https://forms.wv3.io/form?company_id=5c026ffe-afe9-48bb-bc2d-ead2685bcc5f&qwe=ede440f0-5b5c-4144-a8fb-c99985efd38a

ID de exploración:
61bd6ff1-56dd-4f39-b37f-721888bebd69Finalizado
URL enviada:
https://wv3.io/6WjCcOc6Redireccionado
Informe finalizado:

Enlaces: 2 encontrados

EnlaceTexto
https://www.weavehelp.com/hc/en-us/articles/5017862597275HIPAA Compliance
https://getweave.comWeave

Variables JavaScript: 31 encontradas

NombreTipo
onbeforetoggleobject
documentPictureInPictureobject
onscrollendobject
webpackChunk_N_Eobject
__next_set_public_path__function
regeneratorRuntimeobject
nextobject
__NEXT_DATA__object
__SSG_MANIFEST_CBfunction
__NEXT_Pobject

Mensajes de registro de la consola: 1 encontrados

TipoCategoríaRegistro
errornetwork
URL
https://forms.wv3.io/favicon.ico
Texto
Failed to load resource: the server responded with a status of 404 ()

HTML

<!DOCTYPE html><html lang="en"><head><meta charset="utf-8"><meta name="viewport" content="width=device-width"><link rel="icon" type="image/svg+xml" href="/images/favicon.svg"><link rel="preconnect" href="https://fonts.googleapis.com"><link rel="preconnect" href="https://fonts.gstatic.com"><link href="https://fonts.googleapis.com/css2?family=Kaushan+Script&amp;family=Fuzzy+Bubbles&amp;family=Nothing+You+Could+Do&amp;family=Caveat&amp;display=swap" rel="stylesheet" data-optimized-fonts="true"><meta name="next-head-count" content="6"><noscript data-n-css=""></noscript><script defer="" nomodule="" src="/_next/static/chunks/polyfills-c67a75d1b6f99dc8.js"></script><script src="/_next/static/chunks/webpack-0b82c725398189ee.js" defer=""></script><script src="/_next/static/chunks/framework-2e68dedaa8ccd613.js" defer=""></script><script src="/_next/static/chunks/main-2bf99b10453a093e.js" defer=""></script><script src="/_next/static/chunks/pages/_app-fe04955f0b87634d.js" defer=""></script><script src="/_next/static/chunks/pages/form-e1f5e023714da64d.js" defer=""></script><script src="/_next/static/aA8wjbewi8Tfy6CZPYWHm/_buildManifest.js" defer=""></script><script src="/_next/static/aA8wjbewi8Tfy6CZPYWHm/_ssgManifest.js" defer=""></script><style data-emotion="css-global"></style><style data-emotion="css"></style><style data-emotion="css-global" data-s=""></style><style data-emotion="css" data-s=""></style><title>Weave Forms</title><script src="https://acrobatservices.adobe.com/view-sdk/3.27.1_3.2.9-bdeed02a/ViewSDKInterface.js"></script><style type="text/css">.ViewSDK_hideOverflow {
        overflow: hidden;
    }</style><style type="text/css">.ViewSDK_parentRelativeWidth {
        width: 100%;
    }</style><style type="text/css">.ViewSDK_viewportRelativeWidth {
        width: 100vw;
    }</style><style type="text/css">.ViewSDK_parentRelativeHeight {
        height: 100%;
    }</style><style type="text/css">.ViewSDK_viewportRelativeHeight {
        height: 100vh;
    }</style><style type="text/css">.ViewSDK_fullScreenPDFViewer {
        width:100vw !important; height:100vh !important;
        max-width:100vw !important; max-height:100vh !important;
        position:fixed; top:0; left:0; z-index:99999;
        margin: 0 !important; padding: 0 !important;
        border: none !important;
    }</style><style type="text/css">:root { --ViewSDK-mobile-viewport-height:1vh; }</style><style type="text/css">.ViewSDK_fullScreenPDFViewerMobile {
        width:100vw !important; height:calc(100 * var(--ViewSDK-mobile-viewport-height)) !important;
        max-width:100vw !important; max-height:calc(100 * var(--ViewSDK-mobile-viewport-height)) !important;
        position:fixed; top:0; left:0; z-index:99999;
        margin: 0 !important; padding: 0 !important;
        border: none !important;
    }</style><style type="text/css">.ViewSDK_hideOverflow {
        overflow: hidden;
    }</style><style type="text/css">.ViewSDK_parentRelativeWidth {
        width: 100%;
    }</style><style type="text/css">.ViewSDK_viewportRelativeWidth {
