																<children>
																	<radiobutton checkedvalue="no">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="no1" name="insurancePatient"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="5in" overflow="hidden" padding="2px" position="absolute" top="5in" width="0.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="coveredbyinsurance">
																<children>
																	<radiobutton checkedvalue="yes">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="yes2" name="coveredbyinsurance"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="5.60in" overflow="hidden" padding="2px" position="absolute" top="5in" width="0.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="coveredbyinsurance">
																<children>
																	<radiobutton checkedvalue="no">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="no2" name="coveredbyinsurance"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="2.40in" overflow="hidden" padding="2px" position="absolute" top="3.30in" width="0.16in"/>
												<children>
													<template subtype="element" match="clinicselection">
														<children>
															<template subtype="element" match="choose">
																<children>
																	<radiobutton checkedvalue="hospital">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="hospital" name="clinicSelection"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="2.40in" overflow="hidden" padding="2px" position="absolute" top="3.50in" width="0.16in"/>
												<children>
													<template subtype="element" match="clinicselection">
														<children>
															<template subtype="element" match="choose">
																<children>
																	<radiobutton checkedvalue="yellowPages">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="yellowPages" name="clinicSelection"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="3.60in" overflow="hidden" padding="2px" position="absolute" top="3.30in" width="0.16in"/>
												<children>
													<template subtype="element" match="clinicselection">
														<children>
															<template subtype="element" match="choose">
																<children>
																	<radiobutton checkedvalue="insurancePlan">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="insurancePlan" name="clinicSelection"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="3.60in" overflow="hidden" padding="2px" position="absolute" top="3.50in" width="0.16in"/>
												<children>
													<template subtype="element" match="clinicselection">
														<children>
															<template subtype="element" match="choose">
																<children>
																	<radiobutton checkedvalue="closeToHome">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="closeToHome" name="clinicSelection"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="5.20in" overflow="hidden" padding="2px" position="absolute" top="3.30in" width="0.16in"/>
												<children>
													<template subtype="element" match="clinicselection">
														<children>
															<template subtype="element" match="choose">
																<children>
																	<radiobutton checkedvalue="friend">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="friend" name="clinicSelection"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="5.20in" overflow="hidden" padding="2px" position="absolute" top="3.50in" width="0.16in"/>
												<children>
													<template subtype="element" match="clinicselection">
														<children>
															<template subtype="element" match="choose">
																<children>
																	<radiobutton checkedvalue="other0">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="other0" name="clinicSelection"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="3.60in" overflow="hidden" padding="2px" position="absolute" top="3.07in" width="0.16in"/>
												<children>
													<template subtype="element" match="clinicselection">
														<children>
															<template subtype="element" match="choose">
																<children>
																	<radiobutton checkedvalue="doctorName">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="doctorName" name="clinicSelection"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="-0.28in" additional-height="10%">
												<styles height="0.16in" left="2.60in" overflow="hidden" padding="2px" position="absolute" top="6.72in" width="0.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="primary_insurance">
																<children>
																	<template subtype="element" match="patient_relationship">
																		<children>
																			<template subtype="element" match="patientrelationship">
																				<children>
																					<radiobutton checkedvalue="self">
																						<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																						<properties id="self" name="insurancePrimaryPatientRelationship"/>
																						<children>
																							<content subtype="regular"/>
																						</children>
																					</radiobutton>
																				</children>
																				<variables/>
																			</template>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="-0.28in" additional-height="10%">
												<styles height="0.16in" left="3.40in" overflow="hidden" padding="2px" position="absolute" top="7.57in" width="0.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="secondary_insurance">
																<children>
																	<template subtype="element" match="patient_relationship">
																		<children>
																			<template subtype="element" match="patientrelationship">
																				<children>
																					<radiobutton checkedvalue="spouse">
																						<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																						<properties id="spouse1" name="insuranceSecondaryPatientRelationship"/>
																						<children>
																							<content subtype="regular"/>
																						</children>
																					</radiobutton>
																				</children>
																				<variables/>
																			</template>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="-0.28in" additional-height="10%">
												<styles height="0.16in" left="4.20in" overflow="hidden" padding="2px" position="absolute" top="7.57in" width="0.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="secondary_insurance">
																<children>
																	<template subtype="element" match="patient_relationship">
																		<children>
																			<template subtype="element" match="patientrelationship">
																				<children>
																					<radiobutton checkedvalue="child">
																						<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																						<properties id="child1" name="insuranceSecondaryPatientRelationship"/>
																						<children>
																							<content subtype="regular"/>
																						</children>
																					</radiobutton>
																				</children>
																				<variables/>
