{"id":7191,"date":"2026-08-17T16:49:39","date_gmt":"2026-08-17T16:49:39","guid":{"rendered":"https:\/\/onlinedemoserver10.com\/kenneth\/?page_id=7191"},"modified":"2026-08-17T17:02:28","modified_gmt":"2026-08-17T17:02:28","slug":"patient-intake-form","status":"publish","type":"page","link":"https:\/\/onlinedemoserver10.com\/kenneth\/patient-intake-form\/","title":{"rendered":"Patient Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"7191\" class=\"elementor elementor-7191\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-66de7dc e-flex e-con-boxed e-con e-parent\" data-id=\"66de7dc\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-b5472bc e-flex e-con-boxed e-con e-parent\" data-id=\"b5472bc\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-539269b elementor-widget elementor-widget-shortcode\" data-id=\"539269b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">    <div class=\"sds-patient-form-shell\">\n        <form id=\"sds-patient-form\" class=\"sds-patient-form\" method=\"post\" novalidate data-ajax-url=\"https:\/\/onlinedemoserver10.com\/kenneth\/wp-admin\/admin-ajax.php\">\n            <input type=\"hidden\" name=\"action\" value=\"sds_submit_patient_form\">\n            <input type=\"hidden\" name=\"sds_nonce\" value=\"c1306afe8e\">\n            <input type=\"hidden\" name=\"form_version\" value=\"2019.3\">\n            <div class=\"sds-hp\" aria-hidden=\"true\">\n                <label>Leave this field empty <input type=\"text\" name=\"company_website\" tabindex=\"-1\" autocomplete=\"off\"><\/label>\n            <\/div>\n\n            <div class=\"sds-progress\" aria-live=\"polite\">\n                <div class=\"sds-progress-bar\"><span><\/span><\/div>\n                <div class=\"sds-progress-text\">Step 1 of 11<\/div>\n            <\/div>\n            <div id=\"sds-form-message\" class=\"sds-form-message\" role=\"status\" aria-live=\"polite\"><\/div>\n\n            <!-- PAGE 1: PATIENT NOTES -->\n            <section class=\"sds-step is-active\" data-step=\"1\">\n                <div class=\"sds-document-card\">\n                    <header class=\"sds-doc-header\">\n                        <div class=\"sds-brand\">SDS Medical Supplies<\/div>\n                        <h2>PATIENT NOTES<\/h2>\n                    <\/header>\n\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\">\n                            <label for=\"notes_patient\">PATIENT<\/label>\n                            <input type=\"text\" id=\"notes_patient\" name=\"notes_patient\">\n                        <\/div>\n                        <div class=\"sds-field\">\n                            <label for=\"notes_account_number\">ACCOUNT NUMBER<\/label>\n                            <input type=\"text\" id=\"notes_account_number\" name=\"notes_account_number\">\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"sds-field\">\n                        <label for=\"patient_notes\">PATIENT NOTES<\/label>\n                        <textarea id=\"patient_notes\" name=\"patient_notes\" rows=\"18\" class=\"sds-lined-textarea\"><\/textarea>\n                    <\/div>\n                        <div class=\"sds-source-footer\">\n        <div class=\"sds-footer-top\">\n            <span>\u00a9 All Rights Reserved.<br><strong>ACHCU<\/strong><\/span>\n            <span>VERSION 2019.3<\/span>\n            <span>1<\/span>\n        <\/div>\n        <div class=\"sds-footer-company\">\n            <strong>SDS Medical Supplies Inc.<\/strong> | 2375 Wall Street SE, Suite 240 Rm 50, Conyers, GA 30013<br>\n            Office: (770) 285-4104 | Fax: (770) 285-4152 | Monday-Friday 10:00am to 4:00pm\n        <\/div>\n    <\/div>\n                    <\/div>\n            <\/section>\n\n            <!-- PAGE 2: PATIENT INTAKE FORM -->\n            <section class=\"sds-step\" data-step=\"2\">\n                <div class=\"sds-document-card\">\n                    <header class=\"sds-doc-header\">\n                        <div class=\"sds-brand\">SDS Medical Supplies<\/div>\n                        <h2>PATIENT INTAKE FORM<\/h2>\n                    <\/header>\n\n                    <div class=\"sds-field\">\n                        <label for=\"referral_source\">Referral Source<\/label>\n                        <input type=\"text\" id=\"referral_source\" name=\"referral_source\">\n                    <\/div>\n\n                    <h3 class=\"sds-section-title\">Patient Information<\/h3>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\">\n                            <label for=\"last_name\">Last Name <span class=\"sds-required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"last_name\" name=\"last_name\" required autocomplete=\"family-name\">\n                        <\/div>\n                        <div class=\"sds-field\">\n                            <label for=\"first_name\">Full First Name <span class=\"sds-required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"first_name\" name=\"first_name\" required autocomplete=\"given-name\">\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"sds-field\">\n                        <label for=\"address\">Address<\/label>\n                        <input type=\"text\" id=\"address\" name=\"address\" autocomplete=\"street-address\">\n                    <\/div>\n\n                    <div class=\"sds-grid sds-grid-3\">\n                        <div class=\"sds-field\"><label for=\"city\">City<\/label><input type=\"text\" id=\"city\" name=\"city\" autocomplete=\"address-level2\"><\/div>\n                        <div class=\"sds-field\"><label for=\"state\">State<\/label><input type=\"text\" id=\"state\" name=\"state\" autocomplete=\"address-level1\"><\/div>\n                        <div class=\"sds-field\"><label for=\"zip\">Zip<\/label><input type=\"text\" id=\"zip\" name=\"zip\" autocomplete=\"postal-code\"><\/div>\n                    <\/div>\n\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"phone\">Phone <span class=\"sds-required\">*<\/span><\/label><input type=\"tel\" id=\"phone\" name=\"phone\" required autocomplete=\"tel\"><\/div>\n                        <div class=\"sds-field\"><label for=\"patient_email\">Email Address <span class=\"sds-required\">*<\/span> <small>(added for confirmation email)<\/small><\/label><input type=\"email\" id=\"patient_email\" name=\"patient_email\" required autocomplete=\"email\"><\/div>\n                    <\/div>\n\n                    <div class=\"sds-grid sds-grid-3\">\n                        <div class=\"sds-field\">\n                            <span class=\"sds-label\">Gender<\/span>\n                            <div class=\"sds-inline-options\">\n                                <label><input type=\"radio\" name=\"gender\" value=\"Male\"> Male<\/label>\n                                <label><input type=\"radio\" name=\"gender\" value=\"Female\"> Female<\/label>\n                            <\/div>\n                        <\/div>\n                        <div class=\"sds-field\"><label for=\"date_of_birth\">Date of Birth<\/label><input type=\"date\" id=\"date_of_birth\" name=\"date_of_birth\"><\/div>\n                        <div class=\"sds-field\"><label for=\"ssn\">SSN<\/label><input type=\"text\" id=\"ssn\" name=\"ssn\" maxlength=\"11\" inputmode=\"numeric\" autocomplete=\"off\"><\/div>\n                    <\/div>\n\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"ordering_physician\">Ordering\/Prescribing Physician<\/label><input type=\"text\" id=\"ordering_physician\" name=\"ordering_physician\"><\/div>\n                        <div class=\"sds-field\"><label for=\"ordering_license\">License #<\/label><input type=\"text\" id=\"ordering_license\" name=\"ordering_license\"><\/div>\n                    <\/div>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"ordering_address\">Address<\/label><input type=\"text\" id=\"ordering_address\" name=\"ordering_address\"><\/div>\n                        <div class=\"sds-field\"><label for=\"ordering_phone\">Phone #<\/label><input type=\"tel\" id=\"ordering_phone\" name=\"ordering_phone\"><\/div>\n                    <\/div>\n\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"followup_physician\">Follow Up Physician<\/label><input type=\"text\" id=\"followup_physician\" name=\"followup_physician\"><\/div>\n                        <div class=\"sds-field\"><label for=\"followup_license\">License #<\/label><input type=\"text\" id=\"followup_license\" name=\"followup_license\"><\/div>\n                    <\/div>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"followup_address\">Address<\/label><input