        width: 100vw;
    }</style><style type="text/css">.ViewSDK_parentRelativeHeight {
        height: 100%;
    }</style><style type="text/css">.ViewSDK_viewportRelativeHeight {
        height: 100vh;
    }</style><style type="text/css">.ViewSDK_fullScreenPDFViewer {
        width:100vw !important; height:100vh !important;
        max-width:100vw !important; max-height:100vh !important;
        position:fixed; top:0; left:0; z-index:9999;
        margin: 0 !important; padding: 0 !important;
        border: none !important;
    }</style><style type="text/css">.ViewSDK_LBFullScreenPDFViewer {
        width:100vw !important; height:100vh !important;
        max-width:100vw !important; max-height:100vh !important;
        position:fixed; top:0; left:0; z-index:10000;
        margin: 0 !important; padding: 0 !important;
        background-color: rgba(0, 0, 0, 0.2);
        border: none !important;
    }</style><style type="text/css">:root { --ViewSDK-mobile-viewport-height:1vh; }</style><style type="text/css">.ViewSDK_fullScreenPDFViewerMobile {
        width:100vw !important; height:calc(100 * var(--ViewSDK-mobile-viewport-height)) !important;
        max-width:100vw !important; max-height:calc(100 * var(--ViewSDK-mobile-viewport-height)) !important;
        position:fixed; top:0; left:0; z-index:9999;
        margin: 0 !important; padding: 0 !important;
        border: none !important;
    }</style><style type="text/css">.ViewSDK_LBLoader {
        position: absolute;
        left: 50%;
        top: 50%;
        z-index: 10000;
        border: 4px solid #f3f3f3;
        border-top: 4px solid #1473E6;
        width: 56px !important;
        height: 56px !important;
        margin: -32px 0 0 -32px;
        border-radius: 50%;
        -webkit-animation: lbSpin 2s linear infinite;
        animation: lbSpin 2s linear infinite;
    }
    @-webkit-keyframes lbSpin {
        0% { -webkit-transform: rotate(0deg); }
        100% { -webkit-transform: rotate(360deg); }
    }
    @keyframes lbSpin {
        0% { transform: rotate(0deg); }
        100% { transform: rotate(360deg); }
    }</style></head><body data-theme="light"><div id="__next"><div class="css-1rf9cdu"><div class="css-191zapy"><div class="css-b2ldlw"><img src="https://media-secure.getweave.com/5c026ffe-afe9-48bb-bc2d-ead2685bcc5f/branding-api/c3234180-fcba-4c49-b615-aa2ff0b39ac7" alt="Company Logo"></div><h2 class="greeting css-16he0sv">Hello, Sebastian!</h2><p class="css-1l7bfeq">Thank you for choosing Dr. Ernesto V Torres MD. Please take a moment to verify and fill out the required information.</p><section class="css-14d7zmw"><svg focusable="false" width="24" height="24" aria-hidden="true" viewBox="0 0 24 24" class="css-jm4d1m"><circle cx="12" cy="12" r="12" fill="#FFC700"></circle><path d="M12 4.75C11.3096 4.75 10.75 5.30964 10.75 6V13.5C10.75 14.1904 11.3096 14.75 12 14.75C12.6904 14.75 13.25 14.1904 13.25 13.5V6C13.25 5.30964 12.6904 4.75 12 4.75Z" fill="#7A4900"></path><path d="M12 19.25C12.6904 19.25 13.25 18.6904 13.25 18C13.25 17.3096 12.6904 16.75 12 16.75C11.3096 16.75 10.75 17.3096 10.75 18C10.75 18.6904 11.3096 19.25 12 19.25Z" fill="#7A4900"></path></svg><div><p class="css-147es6j">Please only complete this form on a trusted device. If you're using a
            public device, please use caution when entering sensitive or personal
            information. Always close your browser window and permanently delete any file
