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&quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 12px 0px 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\">\n<li class=\"Z1qcYe\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-hveid=\"CAAICBAH\" data-complete=\"true\" data-sae=\"\" data-copy-service-computed-style=\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\"><span class=\"iNqyIf\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-complete=\"true\" data-copy-service-computed-style=\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\"><strong class=\"rQesXe MPyX\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-complete=\"true\" data-copy-service-computed-style=\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\">Nature of Telehealth:<!--TgQPHd|||[]--><\/strong> I understand that telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location.<!--TgQPHd|||[]--><\/span><!--TgQPHd|||[]--><\/li>\n<li class=\"Z1qcYe\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-hveid=\"CAAICBAI\" data-complete=\"true\" data-sae=\"\" data-copy-service-computed-style=\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\"><span class=\"iNqyIf\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-complete=\"true\" data-copy-service-computed-style=\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\"><strong class=\"rQesXe MPyX\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-complete=\"true\" data-copy-service-computed-style=\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\">Benefits &amp; Risks:<!--TgQPHd|||[]--><\/strong> Benefits include convenient access to care. Anticipated risks include potential technical interruptions, unauthorized access due to security failures, or the determination by the provider that virtual care is no longer appropriate for my condition.<!--TgQPHd|||[]--><\/span><!--TgQPHd|||[]--><\/li>\n<li class=\"Z1qcYe\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-hveid=\"CAAICBAJ\" data-complete=\"true\" data-sae=\"\" data-copy-service-computed-style=\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\"><span class=\"iNqyIf\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-complete=\"true\" data-copy-service-computed-style=\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\"><strong class=\"rQesXe MPyX\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-complete=\"true\" data-copy-service-computed-style=\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\">Privacy &amp; Security:<!--TgQPHd|||[]--><\/strong> I understand that the laws protecting the confidentiality of my medical information also apply to telehealth.<!--TgQPHd|||[]--><\/span><!--TgQPHd|||[]--><\/li>\n<li class=\"Z1qcYe\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-hveid=\"CAAICBAK\" data-complete=\"true\" data-sae=\"\" data-copy-service-computed-style=\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\"><span class=\"iNqyIf\" data-sfc-cp=\"\" data-sfc-root=\"ep\" data-complete=\"true\" data-copy-service-computed-style=\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; 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Consent\\\",\\\"img_url\\\":\\\"\\\"},\\\"normal_styles\\\":{\\\"backgroundColor\\\":\\\"#1a7efb\\\",\\\"borderColor\\\":\\\"#1a7efb\\\",\\\"color\\\":\\\"#ffffff\\\",\\\"borderRadius\\\":\\\"\\\",\\\"minWidth\\\":\\\"\\\"},\\\"hover_styles\\\":{\\\"backgroundColor\\\":\\\"#ffffff\\\",\\\"borderColor\\\":\\\"#1a7efb\\\",\\\"color\\\":\\\"#1a7efb\\\",\\\"borderRadius\\\":\\\"\\\",\\\"minWidth\\\":\\\"\\\"},\\\"current_state\\\":\\\"normal_styles\\\"},\\\"editor_options\\\":{\\\"title\\\":\\\"Submit Button\\\"}}}\",\"changes\":\"[{\\\"type\\\":\\\"removed\\\",\\\"label\\\":\\\"Age\\\",\\\"info\\\":\\\"Removed Age \\\"},{\\\"type\\\":\\\"removed\\\",\\\"label\\\":\\\"container\\\",\\\"info\\\":\\\"Removed