false
19
Registration Form
PatientForm
10
Microsoft Sans Serif
850
1100
false
1
false
false
1249
19
Image
Patient Info.gif
0
false
39
31
761
988
None
false
0
Left
false
-16777216
false
1264
19
CheckBox
PreferContactMethod
0
false
345
299
10
10
None
HmPhone
false
0
Left
false
-16777216
false
1263
19
CheckBox
PreferContactMethod
0
false
429
299
10
10
None
WkPhone
false
0
Left
false
-16777216
false
1262
19
CheckBox
PreferContactMethod
0
false
513
299
10
10
None
WirelessPh
false
0
Left
false
-16777216
false
1261
19
CheckBox
PreferRecallMethod
0
false
605
337
10
10
None
Email
false
0
Left
false
-16777216
false
1260
19
CheckBox
StudentStatus
0
false
346
356
10
10
None
Nonstudent
false
0
Left
false
-16777216
false
1259
19
CheckBox
StudentStatus
0
false
443
356
10
10
None
Fulltime
false
0
Left
false
-16777216
false
1258
19
CheckBox
PreferRecallMethod
0
false
512
337
10
10
None
WirelessPh
false
0
Left
false
-16777216
false
1257
19
CheckBox
PreferConfirmMethod
0
false
605
318
10
10
None
Email
false
0
Left
false
-16777216
false
1256
19
CheckBox
PreferRecallMethod
0
false
343
337
10
10
None
HmPhone
false
0
Left
false
-16777216
false
1255
19
CheckBox
PreferRecallMethod
0
false
428
337
10
10
None
WkPhone
false
0
Left
false
-16777216
false
1254
19
InputField
Email
10
Microsoft Sans Serif
false
114
274
575
16
None
false
0
Left
false
-16777216
false
1253
19
InputField
Preferred
10
Microsoft Sans Serif
false
507
204
150
16
None
false
0
Left
false
-16777216
false
1252
19
InputField
Birthdate
10
Microsoft Sans Serif
false
133
236
105
16
None
false
0
Left
false
-16777216
false
1251
19
InputField
SSN
10
Microsoft Sans Serif
false
292
236
140
16
None
false
0
Left
false
-16777216
false
1250
19
InputField
MiddleI
10
Microsoft Sans Serif
false
447
204
50
16
None
false
0
Left
false
-16777216
false
1248
19
InputField
LName
10
Microsoft Sans Serif
false
126
204
150
16
None
false
0
Left
false
-16777216
false
1247
19
InputField
FName
10
Microsoft Sans Serif
false
293
204
145
16
None
false
0
Left
false
-16777216
false
1246
19
InputField
WkPhone
10
Microsoft Sans Serif
false
152
255
120
16
None
false
0
Left
false
-16777216
false
1245
19
InputField
WirelessPhone
10
Microsoft Sans Serif
false
381
255
120
16
None
false
0
Left
false
-16777216
false
1244
19
InputField
wirelessCarrier
10
Microsoft Sans Serif
false
631
255
130
16
None
false
0
Left
false
-16777216
false
1243
19
CheckBox
Position
0
false
683
241
10
10
None
Single
false
0
Left
false
-16777216
false
1242
19
CheckBox
Gender
0
false
499
241
10
10
None
Male
false
0
Left
false
-16777216
false
1241
19
CheckBox
Gender
0
false
536
241
10
10
None
Female
false
0
Left
false
-16777216
false
1240
19
CheckBox
Position
0
false
649
241
10
10
None
Married
false
0
Left
false
-16777216
false
1239
19
CheckBox
StudentStatus
0
false
520
356
10
10
None
Parttime
false
0
Left
false
-16777216
false
1238
19
CheckBox
ins2Relat
0
false
320
710
10
10
None
Spouse
false
0
Left
false
-16777216
false
1237
19
CheckBox
ins2Relat
0
false
394
710
10
10
None
Child
false
0
Left
false
-16777216
false
1236
19
InputField
ins2SubscriberNameF
10
Microsoft Sans Serif
false
184
726
250
16
None
false
0
Left
false
-16777216
false
1235
19
CheckBox
ins2Relat
0
false
267
710
10
10
None
Self
false
0
Left
false
-16777216
false
1234