            downloads when finished.</p></div></section><button type="button" data-testid="accept-continue" class="css-xvg9k css-5d7sqy">Accept &amp; Continue</button></div><div class="css-f76f2p"><ul><li><a class="css-72esm1" href="/legal/privacy-policy/5c026ffe-afe9-48bb-bc2d-ead2685bcc5f" target="_blank">Privacy Policy</a></li> <li><a class="css-72esm1" href="/legal/terms-conditions/5c026ffe-afe9-48bb-bc2d-ead2685bcc5f" target="_blank">Terms and Conditions</a></li> <li><a class="css-72esm1" href="https://www.weavehelp.com/hc/en-us/articles/5017862597275" target="_blank">HIPAA Compliance</a></li></ul><p class="css-1l17zvd css-1qm6zvh"><span class="text">Powered by</span> <a class="css-72esm1" href="https://getweave.com" target="_blank">Weave</a></p></div></div></div><script id="__NEXT_DATA__" type="application/json">{"props":{"pageProps":{"forms":[{"conditions":[{"actions":[{"operation":"show","target":"bl2hp6-cbpxxe","type":"fields"},{"operation":"show","target":"g6coxa-ejql9z","type":"fields"}],"id":"kj65t1-zqtz7x","operator":"and","terms":[{"check":"equals","field":"rc3bnn-79ejte","value":"Yes"}]},{"actions":[{"operation":"show","target":"xywzpg-skgbfy","type":"fields"}],"id":"84kq8s-z0zqdx","operator":"and","terms":[{"check":"equals","field":"vl4tu9-sjnnef","value":"Yes"}]},{"actions":[{"operation":"show","target":"g3vnyw-khaurj","type":"fields"}],"id":"jstyui-c6mbqh","operator":"and","terms":[{"check":"equals","field":"uipzxu-etomi1","value":"Yes"}]},{"actions":[{"operation":"show","target":"eazxao-ewptiz","type":"fields"}],"id":"zusu12-dsijnf","operator":"and","terms":[{"check":"equals","field":"epql6a-rrato2","value":"Cancer,"}]},{"actions":[{"operation":"show","target":"bsbkkc-ncz4o0","type":"fields"}],"id":"gef0xv-kydzyb","operator":"and","terms":[{"check":"answered","field":"mvyh1h-0dt9k3"}]}],"fields":{"13xuxo-vprnew":{"e_sign_required":false,"hidden":false,"id":"13xuxo-vprnew","inputmode":"text","label":"ZIP Code","max_length":7,"meta":{"dataGroup":"person","dataKey":"postalCode","displayName":"Postal Code","type":"postalCode"},"required":true,"value":""},"23tn7b-079dn3":{"e_sign_required":false,"hidden":false,"id":"23tn7b-079dn3","label":"Group #","meta":{"dataGroup":"insurance","dataKey":"primaryGroupNumber","displayName":"Group Number","type":"text"},"required":false,"value":""},"721bcf-bfe47e":{"e_sign_required":false,"hidden":false,"id":"721bcf-bfe47e","inputmode":"numeric","label":"Phone Number:","mask":"(999) 999-9999","meta":{"displayName":"Phone","type":"phone"},"pattern":"[0-9]*","required":false,"validation":"phone","value":""},"73jq97-1hj9nl":{"e_sign_required":false,"hidden":false,"id":"73jq97-1hj9nl","label":"Patient’s  Middle Initial","meta":{"dataGroup":"person","dataKey":"middleName","displayName":"Middle Name","type":"text"},"required":false,"value":""},"7wthvo-6acjhl":{"e_sign_required":false,"hidden":false,"id":"7wthvo-6acjhl","label":"City","meta":{"dataGroup":"person","dataKey":"city","displayName":"City","type":"text"},"required":true,"value":""},"8zmucp-8n0r0w":{"e_sign_required":false,"hidden":false,"id":"8zmucp-8n0r0w","inputmode":"numeric","label":"SSN","mask":"999-99-9999","meta":{"dataGroup":"insurance","dataKey":"primaryInsuranceSSN","displayName":"Insurance SSN","type":"ssn"},"pattern":"[0-9]*","required":false,"validation":"ssn","value":""},"9fd2eb-61efb1":{"e_sign_required":false,"hidden":false,"id":"9fd2eb-61efb1","label":"Preferred Pharmacy Address: ","meta":{"displayName":"Short Text Entry","type":"text"},"required":true,"value":""},"9qvodf-91lskw":{"e_sign_required":false,"hidden":false,"id":"9qvodf-91lskw","label":"Sex","meta":{"dataGroup":"person","dataKey":"gender","displayName":"Gender","type":"radio"},"required":true,"value":"","options":[{"label":"Male","value":"male"},{"label":"Female","value":"female"},{"label":"I prefer not to say","value":"I prefer not to say"}]},"ajqcgn-o3kzed":{"e_sign_required":false,"hidden":false,"id":"ajqcgn-o3kzed","label":"Rich Text","meta":{"displayName":"Rich Text","type":"richText"},"required":false,"value":"\u003cp\u003eDrug Use: \u003c/p\u003e"},"avejcr-wgdt1i":{"e_sign_required":false,"hidden":false,"id":"avejcr-wgdt1i","inputmode":"numeric","label":"Patient’s Cell Phone Number: ","mask":"(999) 999-9999","meta":{"dataGroup":"person","dataKey":"mobilePhone","displayName":"Mobile Phone