type=\"text\" id=\"followup_address\" name=\"followup_address\"><\/div>\n                        <div class=\"sds-field\"><label for=\"followup_phone\">Phone #<\/label><input type=\"tel\" id=\"followup_phone\" name=\"followup_phone\"><\/div>\n                    <\/div>\n\n                    <div class=\"sds-field\"><label for=\"related_diagnoses\">Related Diagnoses for Service(s) Provided<\/label><textarea id=\"related_diagnoses\" name=\"related_diagnoses\" rows=\"3\"><\/textarea><\/div>\n\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"patient_height\">Patient Height<\/label><input type=\"text\" id=\"patient_height\" name=\"patient_height\"><\/div>\n                        <div class=\"sds-field\"><label for=\"patient_weight\">Patient Weight<\/label><input type=\"text\" id=\"patient_weight\" name=\"patient_weight\"><\/div>\n                    <\/div>\n\n                    <div class=\"sds-field\"><label for=\"emergency_contact_person\">Emergency Contact Person<\/label><input type=\"text\" id=\"emergency_contact_person\" name=\"emergency_contact_person\"><\/div>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"emergency_address\">Address<\/label><input type=\"text\" id=\"emergency_address\" name=\"emergency_address\"><\/div>\n                        <div class=\"sds-field\"><label for=\"emergency_phone\">Phone #<\/label><input type=\"tel\" id=\"emergency_phone\" name=\"emergency_phone\"><\/div>\n                    <\/div>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"next_of_kin\">Next of Kin\/Legal Guardian<\/label><input type=\"text\" id=\"next_of_kin\" name=\"next_of_kin\"><\/div>\n                        <div class=\"sds-field\"><label for=\"next_of_kin_phone\">Phone #<\/label><input type=\"tel\" id=\"next_of_kin_phone\" name=\"next_of_kin_phone\"><\/div>\n                    <\/div>\n\n                    <h3 class=\"sds-section-title\">Insurance Coverage<\/h3>\n                    <div class=\"sds-subcard\">\n                        <div class=\"sds-subcard-title\">#1<\/div>\n                        <div class=\"sds-grid sds-grid-2\">\n                            <div class=\"sds-field\"><label for=\"insurance_1\">Insurance Coverage #1<\/label><input type=\"text\" id=\"insurance_1\" name=\"insurance_1\"><\/div>\n                            <div class=\"sds-field\"><label for=\"insurance_1_policy\">Policy #<\/label><input type=\"text\" id=\"insurance_1_policy\" name=\"insurance_1_policy\"><\/div>\n                        <\/div>\n                        <div class=\"sds-grid sds-grid-2\">\n                            <div class=\"sds-field\"><label for=\"insurance_1_address\">Address<\/label><input type=\"text\" id=\"insurance_1_address\" name=\"insurance_1_address\"><\/div>\n                            <div class=\"sds-field\"><label for=\"insurance_1_phone\">Phone #<\/label><input type=\"tel\" id=\"insurance_1_phone\" name=\"insurance_1_phone\"><\/div>\n                        <\/div>\n                        <div class=\"sds-grid sds-grid-2\">\n                            <div class=\"sds-field\"><label for=\"insurance_1_insured_name\">Name of Insured<\/label><input type=\"text\" id=\"insurance_1_insured_name\" name=\"insurance_1_insured_name\"><\/div>\n                            <div class=\"sds-field\"><label for=\"insurance_1_dob\">Date of Birth<\/label><input type=\"date\" id=\"insurance_1_dob\" name=\"insurance_1_dob\"><\/div>\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"sds-subcard\">\n                        <div class=\"sds-subcard-title\">#2<\/div>\n                        <div class=\"sds-grid sds-grid-2\">\n                            <div class=\"sds-field\"><label for=\"insurance_2\">Insurance Coverage #2<\/label><input type=\"text\" id=\"insurance_2\" name=\"insurance_2\"><\/div>\n                            <div class=\"sds-field\"><label for=\"insurance_2_policy\">Policy #<\/label><input type=\"text\" id=\"insurance_2_policy\" name=\"insurance_2_policy\"><\/div>\n                        <\/div>\n                        <div class=\"sds-grid sds-grid-2\">\n                            <div class=\"sds-field\"><label for=\"insurance_2_address\">Address<\/label><input type=\"text\" id=\"insurance_2_address\" name=\"insurance_2_address\"><\/div>\n                            <div class=\"sds-field\"><label for=\"insurance_2_phone\">Phone #<\/label><input type=\"tel\" id=\"insurance_2_phone\" name=\"insurance_2_phone\"><\/div>\n                        <\/div>\n                        <div class=\"sds-grid sds-grid-2\">\n                            <div class=\"sds-field\"><label for=\"insurance_2_insured_name\">Name of Insured<\/label><input type=\"text\" id=\"insurance_2_insured_name\" name=\"insurance_2_insured_name\"><\/div>\n                            <div class=\"sds-field\"><label for=\"insurance_2_dob\">Date of Birth<\/label><input type=\"date\" id=\"insurance_2_dob\" name=\"insurance_2_dob\"><\/div>\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"sds-field\"><label for=\"service_begin_date\">Service Begin Date<\/label><input type=\"date\" id=\"service_begin_date\" name=\"service_begin_date\"><\/div>\n\n                    <div class=\"sds-field sds-question-row\">\n                        <span class=\"sds-label\">Patient Currently Hospitalized?<\/span>\n                            <div class=\"sds-inline-options\">\n        <label><input type=\"radio\" name=\"currently_hospitalized\" value=\"Yes\" > Yes<\/label>\n        <label><input type=\"radio\" name=\"currently_hospitalized\" value=\"No\" > No<\/label>\n    <\/div>\n                        <\/div>\n                    <div class=\"sds-field\"><label for=\"hospital_name\">If Yes, Name of Hospital<\/label><input type=\"text\" id=\"hospital_name\" name=\"hospital_name\"><\/div>\n                    <div class=\"sds-grid sds-grid-3\">\n                        <div class=\"sds-field\"><label for=\"hospital_phone\">Phone #<\/label><input type=\"tel\" id=\"hospital_phone\" name=\"hospital_phone\"><\/div>\n                        <div class=\"sds-field\"><label for=\"hospital_room\">Room #<\/label><input type=\"text\" id=\"hospital_room\" name=\"hospital_room\"><\/div>\n                        <div class=\"sds-field\"><label for=\"discharge_date\">Discharge Date<\/label><input type=\"date\" id=\"discharge_date\" name=\"discharge_date\"><\/div>\n                    <\/div>\n\n                    <div class=\"sds-field\"><label for=\"other_home_health_providers\">Name(s) of other home health providers visiting patient<\/label><input type=\"text\" id=\"other_home_health_providers\" name=\"other_home_health_providers\"><\/div>\n                    <div class=\"sds-field\"><label for=\"equipment_services_needed\">Equipment \/ Services Needed<\/label><textarea id=\"equipment_services_needed\" name=\"equipment_services_needed\" rows=\"6\"><\/textarea><\/div>\n\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"person_taking_referral\">Person Taking Referral<\/label><input type=\"text\" id=\"person_taking_referral\" name=\"person_taking_referral\"><\/div>\n                        <div class=\"sds-field\"><label for=\"date_received\">Date received<\/label><input type=\"date\" id=\"date_received\" name=\"date_received\"><\/div>\n                    <\/div>\n                    <div class=\"sds-grid sds-grid-4\">\n                        <div class=\"sds-field\"><label for=\"patient_contacted_date\">Patient Contacted: Date<\/label><input type=\"date\" id=\"patient_contacted_date\" name=\"patient_contacted_date\"><\/div>\n                        <div class=\"sds-field\"><label for=\"patient_contacted_time\">Time<\/label><input type=\"time\" id=\"patient_contacted_time\" name=\"patient_contacted_time\"><\/div>\n                        <div class=\"sds-field\"><label for=\"expected_delivery_date\">Expected Delivery Date<\/label><input type=\"date\" id=\"expected_delivery_date\" name=\"expected_delivery_date\"><\/div>\n                        <div class=\"sds-field\"><label for=\"expected_delivery_time\">Time<\/label><input type=\"time\" id=\"expected_delivery_time\" name=\"expected_delivery_time\"><\/div>\n                    <\/div>\n                        <div class=\"sds-source-footer\">\n        <div class=\"sds-footer-top\">\n            <span>\u00a9 All Rights Reserved.<br><strong>ACHCU<\/strong><\/span>\n            <span>VERSION 2019.3<\/span>\n            <span>2<\/span>\n        <\/div>\n        <div class=\"sds-footer-company\">\n            <strong>SDS Medical Supplies Inc.