19
InputField
ins1EmployerName
10
Microsoft Sans Serif
false
136
638
190
16
None
false
0
Left
false
-16777216
false
1233
19
InputField
ins1GroupName
10
Microsoft Sans Serif
false
419
638
160
16
None
false
0
Left
false
-16777216
false
1232
19
InputField
ins1GroupNum
10
Microsoft Sans Serif
false
638
638
120
16
None
false
0
Left
false
-16777216
false
1231
19
InputField
ins2GroupName
10
Microsoft Sans Serif
false
419
764
160
16
None
false
0
Left
false
-16777216
false
1230
19
InputField
ins2GroupNum
10
Microsoft Sans Serif
false
638
764
120
16
None
false
0
Left
false
-16777216
false
1229
19
InputField
misc
10
Microsoft Sans Serif
false
136
821
600
200
None
false
0
Left
false
-16777216
false
1228
19
InputField
ins2EmployerName
10
Microsoft Sans Serif
false
136
764
190
16
None
false
0
Left
false
-16777216
false
1227
19
InputField
ins2SubscriberID
10
Microsoft Sans Serif
false
565
726
140
16
None
false
0
Left
false
-16777216
false
1226
19
InputField
ins2CarrierName
10
Microsoft Sans Serif
false
201
745
290
16
None
false
0
Left
false
-16777216
false
1225
19
InputField
ins2CarrierPhone
10
Microsoft Sans Serif
false
552
745
170
16
None
false
0
Left
false
-16777216
false
1224
19
InputField
ins1CarrierPhone
10
Microsoft Sans Serif
false
552
619
170
16
None
false
0
Left
false
-16777216
false
1223
19
InputField
City
10
Microsoft Sans Serif
false
103
506
200
16
None
false
0
Left
false
-16777216
false
1222
19
InputField
State
10
Microsoft Sans Serif
false
359
506
45
16
None
false
0
Left
false
-16777216
false
1221
19
InputField
Zip
10
Microsoft Sans Serif
false
439
506
100
16
None
false
0
Left
false
-16777216
false
1220
19
InputField
Address2
10
Microsoft Sans Serif
false
141
487
425
16
None
false
0
Left
false
-16777216
false
1219
19
InputField
referredFrom
10
Microsoft Sans Serif
false
76
389
600
16
None
false
0
Left
false
-16777216
false
1218
19
CheckBox
addressAndHmPhoneIsSameEntireFamily
0
false
283
453
10
10
None
false
0
Left
false
-16777216
false
1217
19
InputField
Address
10
Microsoft Sans Serif
false
128
468
425
16
None
false
0
Left
false
-16777216
false
1216
19
InputField
ins1SubscriberNameF
10
Microsoft Sans Serif
false
184
599
250
16
None
false
0
Left
false
-16777216
false
1215
19
InputField
ins1SubscriberID
10
Microsoft Sans Serif
false
565
599
140
16
None
false
0
Left
false
-16777216
false
1214
19
InputField
ins1CarrierName
10
Microsoft Sans Serif
false
201
619
290
16
None
false
0
Left
false
-16777216
false
1213
19
CheckBox
ins1Relat
0
false
394
583
10
10
None
Child
false
0
Left
false
-16777216
false
1212
19
InputField
HmPhone
10
Microsoft Sans Serif
false
156
525
120
16
None
false
0
Left
false
-16777216
false
1211
19
CheckBox
ins1Relat
0
false
267
583
10
10
None
Self
false
0
Left
false
-16777216
false
1210
19
CheckBox
ins1Relat
0
false
320
583
10
10
None
Spouse
false
0
Left
false
-16777216
false
1265
19
CheckBox
PreferContactMethod
0
false
607
299
10
10
None
Email
false
0
Left
false
-16777216
false
1266
19
CheckBox
PreferConfirmMethod
0
false
511
318
10
10
None
WirelessPh
false
0
Left
false
-16777216
false
1267
19
CheckBox
PreferConfirmMethod
0
false
428
318
10
10
None
WkPhone
false
0
Left
false
-16777216
false
1268
19
CheckBox
PreferConfirmMethod
0
false
343
318
10
10
None
HmPhone
false
0
Left
false
-16777216