Number","type":"phone"},"pattern":"[0-9]*","required":true,"validation":"phone","value":""},"bl2hp6-cbpxxe":{"e_sign_required":false,"hidden":true,"id":"bl2hp6-cbpxxe","label":"If so, how many cigarettes/cigars per day? ","meta":{"displayName":"Short Text Entry","type":"text"},"required":false,"value":""},"bsbkkc-ncz4o0":{"e_sign_required":false,"hidden":true,"id":"bsbkkc-ncz4o0","label":"","meta":{"displayName":"Multiple Choice","type":"radio"},"required":false,"value":"","options":[{"label":"Type 1","value":"Type 1"},{"label":"Type 2","value":"Type 2"}]},"d19c47-heopul":{"e_sign_required":false,"hidden":false,"id":"d19c47-heopul","label":"Marital Status","meta":{"dataGroup":"person","dataKey":"maritalStatus","displayName":"Marital Status","type":"radio"},"required":false,"value":"","options":[{"label":"Single","value":"single"},{"label":"Married","value":"married"},{"label":"Divorced","value":"divorced"}]},"dphmpe-hpduid":{"e_sign_required":false,"hidden":false,"id":"dphmpe-hpduid","label":"Policy #: ","meta":{"dataGroup":"insurance","dataKey":"primaryInsuranceId","displayName":"Insurance Id","type":"text"},"required":false,"value":""},"eazxao-ewptiz":{"e_sign_required":false,"hidden":true,"id":"eazxao-ewptiz","label":"Type/s","meta":{"displayName":"Short Text Entry","type":"text"},"required":false,"value":""},"eil1gd-b4hpcq":{"e_sign_required":false,"hidden":false,"id":"eil1gd-b4hpcq","label":"Rich Text","meta":{"displayName":"Rich Text","type":"richText"},"required":false,"value":"\u003cp\u003e\u003cstrong\u003eINSURANCE INFORMATION\u003c/strong\u003e\u003c/p\u003e"},"ekamsa-vgtzjf":{"e_sign_required":false,"hidden":false,"id":"ekamsa-vgtzjf","label":"Medication","meta":{"displayName":"Long Text Entry","type":"textarea"},"required":true,"value":""},"epql6a-rrato2":{"condition_ids":["zusu12-dsijnf"],"e_sign_required":false,"hidden":false,"id":"epql6a-rrato2","label":"If YOU or a FAMILY MEMBER has had any of the following, please indicate which family member or if yourself when applicable: *","meta":{"displayName":"Checkboxes","type":"checklist"},"required":true,"value":"","options":[{"label":"No Past or Current Medical history","value":"No Past or Current Medical history"},{"label":"Anemia         ","value":"Anemia         "},{"label":"  Asthma        ","value":"  Asthma        "},{"label":"   Arthritis        ","value":"   Arthritis        "},{"label":"  Anxiety/  Depression     ","value":"  Anxiety/  Depression     "},{"label":" Alcoholism   ","value":" Alcoholism   "},{"label":"  Blood Clots    ","value":"  Blood Clots    "},{"label":"Cancer","value":"Cancer"},{"label":"ADD/ADHD  ","value":"ADD/ADHD  "}]},"frjoz7-gqo4pm":{"e_sign_required":false,"hidden":false,"id":"frjoz7-gqo4pm","label":"Weight (lbs):","meta":{"displayName":"Short Text Entry","type":"text"},"required":true,"value":""},"fygdeb-0shstm":{"e_sign_required":false,"hidden":false,"id":"fygdeb-0shstm","inputmode":"numeric","label":"Preferred Pharmacy Phone Number:","mask":"(999) 999-9999","meta":{"displayName":"Phone","type":"phone"},"pattern":"[0-9]*","required":false,"validation":"phone","value":""},"g2xrnb-l6d3pe":{"e_sign_required":false,"hidden":false,"id":"g2xrnb-l6d3pe","label":"Preferred Pharmacy Name: ","meta":{"displayName":"Short Text Entry","type":"text"},"required":true,"value":""},"g3vnyw-khaurj":{"e_sign_required":false,"hidden":true,"id":"g3vnyw-khaurj","label":"If so, what type/s? ","meta":{"displayName":"Short Text Entry","type":"text"},"required":false,"value":""},"g6coxa-ejql9z":{"e_sign_required":false,"hidden":true,"id":"g6coxa-ejql9z","label":"Number of years smoking","meta":{"displayName":"Short Text Entry","type":"text"},"required":false,"value":""},"gwj5uh-pfvoec":{"e_sign_required":false,"hidden":false,"id":"gwj5uh-pfvoec","label":"Secondary Insurance:","meta":{"dataGroup":"insurance","dataKey":"secondaryInsuranceName","displayName":"Secondary Insurance