<\/strong> | 2375 Wall Street SE, Suite 240 Rm 50, Conyers, GA 30013<br>\n            Office: (770) 285-4104 | Fax: (770) 285-4152 | Monday-Friday 10:00am to 4:00pm\n        <\/div>\n    <\/div>\n                    <\/div>\n            <\/section>\n\n            <!-- PAGE 3: PATIENT SERVICE AGREEMENT -->\n            <section class=\"sds-step\" data-step=\"3\">\n                <div class=\"sds-document-card\">\n                    <header class=\"sds-doc-header\">\n                        <div class=\"sds-brand\">SDS Medical Supplies<\/div>\n                        <h2>PATIENT SERVICE AGREEMENT<\/h2>\n                    <\/header>\n\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"service_patient_name\">Patient Name<\/label><input type=\"text\" id=\"service_patient_name\" name=\"service_patient_name\"><\/div>\n                        <div class=\"sds-field\"><label for=\"service_patient_id\">ID<\/label><input type=\"text\" id=\"service_patient_id\" name=\"service_patient_id\"><\/div>\n                    <\/div>\n\n                    <div class=\"sds-legal-copy\">\n                        <p><u>Authorization\/Consent for Care\/Service:<\/u> I have been informed of the home care options available to me and of the selection of providers from which I may choose. I authorize SDS Medical Supplies under the direction of the prescribing physician, to provide home medical equipment, supplies and services as prescribed by my physician.<\/p>\n\n                        <p><u>Assignment of Benefits\/Authorization for Payment:<\/u> I hereby assign all benefits and payments to be made directly SDS Medical Supplies, for any home medical equipment, supplies and services furnished to me in conjunction with my home care. I authorize SDS Medical Supplies to seek such benefits and payments on my behalf. It is understood that, as a courtesy. SDS Medical Supplies will bill Medicare\/Medicaid or other federally funded sources and other payers and insurer(s) providing coverage, with a copy to SDS Medical Supplies I understand that I am responsible for providing all necessary information and for making sure all certification and enrollment requirements are fulfilled. Any changes in the policy must be reported to SDS Medical Supplies within 30 days of the event. I have been informed by SDS Medical Supplies of the medical necessity for the services prescribed by my physician. I understand that in the event services are deemed not reasonable and necessary, payment may be denied and that I will be fully responsible for payment.<\/p>\n\n                        <p><u>Release of Information:<\/u> I hereby request and authorize SDS Medical Supplies, the prescribing physician, hospital, and any other holder of information relevant to service, to release information upon request, to SDS Medical Supplies, any payer source, physician, or any other medical personnel or agency involved with service. I also authorize SDS Medical Supplies to review medical history and payer information for the purpose of providing home health care.<\/p>\n\n                        <p><u>Financial Responsibility:<\/u> I understand and agree that I am responsible for the payment of any and all sums that may become due for the services provided. These sums include, but are not limited to, all deductibles, co-payments, out-of-pocket requirements, and non-covered services. If for any reason and to any extent, SDS Medical Supplies does not receive payment from my payer source, I hereby agree to pay SDS Medical Supplies for the balance in full, within 30 days of receipt of invoice. All charges not paid within 45 days of billing date shall be assessed late charges. I am liable for all charges, including collection costs and all attorneys cost. I am responsible for all charges regardless of my payer unless my agreement with my health plan holds me harmless.<\/p>\n\n                        <div class=\"sds-initials-row\">\n                            <div class=\"sds-field\"><label for=\"financial_responsibility_initials\">(Initials)<\/label><input type=\"text\" id=\"financial_responsibility_initials\" name=\"financial_responsibility_initials\" maxlength=\"12\"><\/div>\n                            <p>I acknowledge that I have been advised of my financial responsibilities to SDS Medical Supplies<\/p>\n                        <\/div>\n\n                        <p><u>Returned Goods:<\/u> I understand that, due to Federal and State Regulations ancillary items prescribed for home health care cannot be re-dispensed. Therefore, ancillary items cannot be returned for credit. Home Medical Equipment that is rented will be returned after the physician has discontinued service. Sale items cannot be returned. SDS Medical Supplies must be notified within 24 hours of the set-up if any equipment is defective. In the case of defective equipment, an exchange will be made for the defective item.<\/p>\n\n                        <p><u>Patient Handouts:<\/u> I acknowledge that I have received a copy of the Patient Handouts which contains Patient Rights and Responsibilities, Supplier Standards, Home Safety Information, HIPAA Privacy Standards, Emergency Planning, and Advance Directive Information. I acknowledge that I have received company marketing material and information on the company\u2019s scope of services. I acknowledge that the information in the Patient Handouts has been explained to me and that I understand the information. I understand my right to formulate and to issue Advance Directives to be followed should I become incapacitated. I will furnish SDS Medical Supplies with a copy of such document.<\/p>\n\n                        <p><u>Complaint Reporting:<\/u> I acknowledge that I have been informed of the procedure to report a grievance should I become dissatisfied with any portion of my home care experience. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call (770) 285-4104 and speak to customer services. If your complaint is not resolved to your satisfaction within 5 working days, you may initiate a formal grievance, in writing and forward it to the Governing Body. You can expect a written response within 14 working days of receipt.<\/p>\n\n                        <p>You may also make inquiries or complaints about this company by calling Medicare at 1-800-MEDICARE, the Accreditation Commission for Health Care (ACHC) at 919-785-1214 and\/or Georgia Board of Pharmacy at <a href=\"https:\/\/gbp.georgia.gov\/webform\/georgia-professional-licensure-complaint-form\" target=\"_blank\" rel=\"noopener\">Georgia Professional Licensure Complaint Form<\/a>.<\/p>\n                    <\/div>\n\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Patient Signature<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"service_patient_signature\" aria-label=\"Patient Signature\"><\/canvas>\n        <input type=\"hidden\" name=\"service_patient_signature\" id=\"service_patient_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                        <div class=\"sds-field\"><label for=\"service_patient_date\">Date<\/label><input type=\"date\" id=\"service_patient_date\" name=\"service_patient_date\"><\/div>\n                    <\/div>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Witness Signature<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"service_witness_signature\" aria-label=\"Witness Signature\"><\/canvas>\n        <input type=\"hidden\" name=\"service_witness_signature\" id=\"service_witness_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                        <div class=\"sds-field\"><label for=\"service_witness_date\">Date<\/label><input type=\"date\" id=\"service_witness_date\" name=\"service_witness_date\"><\/div>\n                    <\/div>\n                        <div class=\"sds-source-footer\">\n        <div class=\"sds-footer-top\">\n            <span>\u00a9 All Rights Reserved.<br><strong>ACHCU<\/strong><\/span>\n            <span>VERSION 2019.3<\/span>\n            <span>3<\/span>\n        <\/div>\n        <div class=\"sds-footer-company\">\n            <strong>SDS Medical Supplies Inc.<\/strong> | 2375 Wall Street SE, Suite 240 Rm 50, Conyers, GA 30013<br>\n            Office: (770) 285-4104 | Fax: (770) 285-4152 | Monday-Friday 10:00am to 4:00pm\n        <\/div>\n    <\/div>\n                    <\/div>\n            <\/section>\n\n            <!