																			</template>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="-0.28in" additional-height="10%">
												<styles height="0.16in" left="5in" overflow="hidden" padding="2px" position="absolute" top="6.72in" width="0.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="primary_insurance">
																<children>
																	<template subtype="element" match="patient_relationship">
																		<children>
																			<template subtype="element" match="patientrelationship">
																				<children>
																					<radiobutton checkedvalue="other">
																						<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																						<properties id="other" name="insurancePrimaryPatientRelationship"/>
																						<children>
																							<content subtype="regular"/>
																						</children>
																					</radiobutton>
																				</children>
																				<variables/>
																			</template>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="-0.28in" additional-height="10%">
												<styles height="0.16in" left="2.60in" overflow="hidden" padding="2px" position="absolute" top="7.57in" width="0.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="secondary_insurance">
																<children>
																	<template subtype="element" match="patient_relationship">
																		<children>
																			<template subtype="element" match="patientrelationship">
																				<children>
																					<radiobutton checkedvalue="self">
																						<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																						<properties id="self1" name="insuranceSecondaryPatientRelationship"/>
																						<children>
																							<content subtype="regular"/>
																						</children>
																					</radiobutton>
																				</children>
																				<variables/>
																			</template>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="-0.28in" additional-height="10%">
												<styles height="0.16in" left="4.20in" overflow="hidden" padding="2px" position="absolute" top="6.72in" width="0.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="primary_insurance">
																<children>
																	<template subtype="element" match="patient_relationship">
																		<children>
																			<template subtype="element" match="patientrelationship">
																				<children>
																					<radiobutton checkedvalue="child">
																						<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																						<properties id="child" name="insurancePrimaryPatientRelationship"/>
																						<children>
																							<content subtype="regular"/>
																						</children>
																					</radiobutton>
																				</children>
																				<variables/>
																			</template>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="-0.28in" additional-height="10%">
												<styles height="0.16in" left="5in" overflow="hidden" padding="2px" position="absolute" top="7.57in" width="0.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="secondary_insurance">
																<children>
																	<template subtype="element" match="patient_relationship">
																		<children>
																			<template subtype="element" match="patientrelationship">
																				<children>
																					<radiobutton checkedvalue="other">
																						<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																						<properties id="other1" name="insuranceSecondaryPatientRelationship"/>
																						<children>
																							<content subtype="regular"/>
																						</children>
																					</radiobutton>
																				</children>
																				<variables/>
																			</template>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.187in" left="3in" overflow="hidden" padding="2px" position="absolute" top="5.53in" width="2.56in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="employer">
																<children>
																	<template subtype="element" match="address">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;insuranceEmployerAddress&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="-0.28in" additional-height="10%">
												<styles height="0.16in" left="3.4in" overflow="hidden" padding="2px" position="absolute" top="6.73in" width="0.16in"/>
												<children>
													<template subtype="element" match="insurance">
														<children>
															<template subtype="element" match="primary_insurance">
																<children>
																	<template subtype="element" match="patient_relationship">
																		<children>
																			<template subtype="element" match="patientrelationship">
																				<children>
																					<radiobutton checkedvalue="spouse">
																						<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																						<properties id="spouse" name="insurancePrimaryPatientRelationship"/>
																						<children>
																							<content subtype="regular"/>
																						</children>
																					</radiobutton>
																				</children>
																				<variables/>
																			</template>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="0.1in" overflow="hidden" padding="2px" position="absolute" top="1.5in" width="0.16in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="islegalname">
																<children>
																	<radiobutton checkedvalue="yes">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="yes" name="isLegalName"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="0.75in" overflow="hidden" padding="2px" position="absolute" top="1.5in" width="0.16in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="islegalname">
																<children>
																	<radiobutton checkedvalue="no">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<properties id="no" name="isLegalName"/>
																		<children>
																			<content subtype="regular"/>
																		</children>
																	</radiobutton>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
										</children>
									</layout-container>
									<newline break="page"/>
									<layout-container locksize="1">
										<styles height="3.50in" overflow="hidden" position="relative" width="5in"/>
										<children>
											<textbox additional-width="4.89in" additional-height="-0.03in">
												<styles background-color="#b4b4b4" height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="center" top="0.35in" width="7.03in"/>
												<children>
													<text fixtext="Emergency Contact and Medical Information">
														<styles font-family="Arial" font-size="10pt" font-weight="bold"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="0.80in" width="0.96in"/>
												<children>