Company Name","type":"text"},"required":false,"value":""},"i2zbyv-nkyndj":{"e_sign_required":false,"hidden":false,"id":"i2zbyv-nkyndj","label":"Rich Text","meta":{"displayName":"Rich Text","type":"richText"},"required":false,"value":"\u003cp class=\"ql-align-justify\"\u003ePlease list any MEDICATIONS you are currently taking, prescribed, or over the counter, if it does not apply, please write N/A: *\u003c/p\u003e"},"k2eu63-cjus8o":{"e_sign_required":false,"hidden":false,"id":"k2eu63-cjus8o","label":"Frequency","meta":{"displayName":"Long Text Entry","type":"textarea"},"required":true,"value":""},"kqnwgj-wpukse":{"e_sign_required":false,"hidden":false,"id":"kqnwgj-wpukse","label":"Patient’s  First Name","meta":{"dataGroup":"person","dataKey":"firstName","displayName":"First Name","type":"text"},"required":true,"value":""},"mmly4v-e11vf4":{"e_sign_required":false,"hidden":false,"id":"mmly4v-e11vf4","label":"Group #","meta":{"dataGroup":"insurance","dataKey":"secondaryGroupNumber","displayName":"Secondary Group Number","type":"text"},"required":false,"value":""},"mqxyuf-5prrhj":{"e_sign_required":false,"hidden":false,"id":"mqxyuf-5prrhj","label":"Patient is Subscriber/Policy Holder:","meta":{"displayName":"Multiple Choice","type":"radio"},"required":false,"value":"","options":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},"mvyh1h-0dt9k3":{"condition_ids":["gef0xv-kydzyb"],"e_sign_required":false,"hidden":false,"id":"mvyh1h-0dt9k3","label":"","meta":{"displayName":"Checkboxes","type":"checklist"},"required":false,"value":"","options":[{"label":"Diabetes ","value":"Diabetes "},{"label":"Option 2","value":"Option 2"}]},"n2sjyg-y3uumf":{"e_sign_required":false,"hidden":false,"id":"n2sjyg-y3uumf","label":"Please list any previous SURGERIES you have had and include the month/year, please write N/A if no previous surgeries: *","meta":{"displayName":"Short Text Entry","type":"text"},"required":true,"value":""},"nlvm7e-saa3jm":{"e_sign_required":false,"hidden":false,"id":"nlvm7e-saa3jm","label":"Relationship to Patient:","meta":{"displayName":"Short Text Entry","type":"text"},"required":false,"value":""},"nubuux-gmgd11":{"e_sign_required":false,"hidden":false,"id":"nubuux-gmgd11","label":"Patient is Subscriber/Policy Holder:  ","meta":{"displayName":"Multiple Choice","type":"radio"},"required":false,"value":"","options":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},"orrxts-yzsa4a":{"e_sign_required":false,"hidden":false,"id":"orrxts-yzsa4a","label":"Rich Text","meta":{"displayName":"Rich Text","type":"richText"},"required":false,"value":"\u003cp\u003e\u003cstrong\u003eSocial Information*\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\u003cp\u003e\u003cspan class=\"ql-cursor\"\u003e\u003c/span\u003eTobacco Use:\u003c/p\u003e"},"p2oiyv-d1wslz":{"e_sign_required":false,"hidden":false,"id":"p2oiyv-d1wslz","inputmode":"numeric","label":"Today's Date","mask":"99/99/9999","meta":{"displayName":"Date","type":"date"},"pattern":"[0-9]*","placeholder":"MM/DD/YYYY","required":true,"validation":"date","value":""},"pr07ld-cfclvu":{"e_sign_required":false,"hidden":false,"id":"pr07ld-cfclvu","label":"Primary Insurance:","meta":{"dataGroup":"insurance","dataKey":"primaryInsuranceName","displayName":"Insurance Company Name","type":"text"},"required":false,"value":""},"qeocrf-ewxy4m":{"e_sign_required":false,"hidden":false,"id":"qeocrf-ewxy4m","label":"","meta":{"displayName":"Checkboxes","type":"checklist"},"required":false,"value":"","options":[{"label":"Fractures ","value":"Fractures "},{"label":"Gynecological Disease ","value":"Gynecological Disease "},{"label":"Hypertension","value":"Hypertension"},{"label":" High Cholesterol ","value":" High Cholesterol "},{"label":"Heart Attack ","value":"Heart Attack "},{"label":"Kidney Disease ","value":"Kidney Disease "},{"label":"Liver Disease ","value":"Liver Disease "},{"label":"Neurological