-- PAGE 4: PATIENT DELIVERY TICKET -->\n            <section class=\"sds-step\" data-step=\"4\">\n                <div class=\"sds-document-card\">\n                    <header class=\"sds-doc-header\"><div class=\"sds-brand\">SDS Medical Supplies<\/div><h2>PATIENT DELIVERY TICKET<\/h2><\/header>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"delivery_patient\">PATIENT<\/label><input type=\"text\" id=\"delivery_patient\" name=\"delivery_patient\"><\/div>\n                        <div class=\"sds-field\"><label for=\"delivery_phone\">PHONE<\/label><input type=\"tel\" id=\"delivery_phone\" name=\"delivery_phone\"><\/div>\n                    <\/div>\n                    <div class=\"sds-inline-options sds-block-options\">\n                        <label><input type=\"radio\" name=\"delivery_method\" value=\"Picked up at company\"> PICKED UP AT COMPANY<\/label>\n                        <label><input type=\"radio\" name=\"delivery_method\" value=\"Deliver to patient's home\"> DELIVER TO PATIENT\u2019S HOME<\/label>\n                    <\/div>\n\n                    <div class=\"sds-table-wrap\">\n                        <table class=\"sds-form-table\">\n                            <thead><tr><th>QTY<\/th><th>DESCRIPTION<\/th><th>SERIAL NUMBER or LOT NUMBER<\/th><th>RENT<\/th><th>SALE<\/th><th>CHARGES<\/th><\/tr><\/thead>\n                            <tbody>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"delivery_items[0][qty]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[0][description]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[0][serial_or_lot]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[0][rent]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[0][sale]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[0][charges]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"delivery_items[1][qty]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[1][description]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[1][serial_or_lot]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[1][rent]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[1][sale]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[1][charges]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"delivery_items[2][qty]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[2][description]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[2][serial_or_lot]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[2][rent]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[2][sale]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[2][charges]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"delivery_items[3][qty]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[3][description]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[3][serial_or_lot]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[3][rent]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[3][sale]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[3][charges]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"delivery_items[4][qty]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[4][description]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[4][serial_or_lot]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[4][rent]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[4][sale]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[4][charges]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"delivery_items[5][qty]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[5][description]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[5][serial_or_lot]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[5][rent]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[5][sale]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[5][charges]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"delivery_items[6][qty]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[6][description]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[6][serial_or_lot]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[6][rent]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[6][sale]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[6][charges]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"delivery_items[7][qty]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[7][description]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[7][serial_or_lot]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[7][rent]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[7][sale]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[7][charges]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"delivery_items[8][qty]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[8][description]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[8][serial_or_lot]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[8][rent]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[8][sale]\"><\/td>\n                                    <td><input type=\"text\" name=\"delivery_items[8][charges]\"><\/td>\n                                <\/tr>\n                                                        <\/tbody>\n                        <\/table>\n                    <\/div>\n\n                    <div class=\"sds-initials-row\">\n                        <p>I acknowledge that I have been advised of my financial responsibilities to SDS Medical Supplies<\/p>\n                        <div class=\"sds-field\"><label for=\"delivery_financial_initials\">Initials<\/label><input type=\"text\" id=\"delivery_financial_initials\" name=\"delivery_financial_initials\" maxlength=\"12\"><\/div>\n                    <\/div>\n\n                    <label class=\"sds-checkline\"><input type=\"checkbox\" name=\"delivery_warranty_card_given\" value=\"Yes\"> Check if equipment was sold to the patient and that the warranty card(s) is \/ are given to the patient.<\/label>\n                    <p class=\"sds-acknowledgement\">I acknowledge training in the use of equipment and products provided and the performance of the Assessment and Plan of Service on the date noted.<\/p>\n                    <div class=\"sds-grid sds-grid-3\">\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Patient Signature<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"delivery_patient_signature\" aria-label=\"Patient Signature\"><\/canvas>\n        <input type=\"hidden\" name=\"delivery_patient_signature\" id=\"delivery_patient_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                        <div class=\"sds-field\"><label for=\"delivery_date\">Date<\/label><input type=\"date\" id=\"delivery_date\" name=\"delivery_date\"><\/div>\n                        <div class=\"sds-field\"><label for=\"delivery_staff_member\">Staff Member<\/label><input type=\"text\" id=\"delivery_staff_member\" name=\"delivery_staff_member\"><\/div>\n                    <\/div>\n                        <div class=\"sds-source-footer\">\n        <div class=\"sds-footer-top\">\n            <span>\u00a9 All Rights Reserved.<br><strong>ACHCU<\/strong><\/span>\n            <span>VERSION 2019.3<\/span>\n            <span>4<\/span>\n        <\/div>\n        <div class=\"sds-footer-company\">\n            <strong>SDS Medical Supplies Inc.<\/strong> | 2375 Wall Street SE, Suite 240 Rm 50, Conyers, GA 30013<br>\n            Office: (770) 285-4104 | Fax: (770) 285-4152 | Monday-Friday 10:00am to 4:00pm\n        <\/div>\n    <\/div>\n                    <\/div>\n            <\/section>\n\n            <!-- PAGE 5: EQUIPMENT MAINTENANCE -->\n            <section class=\"sds-step\" data-step=\"5\">\n                <div class=\"sds-document-card\">\n                    <header class=\"sds-doc-header\"><div class=\"sds-brand\">SDS Medical Supplies<\/div><h2>PATIENT VISIT REPORT - EQUIPMENT MAINTENANCE<\/h2><\/header>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"maintenance_patient\">Patient<\/label><input type=\"text\" id=\"maintenance_patient\" name=\"maintenance_patient\"><\/div>\n                        <div class=\"sds-field\"><label for=\"maintenance_date\">Date<\/label><input type=\"date\" id=\"maintenance_date\" name=\"maintenance_date\"><\/div>\n                    <\/div>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"maintenance_phone\">Phone<\/label><input type=\"tel\" id=\"maintenance_phone\" name=\"maintenance_phone\"><\/div>\n                        <div>\n                            <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">Any Hospitalizations since last visit?