container \\\"},{\\\"type\\\":\\\"removed\\\",\\\"label\\\":\\\"Proposed Procedure or Treatment\\\",\\\"info\\\":\\\"Removed Proposed Procedure or Treatment \\\"},{\\\"type\\\":\\\"removed\\\",\\\"label\\\":\\\"input_name\\\",\\\"info\\\":\\\"Removed input_name \\\"},{\\\"type\\\":\\\"removed\\\",\\\"label\\\":\\\"Medical Facility or Clinic Name\\\",\\\"info\\\":\\\"Removed Medical Facility or Clinic Name \\\"},{\\\"type\\\":\\\"removed\\\",\\\"label\\\":\\\"Known Allergies or Medical Conditions\\\",\\\"info\\\":\\\"Removed Known Allergies or Medical Conditions \\\"},{\\\"type\\\":\\\"removed\\\",\\\"label\\\":\\\"input_name\\\",\\\"info\\\":\\\"Removed input_name \\\"},{\\\"type\\\":\\\"added\\\",\\\"label\\\":\\\"Date of Birth\\\",\\\"info\\\":\\\"Added Date of Birth \\\"},{\\\"type\\\":\\\"added\\\",\\\"label\\\":\\\"Emergency Contact & Location\\\",\\\"info\\\":\\\"Added Emergency Contact & Location \\\"},{\\\"type\\\":\\\"added\\\",\\\"label\\\":\\\"Current Physical Location During Visits\\\",\\\"info\\\":\\\"Added Current Physical Location During Visits \\\"},{\\\"type\\\":\\\"added\\\",\\\"label\\\":\\\"custom_html\\\",\\\"info\\\":\\\"Added custom_html \\\"},{\\\"type\\\":\\\"added\\\",\\\"label\\\":\\\"terms_and_condition\\\",\\\"info\\\":\\\"Added terms_and_condition \\\"},{\\\"type\\\":\\\"added\\\",\\\"label\\\":\\\"terms_and_condition\\\",\\\"info\\\":\\\"Added terms_and_condition \\\"},{\\\"type\\\":\\\"modified\\\",\\\"label\\\":\\\"Disclosures & Acknowledgments\\\",\\\"key\\\":\\\"label\\\",\\\"new_value\\\":\\\"Disclosures & Acknowledgments\\\",\\\"old_value\\\":\\\"Medical Consent & Release\\\",\\\"info\\\":\\\"Modified Disclosures & Acknowledgments label value from 'Medical Consent & Release' to 'Disclosures & Acknowledgments'\\\",\\\"category\\\":\\\"settings\\\"},{\\\"type\\\":\\\"modified\\\",\\\"label\\\":\\\"custom_html\\\",\\\"key\\\":\\\"html_codes\\\",\\\"new_value\\\":\\\"<p>&nbsp;<\\\\\\\/p>\\\\n<p><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><em class=\\\\\\\"eujQNb\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Please review the following terms regarding your virtual care:<!--TgQPHd|||[]--><\\\\\\\/em><!--TgQPHd|||[]--><\\\\\\\/span><\\\\\\\/p>\\\\n<ul class=\\\\\\\"IaGLZe VimKh\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 12px 0px 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAH\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Nature of Telehealth:<!--TgQPHd|||[]--><\\\\\\\/strong> I understand that telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/li>\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAI\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Benefits &amp; Risks:<!--TgQPHd|||[]--><\\\\\\\/strong> Benefits include convenient access to care. Anticipated risks include potential technical interruptions, unauthorized access due to security failures, or the determination by the provider that virtual care is no longer appropriate for my condition.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/li>\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAJ\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Privacy &amp; Security:<!--TgQPHd|||[]--><\\\\\\\/strong> I understand that the laws protecting the confidentiality of my medical information also apply to telehealth.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/li>\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAK\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Right to Withdraw:<!--TgQPHd|||[]--><\\\\\\\/strong> I understand that I have the right to withhold or withdraw my consent to telehealth services at any time without affecting my right to future care or treatment.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/li>\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAL\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Emergency Protocol:<!