Disease","value":"Neurological Disease"},{"label":"Osteopenia/ Osteoporosis  ","value":"Osteopenia/ Osteoporosis  "},{"label":"Respiratory Disease  ","value":"Respiratory Disease  "},{"label":"Skin Disease ","value":"Skin Disease "},{"label":" Stomach/Colon Disease  ","value":" Stomach/Colon Disease  "},{"label":"Stroke  ","value":"Stroke  "},{"label":"Seizure Disorder  ","value":"Seizure Disorder  "},{"label":"Thyroid Disorder","value":"Thyroid Disorder"},{"label":" Sexually Transmitted Disease","value":" Sexually Transmitted Disease"}]},"qqnyzb-gb70qd":{"e_sign_required":false,"hidden":false,"id":"qqnyzb-gb70qd","label":"Height (ft):","meta":{"displayName":"Short Text Entry","type":"text"},"required":true,"value":""},"qujjid-izoaj9":{"e_sign_required":false,"hidden":false,"id":"qujjid-izoaj9","label":"E-Mail Address","meta":{"dataGroup":"person","dataKey":"email","displayName":"Email","type":"email"},"required":true,"validation":"email","value":""},"qvwkpg-w2arf2":{"e_sign_required":false,"hidden":false,"id":"qvwkpg-w2arf2","label":"Patient’s  Last Name","meta":{"dataGroup":"person","dataKey":"lastName","displayName":"Last Name","type":"text"},"required":true,"value":""},"rc3bnn-79ejte":{"condition_ids":["kj65t1-zqtz7x"],"e_sign_required":false,"hidden":false,"id":"rc3bnn-79ejte","label":"Do you smoke?","meta":{"displayName":"Multiple Choice","type":"radio"},"required":true,"value":"","options":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},"rngcki-tspwd1":{"e_sign_required":false,"hidden":false,"id":"rngcki-tspwd1","label":"If you do not know or it does not apply, please write N/A","meta":{"displayName":"Short Text Entry","type":"text"},"required":false,"value":""},"rycewh-w2fdv5":{"e_sign_required":false,"hidden":false,"id":"rycewh-w2fdv5","label":"State","meta":{"dataGroup":"person","dataKey":"state","displayName":"State","optionSet":"states","optionsDisplay":"US States","type":"select"},"required":true,"value":"","options":[{"abbr":"AL","label":"Alabama","value":"Alabama"},{"abbr":"AK","label":"Alaska","value":"Alaska"},{"abbr":"AZ","label":"Arizona","value":"Arizona"},{"abbr":"AR","label":"Arkansas","value":"Arkansas"},{"abbr":"CA","label":"California","value":"California"},{"abbr":"CO","label":"Colorado","value":"Colorado"},{"abbr":"CT","label":"Connecticut","value":"Connecticut"},{"abbr":"DE","label":"Delaware","value":"Delaware"},{"abbr":"FL","label":"Florida","value":"Florida"},{"abbr":"GA","label":"Georgia","value":"Georgia"},{"abbr":"HI","label":"Hawaii","value":"Hawaii"},{"abbr":"ID","label":"Idaho","value":"Idaho"},{"abbr":"IL","label":"Illinois","value":"Illinois"},{"abbr":"IN","label":"Indiana","value":"Indiana"},{"abbr":"IA","label":"Iowa","value":"Iowa"},{"abbr":"KS","label":"Kansas","value":"Kansas"},{"abbr":"KY","label":"Kentucky","value":"Kentucky"},{"abbr":"LA","label":"Louisiana","value":"Louisiana"},{"abbr":"ME","label":"Maine","value":"Maine"},{"abbr":"MD","label":"Maryland","value":"Maryland"},{"abbr":"MA","label":"Massachusetts","value":"Massachusetts"},{"abbr":"MI","label":"Michigan","value":"Michigan"},{"abbr":"MN","label":"Minnesota","value":"Minnesota"},{"abbr":"MS","label":"Mississippi","value":"Mississippi"},{"abbr":"MO","label":"Missouri","value":"Missouri"},{"abbr":"MT","label":"Montana","value":"Montana"},{"abbr":"NE","label":"Nebraska","value":"Nebraska"},{"abbr":"NV","label":"Nevada","value":"Nevada"},{"abbr":"NH","label":"New Hampshire","value":"New Hampshire"},{"abbr":"NJ","label":"New Jersey","value":"New Jersey"},{"abbr":"NM","label":"New Mexico","value":"New Mexico"},{"abbr":"NY","label":"New York","value":"New York"},{"abbr":"NC","label":"North Carolina","value":"North Carolina"},{"abbr":"ND","label":"North Dakota","value":"North Dakota"},{"abbr":"OH","label":"Ohio","value":"Ohio"},{"abbr":"OK","label":"Oklahoma","value":"Oklahoma"},{"abbr":"OR","label":"Oregon","value":"Oregon"},{"abbr":"PA","label":"Pennsylvania","value":"Pennsylvania"},{"abbr":"RI","label":"Rhode