<\/span>    <div class=\"sds-inline-options\">\n        <label><input type=\"radio\" name=\"maintenance_hospitalizations\" value=\"Yes\" > Yes<\/label>\n        <label><input type=\"radio\" name=\"maintenance_hospitalizations\" value=\"No\" > No<\/label>\n    <\/div>\n    <\/div>\n                            <div class=\"sds-field\"><label for=\"maintenance_hospitalization_details\">Hospitalization Details (if applicable)<\/label><input type=\"text\" id=\"maintenance_hospitalization_details\" name=\"maintenance_hospitalization_details\"><\/div>\n                        <\/div>\n                    <\/div>\n                    <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">Any changes in Insurance or Physician since last visit?<\/span>    <div class=\"sds-inline-options\">\n        <label><input type=\"radio\" name=\"maintenance_insurance_physician_changes\" value=\"Yes\" > Yes<\/label>\n        <label><input type=\"radio\" name=\"maintenance_insurance_physician_changes\" value=\"No\" > No<\/label>\n    <\/div>\n    <\/div>\n                    <div class=\"sds-field\"><label for=\"maintenance_insurance_physician_change_details\">Insurance \/ Physician Change Details (if applicable)<\/label><input type=\"text\" id=\"maintenance_insurance_physician_change_details\" name=\"maintenance_insurance_physician_change_details\"><\/div>\n\n                    <h3 class=\"sds-box-title\">EQUIPMENT INFORMATION<\/h3>\n                    <div class=\"sds-table-wrap\">\n                        <table class=\"sds-form-table\">\n                            <thead><tr><th>Manufacturer<\/th><th>Model#<\/th><th>Serial #<\/th><th>Hours (if applicable)<\/th><th>Settings (if applicable)<\/th><th>Maintenance Performed<\/th><\/tr><\/thead>\n                            <tbody>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[0][manufacturer]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[0][model]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[0][serial]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[0][hours]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[0][settings]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[0][maintenance_performed]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[1][manufacturer]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[1][model]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[1][serial]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[1][hours]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[1][settings]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[1][maintenance_performed]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[2][manufacturer]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[2][model]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[2][serial]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[2][hours]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[2][settings]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[2][maintenance_performed]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[3][manufacturer]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[3][model]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[3][serial]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[3][hours]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[3][settings]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[3][maintenance_performed]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[4][manufacturer]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[4][model]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[4][serial]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[4][hours]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[4][settings]\"><\/td>\n                                    <td><input type=\"text\" name=\"maintenance_equipment[4][maintenance_performed]\"><\/td>\n                                <\/tr>\n                                                        <\/tbody>\n                        <\/table>\n                    <\/div>\n\n                    <div class=\"sds-bordered-box\">\n                        <h3 class=\"sds-box-title\">EQUIPMENT EXCHANGES AND D\/C\u2019S<\/h3>\n                                                <div class=\"sds-grid sds-grid-5\">\n                            <div class=\"sds-field\"><label>Old Unit<\/label><input type=\"text\" name=\"maintenance_exchanges[0][old_unit]\"><\/div>\n                            <div class=\"sds-field\"><label>SN<\/label><input type=\"text\" name=\"maintenance_exchanges[0][old_sn]\"><\/div>\n                            <div class=\"sds-field\"><label>New Unit<\/label><input type=\"text\" name=\"maintenance_exchanges[0][new_unit]\"><\/div>\n                            <div class=\"sds-field\"><label>SN<\/label><input type=\"text\" name=\"maintenance_exchanges[0][new_sn]\"><\/div>\n                            <div class=\"sds-field\"><label>Reason<\/label><input type=\"text\" name=\"maintenance_exchanges[0][reason]\"><\/div>\n                        <\/div>\n                                                <div class=\"sds-grid sds-grid-5\">\n                            <div class=\"sds-field\"><label>Old Unit<\/label><input type=\"text\" name=\"maintenance_exchanges[1][old_unit]\"><\/div>\n                            <div class=\"sds-field\"><label>SN<\/label><input type=\"text\" name=\"maintenance_exchanges[1][old_sn]\"><\/div>\n                            <div class=\"sds-field\"><label>New Unit<\/label><input type=\"text\" name=\"maintenance_exchanges[1][new_unit]\"><\/div>\n                            <div class=\"sds-field\"><label>SN<\/label><input type=\"text\" name=\"maintenance_exchanges[1][new_sn]\"><\/div>\n                            <div class=\"sds-field\"><label>Reason<\/label><input type=\"text\" name=\"maintenance_exchanges[1][reason]\"><\/div>\n                        <\/div>\n                                                                        <div class=\"sds-grid sds-grid-3\">\n                            <div class=\"sds-field\"><label>D\/C\u2019d Unit<\/label><input type=\"text\" name=\"maintenance_dc[0][unit]\"><\/div>\n                            <div class=\"sds-field\"><label>SN<\/label><input type=\"text\" name=\"maintenance_dc[0][sn]\"><\/div>\n                            <div class=\"sds-field\"><label>Reason<\/label><input type=\"text\" name=\"maintenance_dc[0][reason]\"><\/div>\n                        <\/div>\n                                                <div class=\"sds-grid sds-grid-3\">\n                            <div class=\"sds-field\"><label>D\/C\u2019d Unit<\/label><input type=\"text\" name=\"maintenance_dc[1][unit]\"><\/div>\n                            <div class=\"sds-field\"><label>SN<\/label><input type=\"text\" name=\"maintenance_dc[1][sn]\"><\/div>\n                            <div class=\"sds-field\"><label>Reason<\/label><input type=\"text\" name=\"maintenance_dc[1][reason]\"><\/div>\n                        <\/div>\n                                            <\/div>\n\n                    <div class=\"sds-bordered-box\"><h3 class=\"sds-box-title\">SUPPLIES DISPENSED<\/h3><textarea name=\"maintenance_supplies_dispensed\" rows=\"5\"><\/textarea><\/div>\n                    <div class=\"sds-bordered-box\">\n                        <h3 class=\"sds-box-title\">PLAN OF SERVICE UPDATE<\/h3>\n                        <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">Outcomes being met?<\/span>    <div class=\"sds-inline-options\">\n        <label><input type=\"radio\" name=\"maintenance_outcomes_met\" value=\"Yes\" > Yes<\/label>\n        <label><input type=\"radio\" name=\"maintenance_outcomes_met\" value=\"No\" > No<\/label>\n    <\/div>\n    <small>(If No, document education provided below and document any concerns)<\/small><\/div>\n                        <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">Equipment functional?<\/span>    <div class=\"sds-inline-options\">\n        <label><input type=\"radio\" name=\"maintenance_equipment_functional\" value=\"Yes\" > Yes<\/label>\n        <label><input type=\"radio\" name=\"maintenance_equipment_functional\" value=\"No\" > No<\/label>\n    <\/div>\n    <span class=\"sds-label\">If No, was it<\/span><div class=\"sds-inline-options\"><label><input type=\"radio\" name=\"maintenance_equipment_resolution\" value=\"Repaired\"> Repaired?<\/label><label><input type=\"radio\" name=\"maintenance_equipment_resolution\" value=\"Replaced\"> Replaced?<\/label><\/div><\/div>\n                        <div class=\"sds-field\">\n                            <span class=\"sds-label\">Patient reeducated on the following?