--TgQPHd|||[]--><\\\\\\\/strong> I agree that if I am experiencing a medical emergency during a session, I will call emergency services or proceed to the nearest emergency room.<!--TgQPHd|||[]--><\\\\\\\/span>\\\\u00a0<\\\\\\\/li>\\\\n<\\\\\\\/ul>\\\\n<p>&nbsp;<\\\\\\\/p>\\\",\\\"old_value\\\":\\\"<p>&nbsp;<\\\\\\\/p>\\\\n<p>General Authorizations<\\\\\\\/p>\\\\n<ul>\\\\n<li>I authorize routine medical evaluations and diagnostic tests<\\\\\\\/li>\\\\n<li>I authorize emergency medical treatment if required<\\\\\\\/li>\\\\n<li>I authorize the release of necessary medical records to insurance providers<\\\\\\\/li>\\\\n<li>I accept financial responsibility for all co-pays deductibles or treatments not covered by insurance<\\\\\\\/li>\\\\n<li>I acknowledge that I have received and read the Notice of Privacy Practices<\\\\\\\/li>\\\\n<li>I consent to receive medical evaluations via virtual telehealth services if necessary<\\\\\\\/li>\\\\n<li>I authorize the clinic to log and share vaccination records with state health registries<\\\\\\\/li>\\\\n<\\\\\\\/ul>\\\\n<p>Clinical Acknowledgments<\\\\\\\/p>\\\\n<ul>\\\\n<li>I consent to the specific procedure treatment or service outlined by my medical team<\\\\\\\/li>\\\\n<li>I acknowledge the treating provider or clinic name has been fully disclosed to me<\\\\\\\/li>\\\\n<li>I confirm that all treatment risks and alternative options were explained to my satisfaction<\\\\\\\/li>\\\\n<\\\\\\\/ul>\\\\n<p>&nbsp;<\\\\\\\/p>\\\",\\\"info\\\":\\\"Modified custom_html html_codes value from '<p>&nbsp;<\\\\\\\/p>\\\\n<p>General Authorizations<\\\\\\\/p>\\\\n<ul>\\\\n<li>I authorize routine medical evaluations and diagnostic tests<\\\\\\\/li>\\\\n<li>I authorize emergency medical treatment if required<\\\\\\\/li>\\\\n<li>I authorize the release of necessary medical records to insurance providers<\\\\\\\/li>\\\\n<li>I accept financial responsibility for all co-pays deductibles or treatments not covered by insurance<\\\\\\\/li>\\\\n<li>I acknowledge that I have received and read the Notice of Privacy Practices<\\\\\\\/li>\\\\n<li>I consent to receive medical evaluations via virtual telehealth services if necessary<\\\\\\\/li>\\\\n<li>I authorize the clinic to log and share vaccination records with state health registries<\\\\\\\/li>\\\\n<\\\\\\\/ul>\\\\n<p>Clinical Acknowledgments<\\\\\\\/p>\\\\n<ul>\\\\n<li>I consent to the specific procedure treatment or service outlined by my medical team<\\\\\\\/li>\\\\n<li>I acknowledge the treating provider or clinic name has been fully disclosed to me<\\\\\\\/li>\\\\n<li>I confirm that all treatment risks and alternative options were explained to my satisfaction<\\\\\\\/li>\\\\n<\\\\\\\/ul>\\\\n<p>&nbsp;<\\\\\\\/p>' to '<p>&nbsp;<\\\\\\\/p>\\\\n<p><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><em class=\\\\\\\"eujQNb\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Please review the following terms regarding your virtual care:<!--TgQPHd|||[]--><\\\\\\\/em><!--TgQPHd|||[]--><\\\\\\\/span><\\\\\\\/p>\\\\n<ul class=\\\\\\\"IaGLZe VimKh\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 12px 0px 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAH\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Nature of Telehealth:<!--TgQPHd|||[]--><\\\\\\\/strong> I understand that telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/li>\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAI\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Benefits &amp; Risks:<!--TgQPHd|||[]--><\\\\\\\/strong> Benefits include convenient access to care. Anticipated risks include potential technical interruptions, unauthorized access due to security failures, or the determination by the provider that virtual care is no longer appropriate for my condition.