Island","value":"Rhode Island"},{"abbr":"SC","label":"South Carolina","value":"South Carolina"},{"abbr":"SD","label":"South Dakota","value":"South Dakota"},{"abbr":"TN","label":"Tennessee","value":"Tennessee"},{"abbr":"TX","label":"Texas","value":"Texas"},{"abbr":"UT","label":"Utah","value":"Utah"},{"abbr":"VT","label":"Vermont","value":"Vermont"},{"abbr":"VA","label":"Virginia","value":"Virginia"},{"abbr":"WA","label":"Washington","value":"Washington"},{"abbr":"WV","label":"West Virginia","value":"West Virginia"},{"abbr":"WI","label":"Wisconsin","value":"Wisconsin"},{"abbr":"WY","label":"Wyoming","value":"Wyoming"},{"abbr":"PR","label":"Puerto Rico","value":"Puerto Rico"},{"abbr":"DC","label":"District of Columbia","value":"District of Columbia"},{"abbr":"VI","label":"US Virgin Islands","value":"US Virgin Islands"}]},"sr4pjy-mcckp8":{"e_sign_required":false,"hidden":false,"id":"sr4pjy-mcckp8","label":"REASON OF YOUR VISIT TODAY","meta":{"displayName":"Short Text Entry","type":"text"},"required":true,"value":""},"u1mbtt-d29lwe":{"e_sign_required":false,"hidden":false,"id":"u1mbtt-d29lwe","inputmode":"numeric","label":"Date of Birth","mask":"99/99/9999","meta":{"dataGroup":"person","dataKey":"birthdate","displayName":"Birthdate","type":"date"},"pattern":"[0-9]*","placeholder":"MM/DD/YYYY","required":true,"validation":"date","value":""},"uipzxu-etomi1":{"condition_ids":["jstyui-c6mbqh"],"e_sign_required":false,"hidden":false,"id":"uipzxu-etomi1","label":"Any history of illegal drug use? ","meta":{"displayName":"Multiple Choice","type":"radio"},"required":true,"value":"","options":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},"ujjns5-ocr23c":{"e_sign_required":false,"hidden":false,"id":"ujjns5-ocr23c","label":"Emergency Contact Name","meta":{"displayName":"Short Text Entry","type":"text"},"required":false,"value":""},"v1vr0k-fvxzqw":{"e_sign_required":false,"hidden":false,"id":"v1vr0k-fvxzqw","label":"Dosage","meta":{"displayName":"Long Text Entry","type":"textarea"},"required":true,"value":""},"vl4tu9-sjnnef":{"condition_ids":["84kq8s-z0zqdx"],"e_sign_required":false,"hidden":false,"id":"vl4tu9-sjnnef","label":"Do you drink alcohol?","meta":{"displayName":"Multiple Choice","type":"radio"},"required":true,"value":"","options":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"},{"label":"Socially","value":"Socially"}]},"wn5h8x-yeehdh":{"e_sign_required":false,"hidden":false,"id":"wn5h8x-yeehdh","label":"Age","meta":{"displayName":"Short Text Entry","type":"text"},"required":true,"value":""},"womzfc-tjokh5":{"e_sign_required":false,"hidden":false,"id":"womzfc-tjokh5","label":"Address","meta":{"dataGroup":"person","dataKey":"address1","displayName":"Address Line 1","type":"text"},"required":true,"value":""},"wzaeml-pgdu46":{"e_sign_required":false,"hidden":false,"id":"wzaeml-pgdu46","label":"Policy #","meta":{"dataGroup":"insurance","dataKey":"secondaryInsuranceId","displayName":"Secondary Insurance Id","type":"text"},"required":false,"value":""},"xwj8xr-oym6bk":{"e_sign_required":false,"hidden":false,"id":"xwj8xr-oym6bk","label":"Rich Text","meta":{"displayName":"Rich Text","type":"richText"},"required":false,"value":"\u003cp\u003eAlcohol Use: \u003c/p\u003e"},"xywzpg-skgbfy":{"e_sign_required":false,"hidden":true,"id":"xywzpg-skgbfy","label":" If so, how much alcohol per week?","meta":{"displayName":"Short Text Entry","type":"text"},"required":false,"value":""},"ydp0mh-dvhdgp":{"e_sign_required":false,"hidden":false,"id":"ydp0mh-dvhdgp","label":"Allergies to Medications or Foods (list reactions), please write N/A or NKDA if you do not have any allergies: ","meta":{"displayName":"Short Text Entry","type":"text"},"required":true,"value":""},"zzvxm5-huaqji":{"e_sign_required":false,"hidden":false,"id":"zzvxm5-huaqji","label":"Rich Text","meta":{"displayName":"Rich