<\/span>\n                            <div class=\"sds-check-grid\">\n                                                                    <label><input type=\"checkbox\" name=\"maintenance_reeducation[]\" value=\"Use of Equipment\"> Use of Equipment<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"maintenance_reeducation[]\" value=\"Doctor&#039;s Prescription\"> Doctor&#039;s Prescription<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"maintenance_reeducation[]\" value=\"Emergency Preparedness\"> Emergency Preparedness<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"maintenance_reeducation[]\" value=\"Troubleshooting Equipment\"> Troubleshooting Equipment<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"maintenance_reeducation[]\" value=\"Fire \/ Electrical \/ Home Safety\"> Fire \/ Electrical \/ Home Safety<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"maintenance_reeducation[]\" value=\"When to call for services\"> When to call for services<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"maintenance_reeducation[]\" value=\"Changes in Doctor&#039;s Orders\"> Changes in Doctor&#039;s Orders<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"maintenance_reeducation[]\" value=\"Use of Back up Equipment\"> Use of Back up Equipment<\/label>\n                                                            <\/div>\n                        <\/div>\n                        <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">Any other safety or health hazards?<\/span>    <div class=\"sds-inline-options\">\n        <label><input type=\"radio\" name=\"maintenance_other_hazards\" value=\"Yes\" > Yes<\/label>\n        <label><input type=\"radio\" name=\"maintenance_other_hazards\" value=\"No\" > No<\/label>\n    <\/div>\n    <small>(If Yes, document concerns)<\/small><\/div>\n                        <div class=\"sds-field\"><label for=\"maintenance_concerns\">Concerns \/ Education Provided<\/label><textarea id=\"maintenance_concerns\" name=\"maintenance_concerns\" rows=\"4\"><\/textarea><\/div>\n                    <\/div>\n                    <p class=\"sds-acknowledgement\"><strong>I acknowledge performance of the Patient Visit and Plan of Service update on the date noted:<\/strong><\/p>\n                    <div class=\"sds-grid sds-grid-3\">\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Patient<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"maintenance_patient_signature\" aria-label=\"Patient\"><\/canvas>\n        <input type=\"hidden\" name=\"maintenance_patient_signature\" id=\"maintenance_patient_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                        <div class=\"sds-field\"><label for=\"maintenance_ack_date\">Date<\/label><input type=\"date\" id=\"maintenance_ack_date\" name=\"maintenance_ack_date\"><\/div>\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Technician\/Therapist<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"maintenance_technician_signature\" aria-label=\"Technician\/Therapist\"><\/canvas>\n        <input type=\"hidden\" name=\"maintenance_technician_signature\" id=\"maintenance_technician_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                    <\/div>\n                        <div class=\"sds-source-footer\">\n        <div class=\"sds-footer-top\">\n            <span>\u00a9 All Rights Reserved.<br><strong>ACHCU<\/strong><\/span>\n            <span>VERSION 2019.3<\/span>\n            <span>5<\/span>\n        <\/div>\n        <div class=\"sds-footer-company\">\n            <strong>SDS Medical Supplies Inc.<\/strong> | 2375 Wall Street SE, Suite 240 Rm 50, Conyers, GA 30013<br>\n            Office: (770) 285-4104 | Fax: (770) 285-4152 | Monday-Friday 10:00am to 4:00pm\n        <\/div>\n    <\/div>\n                    <\/div>\n            <\/section>\n\n            <!-- PAGE 6: EQUIPMENT PICK UP -->\n            <section class=\"sds-step\" data-step=\"6\">\n                <div class=\"sds-document-card\">\n                    <header class=\"sds-doc-header\"><div class=\"sds-brand\">SDS Medical Supplies<\/div><h2>PATIENT VISIT REPORT - EQUIPMENT PICK UP<\/h2><\/header>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"pickup_patient\">Patient<\/label><input type=\"text\" id=\"pickup_patient\" name=\"pickup_patient\"><\/div>\n                        <div class=\"sds-field\"><label for=\"pickup_date\">Date<\/label><input type=\"date\" id=\"pickup_date\" name=\"pickup_date\"><\/div>\n                    <\/div>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"pickup_phone\">Phone<\/label><input type=\"tel\" id=\"pickup_phone\" name=\"pickup_phone\"><\/div>\n                        <div>\n                            <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">Any Hospitalizations since last visit?<\/span>    <div class=\"sds-inline-options\">\n        <label><input type=\"radio\" name=\"pickup_hospitalizations\" value=\"Yes\" > Yes<\/label>\n        <label><input type=\"radio\" name=\"pickup_hospitalizations\" value=\"No\" > No<\/label>\n    <\/div>\n    <\/div>\n                            <div class=\"sds-field\"><label for=\"pickup_hospitalization_details\">Hospitalization Details (if applicable)<\/label><input type=\"text\" id=\"pickup_hospitalization_details\" name=\"pickup_hospitalization_details\"><\/div>\n                        <\/div>\n                    <\/div>\n                    <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">Any changes in Insurance or Physician since last visit?<\/span>    <div class=\"sds-inline-options\">\n        <label><input type=\"radio\" name=\"pickup_insurance_physician_changes\" value=\"Yes\" > Yes<\/label>\n        <label><input type=\"radio\" name=\"pickup_insurance_physician_changes\" value=\"No\" > No<\/label>\n    <\/div>\n    <\/div>\n                    <div class=\"sds-field\"><label for=\"pickup_insurance_physician_change_details\">Insurance \/ Physician Change Details (if applicable)<\/label><input type=\"text\" id=\"pickup_insurance_physician_change_details\" name=\"pickup_insurance_physician_change_details\"><\/div>\n\n                    <h3 class=\"sds-box-title\">EQUIPMENT PICKED UP<\/h3>\n                    <div class=\"sds-table-wrap\">\n                        <table class=\"sds-form-table\">\n                            <thead><tr><th>Manufacturer<\/th><th>Model#<\/th><th>Serial #<\/th><th>Hours (if applicable)<\/th><th>Reason<\/th><\/tr><\/thead>\n                            <tbody>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"pickup_equipment[0][manufacturer]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[0][model]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[0][serial]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[0][hours]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[0][reason]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"pickup_equipment[1][manufacturer]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[1][model]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[1][serial]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[1][hours]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[1][reason]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"pickup_equipment[2][manufacturer]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[2][model]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[2][serial]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[2][hours]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[2][reason]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"pickup_equipment[3][manufacturer]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[3][model]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[3][serial]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[3][hours]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[3][reason]\"><\/td>\n                                <\/tr>\n                                                            <tr>\n                                    <td><input type=\"text\" name=\"pickup_equipment[4][manufacturer]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[4][model]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[4][serial]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[4][hours]\"><\/td>\n                                    <td><input type=\"text\" name=\"pickup_equipment[4][reason]\"><\/td>\n                                <\/tr>\n                                                        <\/tbody>\n                        <\/table>\n                    <\/div>\n\n                    <div class=\"sds-bordered-box\">\n                        <h3 class=\"sds-box-title\">PLAN OF SERVICE UPDATE<\/h3>\n                        <label class=\"sds-checkline sds-centered-check\"><input type=\"checkbox\" name=\"pickup_no_company_equipment_remains\" value=\"Yes\"> No Company Owned Equipment Remains in the Patient\u2019s Home<\/label>\n                        <p class=\"sds-center-text\">Evaluate Plan of Service and update as needed below if any company equipment remains in the home<\/p>\n                        <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">Outcomes being met?