													<text fixtext="Patient&apos;s  name:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="1in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="0.80in" width="1.96in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="patientName">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;ecmiPatientName&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="3.20in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="0.80in" width="0.68in"/>
												<children>
													<text fixtext="Date of birth:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="3.9in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="0.81in" width="1.11in"/>
												<children>
													<template subtype="element" match="patient">
														<children>
															<template subtype="element" match="birthday">
																<children>
																	<calltemplate subtype="named" match="EditableForm">
																		<parameters>
																			<parameter name="id" value="&quot;ecmiBirthDate&quot;"/>
																		</parameters>
																	</calltemplate>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="5.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="0.80in" width="0.27in"/>
												<children>
													<text fixtext="Sex:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="6.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="0.80in" width="0.16in"/>
												<children>
													<text fixtext="F">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="6.20in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="0.80in" width="0.16in"/>
												<children>
													<text fixtext="M">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="1.40in" width="1.4in"/>
												<children>
													<text fixtext="Guardian&apos;s name">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="1.20in" width="3.36in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="parent1">
																<children>
																	<template subtype="element" match="name">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiGuardianName1&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="1.40in" width="1.4in"/>
												<children>
													<text fixtext="Guardian&apos;s name">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="1.20in" width="3.43in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="parent2">
																<children>
																	<template subtype="element" match="name">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiGuardianName2&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="1.80in" width="1.56in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="parent1">
																<children>
																	<template subtype="element" match="home.phone">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiHomePhone1&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="2in" width="0.76in"/>
												<children>
													<text fixtext="Home phone">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="1.80in" width="1.56in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="parent2">
																<children>
																	<template subtype="element" match="home.phone">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiHomePhone2&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="2in" width="0.76in"/>
												<children>
													<text fixtext="Home phone">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="1.80in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="1.80in" width="1.56in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="parent1">
																<children>
																	<template subtype="element" match="work.phone">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiWorkPhone1&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="1.80in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="2in" width="0.76in"/>
												<children>
													<text fixtext="Work phone">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="5.40in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="1.80in" width="1.63in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="parent2">
																<children>
																	<template subtype="element" match="work.phone">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiWorkPhone2&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="5.40in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="2in" width="0.76in"/>
												<children>
													<text fixtext="Work phone">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="2.40in" width="3.36in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="parent1">
																<children>
																	<template subtype="element" match="address">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiAddress1&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="2.60in" width="1.56in"/>
												<children>
													<text fixtext="Address (City, State, ZIP)">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="2.40in" width="3.43in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="parent2">
																<children>
																	<template subtype="element" match="address">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiAddress2&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="2.60in" width="1.56in"/>
												<children>
													<text fixtext="Address (City, State, ZIP)">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="4.89in" additional-height="-0.03in">
												<styles background-color="#e1e1e1" height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="center" top="3in" width="7.03in"/>
												<children>
													<text fixtext="Alternative Emergency Contacts">
														<styles font-family="Arial" font-size="8pt" font-weight="bold"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="3.40in" width="3.36in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="emergencyContact1">
																<children>
																	<template subtype="element" match="contact">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiPrimaryContact&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="3.60in" width="1.4in"/>
												<children>
													<text fixtext="Primary emergency contact">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="3.40in" width="3.43in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="emergencyContact2">
																<children>
																	<template subtype="element" match="contact">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiSecondaryContact&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="3.60in" width="1.56in"/>
												<children>
													<text fixtext="Secondary emergency contact">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="4in" width="1.56in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="emergencyContact1">
																<children>
																	<template subtype="element" match="home.phone">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiPrimaryHomePhone&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="4.20in" width="0.76in"/>
												<children>
													<text fixtext="Home phone">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="1.80in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="4in" width="1.56in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="emergencyContact1">