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/li>\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAJ\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Privacy &amp; Security:<!--TgQPHd|||[]--><\\\\\\\/strong> I understand that the laws protecting the confidentiality of my medical information also apply to telehealth.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/li>\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAK\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Right to Withdraw:<!--TgQPHd|||[]--><\\\\\\\/strong> I understand that I have the right to withhold or withdraw my consent to telehealth services at any time without affecting my right to future care or treatment.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/li>\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAL\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" 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text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">I certify that I have read this form, understand its contents, and give my voluntary consent.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/p>\\\",\\\"info\\\":\\\"Modified terms_and_condition tnc_html value from '<p><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">I certify that I have read this form, understand its contents, and give my voluntary consent.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/p>' to '<p><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: 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required\\\"},\\\"valid_phone_number\\\":{\\\"value\\\":false,\\\"global\\\":true,\\\"message\\\":\\\"Phone number is not valid\\\",\\\"global_message\\\":\\\"Phone number is not valid\\\"}},\\\"conditional_logics\\\":[]},\\\"editor_options\\\":{\\\"title\\\":\\\"Phone\\\\\\\/Mobile\\\",\\\"icon_class\\\":\\\"el-icon-phone-outline\\\",\\\"template\\\":\\\"inputText\\\"},\\\"uniqElKey\\\":\\\"el_178523605513882\\\"},{\\\"index\\\":1,\\\"element\\\":\\\"section_break\\\",\\\"attributes\\\":{\\\"id\\\":\\\"\\\",\\\"class\\\":\\\"\\\"},\\\"settings\\\":{\\\"label\\\":\\\"Disclosures & Acknowledgments\\\",\\\"description\\\":\\\"\\\",\\\"align\\\":\\\"center\\\",\\\"conditional_logics\\\":[]},\\\"editor_options\\\":{\\\"title\\\":\\\"Section Break\\\",\\\"icon_class\\\":\\\"ff-edit-section-break\\\",\\\"template\\\":\\\"sectionBreak\\\"},\\\"uniqElKey\\\":\\\"el_178523538060874\\\"},{\\\"index\\\":17,\\\"element\\\":\\\"custom_html\\\",\\\"attributes\\\":[],\\\"settings\\\":{\\\"html_codes\\\":\\\"<p>&nbsp;<\\\\\\\/p>\\\\n<p><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><em class=\\\\\\\"eujQNb\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Please review the following terms regarding your virtual care:<!--TgQPHd|||[]--><\\\\\\\/em><!--TgQPHd|||[]--><\\\\\\\/span><\\\\\\\/p>\\\\n<ul class=\\\\\\\"IaGLZe VimKh\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 12px 0px 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAH\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Nature of Telehealth:<!--TgQPHd|||[]--><\\\\\\\/strong> I understand that telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/li>\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAI\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Benefits &amp; Risks:<!--TgQPHd|||[]--><\\\\\\\/strong> Benefits include convenient access to care. Anticipated risks include potential technical interruptions, unauthorized access due to security failures, or the determination by the provider that virtual care is no longer appropriate for my condition.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/li>\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAJ\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Privacy &amp; Security:<!