<\/span>    <div class=\"sds-inline-options\">\n        <label><input type=\"radio\" name=\"pickup_outcomes_met\" value=\"Yes\" > Yes<\/label>\n        <label><input type=\"radio\" name=\"pickup_outcomes_met\" value=\"No\" > No<\/label>\n    <\/div>\n    <small>(If No, document education provided below and document any concerns)<\/small><\/div>\n                        <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">Equipment functional?<\/span>    <div class=\"sds-inline-options\">\n        <label><input type=\"radio\" name=\"pickup_equipment_functional\" value=\"Yes\" > Yes<\/label>\n        <label><input type=\"radio\" name=\"pickup_equipment_functional\" value=\"No\" > No<\/label>\n    <\/div>\n    <span class=\"sds-label\">If No, was it<\/span><div class=\"sds-inline-options\"><label><input type=\"radio\" name=\"pickup_equipment_resolution\" value=\"Repaired\"> Repaired?<\/label><label><input type=\"radio\" name=\"pickup_equipment_resolution\" value=\"Replaced\"> Replaced?<\/label><\/div><\/div>\n                        <div class=\"sds-field\">\n                            <span class=\"sds-label\">Patient reeducated on the following?<\/span>\n                            <div class=\"sds-check-grid\">\n                                                                    <label><input type=\"checkbox\" name=\"pickup_reeducation[]\" value=\"Use of Equipment\"> Use of Equipment<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"pickup_reeducation[]\" value=\"Doctor&#039;s Prescription\"> Doctor&#039;s Prescription<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"pickup_reeducation[]\" value=\"Emergency Preparedness\"> Emergency Preparedness<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"pickup_reeducation[]\" value=\"Troubleshooting Equipment\"> Troubleshooting Equipment<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"pickup_reeducation[]\" value=\"Fire \/ Electrical \/ Home Safety\"> Fire \/ Electrical \/ Home Safety<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"pickup_reeducation[]\" value=\"When to call for services\"> When to call for services<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"pickup_reeducation[]\" value=\"Changes in Doctor&#039;s Orders\"> Changes in Doctor&#039;s Orders<\/label>\n                                                                    <label><input type=\"checkbox\" name=\"pickup_reeducation[]\" value=\"Use of Back up Equipment\"> Use of Back up Equipment<\/label>\n                                                            <\/div>\n                        <\/div>\n                        <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">Any other safety or health hazards?<\/span>    <div class=\"sds-inline-options\">\n        <label><input type=\"radio\" name=\"pickup_other_hazards\" value=\"Yes\" > Yes<\/label>\n        <label><input type=\"radio\" name=\"pickup_other_hazards\" value=\"No\" > No<\/label>\n    <\/div>\n    <small>(If Yes, document concerns)<\/small><\/div>\n                        <div class=\"sds-field\"><label for=\"pickup_concerns\">Concerns<\/label><textarea id=\"pickup_concerns\" name=\"pickup_concerns\" rows=\"4\"><\/textarea><\/div>\n                    <\/div>\n                    <p class=\"sds-acknowledgement\"><strong>I acknowledge the equipment listed above was picked up and the Plan of Service was updated on the date noted:<\/strong><\/p>\n                    <div class=\"sds-grid sds-grid-3\">\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Patient<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"pickup_patient_signature\" aria-label=\"Patient\"><\/canvas>\n        <input type=\"hidden\" name=\"pickup_patient_signature\" id=\"pickup_patient_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                        <div class=\"sds-field\"><label for=\"pickup_ack_date\">Date<\/label><input type=\"date\" id=\"pickup_ack_date\" name=\"pickup_ack_date\"><\/div>\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Technician\/Therapist<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"pickup_technician_signature\" aria-label=\"Technician\/Therapist\"><\/canvas>\n        <input type=\"hidden\" name=\"pickup_technician_signature\" id=\"pickup_technician_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                    <\/div>\n                        <div class=\"sds-source-footer\">\n        <div class=\"sds-footer-top\">\n            <span>\u00a9 All Rights Reserved.<br><strong>ACHCU<\/strong><\/span>\n            <span>VERSION 2019.3<\/span>\n            <span>6<\/span>\n        <\/div>\n        <div class=\"sds-footer-company\">\n            <strong>SDS Medical Supplies Inc.<\/strong> | 2375 Wall Street SE, Suite 240 Rm 50, Conyers, GA 30013<br>\n            Office: (770) 285-4104 | Fax: (770) 285-4152 | Monday-Friday 10:00am to 4:00pm\n        <\/div>\n    <\/div>\n                    <\/div>\n            <\/section>\n\n            <!-- PAGE 7: EQUIPMENT MANAGEMENT -->\n            <section class=\"sds-step\" data-step=\"7\">\n                <div class=\"sds-document-card\">\n                    <header class=\"sds-doc-header\"><div class=\"sds-brand\">SDS Medical Supplies<\/div><h2>EQUIPMENT MANAGEMENT ADMISSION ASSESSMENT AND PLAN OF SERVICE<\/h2><\/header>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"management_patient\">Patient<\/label><input type=\"text\" id=\"management_patient\" name=\"management_patient\"><\/div>\n                        <div class=\"sds-field\"><label for=\"management_date\">Date<\/label><input type=\"date\" id=\"management_date\" name=\"management_date\"><\/div>\n                    <\/div>\n                    <div class=\"sds-field\"><label for=\"management_phone\">Phone<\/label><input type=\"tel\" id=\"management_phone\" name=\"management_phone\"><\/div>\n\n                    <h3 class=\"sds-box-title\">EQUIPMENT DISPENSED<\/h3>\n                    <div class=\"sds-table-wrap\"><table class=\"sds-form-table\"><thead><tr><th>Manufacturer<\/th><th>Model#<\/th><th>Serial #<\/th><th>Hours (if applicable)<\/th><th>Settings (if applicable)<\/th><\/tr><\/thead><tbody>\n                    <tr>\n                        <td><input type=\"text\" name=\"management_equipment[0][manufacturer]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[0][model]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[0][serial]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[0][hours]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[0][settings]\"><\/td>\n                    <\/tr><tr>\n                        <td><input type=\"text\" name=\"management_equipment[1][manufacturer]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[1][model]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[1][serial]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[1][hours]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[1][settings]\"><\/td>\n                    <\/tr><tr>\n                        <td><input type=\"text\" name=\"management_equipment[2][manufacturer]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[2][model]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[2][serial]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[2][hours]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[2][settings]\"><\/td>\n                    <\/tr><tr>\n                        <td><input type=\"text\" name=\"management_equipment[3][manufacturer]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[3][model]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[3][serial]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[3][hours]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[3][settings]\"><\/td>\n                    <\/tr><tr>\n                        <td><input