																<children>
																	<template subtype="element" match="work.phone">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiPrimaryWorkPhone&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="1.80in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="4.20in" width="0.76in"/>
												<children>
													<text fixtext="Work phone">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="4in" width="1.56in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="emergencyContact2">
																<children>
																	<template subtype="element" match="home.phone">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiSecondaryHomePhone&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="4.20in" width="0.76in"/>
												<children>
													<text fixtext="Home phone">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="5.40in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="4in" width="1.63in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="emergencyContact2">
																<children>
																	<template subtype="element" match="work.phone">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiSecondaryWorkPhone&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="5.40in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="4.20in" width="0.76in"/>
												<children>
													<text fixtext="Work phone">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="4.60in" width="3.36in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="emergencyContact1">
																<children>
																	<template subtype="element" match="address">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiPrimaryAddress&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="4.80in" width="1.56in"/>
												<children>
													<text fixtext="Address (City, State, ZIP)">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="4.60in" width="3.43in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="emergencyContact2">
																<children>
																	<template subtype="element" match="address">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiSecondaryAddress&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="3.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="4.80in" width="1.56in"/>
												<children>
													<text fixtext="Address (City, State, ZIP)">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="4.89in" additional-height="-0.03in">
												<styles background-color="#e1e1e1" height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="center" top="5.20in" width="7.03in"/>
												<children>
													<text fixtext="Medical Information">
														<styles font-family="Arial" font-size="8pt" font-weight="bold"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="5.60in" width="7.03in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="medicalInfo">
																<children>
																	<template subtype="element" match="preference">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiPreference&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="5.80in" width="1.56in"/>
												<children>
													<text fixtext="Preferred hospital/clinic">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="6.20in" width="4.16in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="medicalInfo">
																<children>
																	<template subtype="element" match="physicianName">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiPhysicianName&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="6.40in" width="1.56in"/>
												<children>
													<text fixtext="General physician&apos;s name">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="4.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="6.40in" width="0.76in"/>
												<children>
													<text fixtext="Phone number">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="4.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="6.20in" width="2.43in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="medicalInfo">
																<children>
																	<template subtype="element" match="phoneNo">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiPhoneName&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="6.80in" width="4.16in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="medicalInfo">
																<children>
																	<template subtype="element" match="insuranceCompanyName">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiInsuranceCompany&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="7in" width="1.56in"/>
												<children>
													<text fixtext="Insurance company">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="4.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="7in" width="0.76in"/>
												<children>
													<text fixtext="Policy number">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="4.60in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="6.80in" width="2.43in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="medicalInfo">
																<children>
																	<template subtype="element" match="policyNo">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiPolicyNumber&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.32in" additional-height="10%">
												<styles border-bottom-color="black" border-bottom-style="solid" border-bottom-width="1px" height="0.187in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="7.40in" width="7.03in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="medicalInfo">
																<children>
																	<template subtype="element" match="specialConsiderations">
																		<children>
																			<calltemplate subtype="named" match="EditableForm">
																				<parameters>
																					<parameter name="id" value="&quot;ecmiSpecHealthConsiderations&quot;"/>
																				</parameters>
																			</calltemplate>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="7.60in" width="2.16in"/>
												<children>
													<text fixtext="Allergies and special health considerations">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.76in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="8in" width="7.03in"/>
												<children>
													<text fixtext="I, ">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="patientName">
																<children>
																	<content subtype="regular">
																		<styles border-bottom-color="#787878" border-bottom-style="solid" border-bottom-width="1px" font-size="8pt"/>
																	</content>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
													<text fixtext=","/>
													<text fixtext=" authorize all medical and surgical treatment, as well as X-ray, laboratory, anesthesia, and any other medical and/or hospital procedures that may be performed or prescribed by the attending physician and/or paramedics for my child, and I waive my right to informed consent of treatment, but only in the event that neither parent/guardian can be reached in the case of an emergency. ">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="9in" width="0.95in"/>
												<children>