--TgQPHd|||[]--><\\\\\\\/strong> I understand that the laws protecting the confidentiality of my medical information also apply to telehealth.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/li>\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAK\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Right to Withdraw:<!--TgQPHd|||[]--><\\\\\\\/strong> I understand that I have the right to withhold or withdraw my consent to telehealth services at any time without affecting my right to future care or treatment.<!--TgQPHd|||[]--><\\\\\\\/span><!--TgQPHd|||[]--><\\\\\\\/li>\\\\n<li class=\\\\\\\"Z1qcYe\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-hveid=\\\\\\\"CAAICBAL\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-sae=\\\\\\\"\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px 0px 12px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 400; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\"><strong class=\\\\\\\"rQesXe MPyX\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; font-size: 16px; font-weight: 700; margin: 0px; text-decoration: none; border-bottom: 0px rgb(230, 232, 240);\\\\\\\">Emergency Protocol:<!--TgQPHd|||[]--><\\\\\\\/strong> I agree that if I am experiencing a medical emergency during a session, I will call emergency services or proceed to the nearest emergency room.<!--TgQPHd|||[]--><\\\\\\\/span>\\\\u00a0<\\\\\\\/li>\\\\n<\\\\\\\/ul>\\\\n<p>&nbsp;<\\\\\\\/p>\\\",\\\"conditional_logics\\\":{\\\"type\\\":\\\"any\\\",\\\"status\\\":false,\\\"conditions\\\":[{\\\"field\\\":\\\"\\\",\\\"value\\\":\\\"\\\",\\\"operator\\\":\\\"\\\"}],\\\"condition_groups\\\":[{\\\"rules\\\":[{\\\"field\\\":\\\"\\\",\\\"value\\\":\\\"\\\",\\\"operator\\\":\\\"\\\"}],\\\"title\\\":\\\"\\\",\\\"isEditingTitle\\\":false,\\\"isPreviewOpen\\\":false,\\\"isGroupOpen\\\":true}]},\\\"container_class\\\":\\\"\\\"},\\\"editor_options\\\":{\\\"title\\\":\\\"Custom HTML\\\",\\\"icon_class\\\":\\\"ff-edit-html\\\",\\\"template\\\":\\\"customHTML\\\"},\\\"uniqElKey\\\":\\\"el_178523839081379\\\"},{\\\"index\\\":1,\\\"element\\\":\\\"section_break\\\",\\\"attributes\\\":{\\\"id\\\":\\\"\\\",\\\"class\\\":\\\"\\\"},\\\"settings\\\":{\\\"label\\\":\\\"Consent & Authorization\\\",\\\"description\\\":\\\"\\\",\\\"align\\\":\\\"center\\\",\\\"conditional_logics\\\":[]},\\\"editor_options\\\":{\\\"title\\\":\\\"Section Break\\\",\\\"icon_class\\\":\\\"ff-edit-section-break\\\",\\\"template\\\":\\\"sectionBreak\\\"},\\\"uniqElKey\\\":\\\"el_178523576854721\\\"},{\\\"index\\\":17,\\\"element\\\":\\\"custom_html\\\",\\\"attributes\\\":[],\\\"settings\\\":{\\\"html_codes\\\":\\\"<p>Acknowledgment Checkboxes<\\\\\\\/p>\\\",\\\"conditional_logics\\\":{\\\"type\\\":\\\"any\\\",\\\"status\\\":false,\\\"conditions\\\":[{\\\"field\\\":\\\"\\\",\\\"value\\\":\\\"\\\",\\\"operator\\\":\\\"\\\"}],\\\"condition_groups\\\":[{\\\"rules\\\":[{\\\"field\\\":\\\"\\\",\\\"value\\\":\\\"\\\",\\\"operator\\\":\\\"\\\"}],\\\"title\\\":\\\"\\\",\\\"isEditingTitle\\\":false,\\\"isPreviewOpen\\\":false,\\\"isGroupOpen\\\":true}]},\\\"container_class\\\":\\\"\\\"},\\\"editor_options\\\":{\\\"title\\\":\\\"Custom HTML\\\",\\\"icon_class\\\":\\\"ff-edit-html\\\",\\\"template\\\":\\\"customHTML\\\"},\\\"uniqElKey\\\":\\\"el_178549607956417\\\"},{\\\"index\\\":5,\\\"element\\\":\\\"terms_and_condition\\\",\\\"attributes\\\":{\\\"type\\\":\\\"checkbox\\\",\\\"name\\\":\\\"terms-n-condition\\\",\\\"value\\\":false,\\\"class\\\":\\\"\\\"},\\\"settings\\\":{\\\"tnc_html\\\":\\\"<p><span class=\\\\\\\"iNqyIf\\\\\\\" data-sfc-cp=\\\\\\\"\\\\\\\" data-sfc-root=\\\\\\\"ep\\\\\\\" data-complete=\\\\\\\"true\\\\\\\" data-copy-service-computed-style=\\\\\\\"font-family: &quot;Google Sans&quot;, Arial, sans-serif; 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