Text","type":"richText"},"required":false,"value":"\u003cp\u003e\u003cstrong\u003ePharmacy Information *\u003c/strong\u003e\u003c/p\u003e"}},"form":{"company_id":"5c026ffe-afe9-48bb-bc2d-ead2685bcc5f","id":"86581fe6-67bf-4601-a9e7-a3864fd469cc","name":"Patient  Registration Form","sections":["turaat-yi2psr","98whud-tny1v1"],"visibility":"Global"},"sections":{"98whud-tny1v1":{"fields":["rngcki-tspwd1","qqnyzb-gb70qd","frjoz7-gqo4pm","i2zbyv-nkyndj","ekamsa-vgtzjf","v1vr0k-fvxzqw","k2eu63-cjus8o","ydp0mh-dvhdgp","n2sjyg-y3uumf","orrxts-yzsa4a","rc3bnn-79ejte","bl2hp6-cbpxxe","g6coxa-ejql9z","xwj8xr-oym6bk","vl4tu9-sjnnef","xywzpg-skgbfy","ajqcgn-o3kzed","uipzxu-etomi1","g3vnyw-khaurj","epql6a-rrato2","eazxao-ewptiz","mvyh1h-0dt9k3","bsbkkc-ncz4o0","qeocrf-ewxy4m","zzvxm5-huaqji","g2xrnb-l6d3pe","9fd2eb-61efb1","fygdeb-0shstm"],"id":"98whud-tny1v1","title":"HEALTH HISTORY"},"turaat-yi2psr":{"fields":["kqnwgj-wpukse","qvwkpg-w2arf2","73jq97-1hj9nl","p2oiyv-d1wslz","u1mbtt-d29lwe","wn5h8x-yeehdh","9qvodf-91lskw","avejcr-wgdt1i","qujjid-izoaj9","womzfc-tjokh5","7wthvo-6acjhl","rycewh-w2fdv5","13xuxo-vprnew","d19c47-heopul","ujjns5-ocr23c","nlvm7e-saa3jm","721bcf-bfe47e","sr4pjy-mcckp8","eil1gd-b4hpcq","pr07ld-cfclvu","dphmpe-hpduid","23tn7b-079dn3","mqxyuf-5prrhj","8zmucp-8n0r0w","gwj5uh-pfvoec","wzaeml-pgdu46","mmly4v-e11vf4","nubuux-gmgd11"],"id":"turaat-yi2psr"}}}],"formToken":"ede440f0-5b5c-4144-a8fb-c99985efd38a","companyToken":"5c026ffe-afe9-48bb-bc2d-ead2685bcc5f","formType":null,"isGenericForm":false,"logoSrc":"https://media-secure.getweave.com/5c026ffe-afe9-48bb-bc2d-ead2685bcc5f/branding-api/c3234180-fcba-4c49-b615-aa2ff0b39ac7","notFound":false,"fatalError":false,"isSubmitted":false,"conditionMapper":{"86581fe6-67bf-4601-a9e7-a3864fd469cc":{"kj65t1-zqtz7x":0,"84kq8s-z0zqdx":1,"jstyui-c6mbqh":2,"zusu12-dsijnf":3,"gef0xv-kydzyb":4}},"officeName":"Dr. Ernesto V Torres MD","person":{"firstName":"Sebastian","lastName":"Michelini","phoneNumber":"9547449737"},"hideFooterLinks":false,"disableReviewMode":false,"expiryDate":"2024-11-05T17:41:58Z","medicalHistory":null,"primaryInsurance":null,"secondaryInsurance":null,"prePopulateElements":null,"isCountryDropdownEnabled":false,"formsEnv":{"baseApiUrl":"https://api.weaveconnect.com","adobeJSApiKey":"887905d96b3f4608931446db3c37a867","environment":"production","sentryDSN":"https://[email protected]/4503965556211712"},"_sentryTraceData":"1caa5ac897fc4732bfd9bc69cad9f935-af2f0b4b7376c5aa-0","_sentryBaggage":"sentry-environment=production,sentry-release=6f63331385b8a6815b89b83663005f89b552387e,sentry-public_key=68fa9088b4a34ce89d813cc8e53af4c5,sentry-trace_id=1caa5ac897fc4732bfd9bc69cad9f935,sentry-sample_rate=0.05,sentry-transaction=%2Fform,sentry-sampled=false"},"__N_SSP":true},"page":"/form","query":{"company_id":"5c026ffe-afe9-48bb-bc2d-ead2685bcc5f","qwe":"ede440f0-5b5c-4144-a8fb-c99985efd38a"},"buildId":"aA8wjbewi8Tfy6CZPYWHm","isFallback":false,"isExperimentalCompile":false,"gssp":true,"scriptLoader":[]}</script><script src="https://www.googletagmanager.com/gtag/js?id=G-58X4WTM8FQ" async="true" data-nscript="afterInteractive"></script><script src="https://acrobatservices.adobe.com/view-sdk/viewer.js" data-nscript="afterInteractive"></script><script id="googleTagInit" data-nscript="afterInteractive">
                window.dataLayer = window.dataLayer || [];
                function gtag(){dataLayer.push(arguments);}
                gtag('js', new Date());
                gtag('config', 'G-58X4WTM8FQ');
              </script><next-route-announcer><p aria-live="assertive" id="__next-route-announcer__" role="alert" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px; overflow: hidden; padding: 0px; position: absolute; top: 0px; width: 1px; white-space: nowrap; overflow-wrap: normal;"></p></next-route-announcer><div id="alertsList-c8927a"><div class="css-1d9iyb3"></div></div></body></html>