													<text fixtext="Patient signature:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<textbox additional-width="0.35in" additional-height="-0.03in">
												<styles height="0.16in" left="5in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="9in" width="0.3in"/>
												<children>
													<text fixtext="Date:">
														<styles font-family="Arial" font-size="8pt"/>
													</text>
												</children>
											</textbox>
											<shape subtype="line" from-x="1.05in" from-y="9.20in" to-x="4.40in" to-y="9.20in">
												<properties color="black" width="1px"/>
											</shape>
											<shape subtype="line" from-x="5.40in" from-y="9.20in" to-x="6.90in" to-y="9.20in">
												<properties color="black" width="1px"/>
											</shape>
											<textbox autoresize="1" additional-width="6px" additional-height="10%">
												<styles height="0.26in" left="5.45in" overflow="hidden" padding="2px" position="absolute" text-align="right" top="0in" width="1.58in"/>
												<children>
													<condition>
														<children>
															<conditionbranch xpath="$SV_OutputFormat = &apos;PDF&apos; and $USE_PDF_FORM = &apos;yes&apos;">
																<children>
																	<button pdfform-type="PrevPage-pdfform">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<children>
																			<text fixtext="Previous page"/>
																			<newline/>
																		</children>
																		<action>
																			<none/>
																		</action>
																		<hyperlink/>
																	</button>
																</children>
															</conditionbranch>
														</children>
													</condition>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.26in" left="0in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="0in" width="1.1in"/>
												<children>
													<condition>
														<children>
															<conditionbranch xpath="$SV_OutputFormat = &apos;PDF&apos; and $USE_PDF_FORM = &apos;yes&apos;">
																<children>
																	<button pdfform-type="Submit-pdfform">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<children>
																			<text fixtext="Submit"/>
																		</children>
																		<action>
																			<none/>
																		</action>
																		<hyperlink/>
																	</button>
																</children>
															</conditionbranch>
														</children>
													</condition>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.26in" left="2.38in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="0in" width="1.1in"/>
												<children>
													<condition>
														<children>
															<conditionbranch xpath="$SV_OutputFormat = &apos;PDF&apos; and $USE_PDF_FORM = &apos;yes&apos;">
																<children>
																	<button>
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<children>
																			<text fixtext="Reset"/>
																		</children>
																		<action>
																			<none/>
																		</action>
																		<hyperlink/>
																	</button>
																</children>
															</conditionbranch>
														</children>
													</condition>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.26in" left="1.19in" overflow="hidden" padding="2px" position="absolute" text-align="justify" top="0in" width="1.1in"/>
												<children>
													<condition>
														<children>
															<conditionbranch xpath="$SV_OutputFormat = &apos;PDF&apos; and $USE_PDF_FORM = &apos;yes&apos;">
																<children>
																	<button pdfform-type="Print-pdfform">
																		<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																		<children>
																			<text fixtext="Print"/>
																		</children>
																		<action>
																			<none/>
																		</action>
																		<hyperlink/>
																	</button>
																</children>
															</conditionbranch>
														</children>
													</condition>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="6in" overflow="hidden" padding="2px" position="absolute" top="0.82in" width="0.16in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="medicalInfo">
																<children>
																	<template subtype="element" match="sex">
																		<children>
																			<radiobutton checkedvalue="male">
																				<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																				<properties id="male1" name="sex1"/>
																				<children>
																					<content subtype="regular"/>
																				</children>
																			</radiobutton>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
											<textbox additional-width="20%" additional-height="10%">
												<styles height="0.16in" left="6.4in" overflow="hidden" padding="2px" position="absolute" top="0.82in" width="0.16in"/>
												<children>
													<template subtype="element" match="emergencyContactForm">
														<children>
															<template subtype="element" match="medicalInfo">
																<children>
																	<template subtype="element" match="sex">
																		<children>
																			<radiobutton checkedvalue="female">
																				<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
																				<properties id="female1" name="sex1"/>
																				<children>
																					<content subtype="regular"/>
																				</children>
																			</radiobutton>
																		</children>
																		<variables/>
																	</template>
																</children>
																<variables/>
															</template>
														</children>
														<variables/>
													</template>
												</children>
											</textbox>
										</children>
									</layout-container>
								</children>
								<variables/>
							</template>
						</children>
						<variables/>
					</template>
				</children>
			</globaltemplate>
		</children>
	</mainparts>
	<globalparts/>
	<designfragments>
		<children>
			<globaltemplate subtype="named" match="EditableForm">
				<parameters>
					<parameter name="id" type="xs:string" default-value="&apos;&apos;"/>
				</parameters>
				<children>
					<condition>
						<children>
							<conditionbranch xpath="$USE_PDF_FORM=&quot;yes&quot; and $SV_OutputFormat = &apos;PDF&apos;">
								<children>
									<editfield>
										<editorproperties _xpdfform-enabled="$USE_PDF_FORM"/>
										<properties _xid="$id"/>
										<styles font-family="Arial" font-size="8pt"/>
										<children>
											<content subtype="regular"/>
										</children>
									</editfield>
								</children>
							</conditionbranch>
							<conditionbranch>
								<children>
									<content subtype="regular">
										<styles font-family="Arial" font-size="8pt"/>
									</content>
								</children>
							</conditionbranch>
						</children>
					</condition>
				</children>
			</globaltemplate>
		</children>
	</designfragments>
	<xmltables/>
	<authentic-custom-toolbar-buttons/>
</structure>