type=\"text\" name=\"management_equipment[4][manufacturer]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[4][model]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[4][serial]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[4][hours]\"><\/td>\n                        <td><input type=\"text\" name=\"management_equipment[4][settings]\"><\/td>\n                    <\/tr><\/tbody><\/table><\/div>\n\n                    <div class=\"sds-bordered-box\"><h3 class=\"sds-box-title\">SUPPLIES DISPENSED<\/h3><textarea name=\"management_supplies_dispensed\" rows=\"5\"><\/textarea><\/div>\n                    <div class=\"sds-bordered-box\">\n                        <h3 class=\"sds-box-title\">HOME ASSESSMENT-ENVIRONMENTAL \/ SAFETY<\/h3>\n                        <label class=\"sds-checkline\"><input type=\"checkbox\" name=\"management_picked_up_at_company\" value=\"Yes\"> CHECK IF PICKED UP AT COMPANY (Do not complete the home assessment if picked up at the company)<\/label>\n                                                    <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">ARCHITECTURAL BARRIERS<\/span><div class=\"sds-inline-options\"><label><input type=\"radio\" name=\"management_architectural_barriers\" value=\"Adequate\"> ADEQUATE<\/label><label><input type=\"radio\" name=\"management_architectural_barriers\" value=\"Inadequate\"> INADEQUATE<\/label><\/div><\/div>\n                                                    <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">SHELTER, HEAT, WATER, PLUMBING, REFRIGERATION, COOKING<\/span><div class=\"sds-inline-options\"><label><input type=\"radio\" name=\"management_shelter_heat_water\" value=\"Adequate\"> ADEQUATE<\/label><label><input type=\"radio\" name=\"management_shelter_heat_water\" value=\"Inadequate\"> INADEQUATE<\/label><\/div><\/div>\n                                                    <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">ELECTRICAL (check ground, no use of extension cords)<\/span><div class=\"sds-inline-options\"><label><input type=\"radio\" name=\"management_electrical\" value=\"Adequate\"> ADEQUATE<\/label><label><input type=\"radio\" name=\"management_electrical\" value=\"Inadequate\"> INADEQUATE<\/label><\/div><\/div>\n                                                    <div class=\"sds-field sds-question-row\"><span class=\"sds-label\">FIRE SAFETY (has smoke detector\/alarm and extinguisher)<\/span><div class=\"sds-inline-options\"><label><input type=\"radio\" name=\"management_fire_safety\" value=\"Adequate\"> ADEQUATE<\/label><label><input type=\"radio\" name=\"management_fire_safety\" value=\"Inadequate\"> INADEQUATE<\/label><\/div><\/div>\n                                                <div class=\"sds-field\"><label for=\"management_smoking_home\">DOES ANYONE SMOKE IN THE HOME?<\/label><input type=\"text\" id=\"management_smoking_home\" name=\"management_smoking_home\"><\/div>\n                        <div class=\"sds-field\"><label for=\"management_safety_hazards\">DOCUMENT ANY OTHER SAFETY OR HEALTH HAZARDS CONCERNS AND INFORMATION GIVEN THE PATIENT<\/label><textarea id=\"management_safety_hazards\" name=\"management_safety_hazards\" rows=\"4\"><\/textarea><\/div>\n                    <\/div>\n\n                    <div class=\"sds-bordered-box sds-plan-copy\">\n                        <h3 class=\"sds-box-title\">PLAN OF SERVICE<\/h3>\n                        <p><u>Identified Needs\/Problems:<\/u><\/p>\n                        <ul>\n                            <li>The patient is or may be unfamiliar with use and maintenance of the home medical equipment dispensed.<\/li>\n                            <li>The patient may be uncertain of home safety.<\/li>\n                            <li>The patient may be required to troubleshoot the equipment or use back-up equipment.<\/li>\n                            <li>The patient may require follow-up services.<\/li>\n                        <\/ul>\n                        <p><u>Expected Outcomes:<\/u><\/p>\n                        <ul>\n                            <li>The patient will be provided prescribed equipment to comply with the physician\u2019s prescription.<\/li>\n                            <li>The patient will use the home medical equipment as prescribed by the physician.<\/li>\n                            <li>The patient will use and maintain home medical equipment in a safe\/proper manner.<\/li>\n                            <li>The patient will adhere to home safety guidelines.<\/li>\n                            <li>The patient will be able to troubleshoot any equipment problems and\/or use back-up system.<\/li>\n                            <li>The patient will know how to obtain follow-up services as needed.<\/li>\n                        <\/ul>\n                        <p><u>Services\/Actions Provided:<\/u><\/p>\n                        <ul>\n                            <li>Deliver and set-up home medical equipment at a mutually agreed upon time and place.<\/li>\n                            <li>Provide training in safe\/proper use and maintenance of all home medical equipment.<\/li>\n                            <li>Provide training and written handout in patient rights and responsibilities, supplier standards, home safety, HIPAA Privacy standards, emergency planning, scope of service \/ marketing info and provide financial responsibilities<\/li>\n                            <li>Demonstrate troubleshooting of equipment and correct use of back-up system (if provided).<\/li>\n                            <li>Provide written instructions for use of the home medical equipment.<\/li>\n                            <li>Provide written instructions for obtaining routine\/emergency follow-up services<\/li>\n                        <\/ul>\n                        <div class=\"sds-field\">\n                            <span class=\"sds-label\">Equipment sale \/ warranty card status<\/span>\n                            <div class=\"sds-inline-options\">\n                                <label><input type=\"radio\" name=\"management_warranty_card_status\" value=\"Warranty card given\"> Check if equipment was sold to the patient and that the warranty card(s) is \/ are given to the patient.<\/label>\n                                <label><input type=\"radio\" name=\"management_warranty_card_status\" value=\"N\/A - no sale items\"> N\/A - no sale items are provided.<\/label>\n                            <\/div>\n                        <\/div>\n                    <\/div>\n                    <p class=\"sds-acknowledgement\">I acknowledge training in the use of equipment and products provided and the performance of the Equipment Management Admission Assessment and Plan of Service on the date noted.<\/p>\n                    <div class=\"sds-grid sds-grid-3\">\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Patient Signature<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"management_patient_signature\" aria-label=\"Patient Signature\"><\/canvas>\n        <input type=\"hidden\" name=\"management_patient_signature\" id=\"management_patient_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                        <div class=\"sds-field\"><label for=\"management_ack_date\">Date<\/label><input type=\"date\" id=\"management_ack_date\" name=\"management_ack_date\"><\/div>\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Staff Member<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"management_staff_signature\" aria-label=\"Staff Member\"><\/canvas>\n        <input type=\"hidden\" name=\"management_staff_signature\" id=\"management_staff_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                    <\/div>\n                        <div class=\"sds-source-footer\">\n        <div class=\"sds-footer-top\">\n            <span>\u00a9 All Rights Reserved.<br><strong>ACHCU<\/strong><\/span>\n            <span>VERSION 2019.3<\/span>\n            <span>7<\/span>\n        <\/div>\n        <div class=\"sds-footer-company\">\n            <strong>SDS Medical Supplies Inc.<\/strong> | 2375 Wall Street SE, Suite 240 Rm 50, Conyers, GA 30013<br>\n            Office: (770) 285-4104 | Fax: (770) 285-4152 | Monday-Friday 10:00am to 4:00pm\n        <\/div>\n    <\/div>\n                    <\/div>\n            <\/section>\n\n            <!-- PAGE 8: FITTER SERVICES -->\n            <section class=\"sds-step\" data-step=\"8\">\n                <div class=\"sds-document-card\">\n                    <header class=\"sds-doc-header\"><div class=\"sds-brand\">SDS Medical Supplies<\/div><h2>FITTER SERVICES: ADMISSION ASSESSMENT AND PLAN OF SERVICE<\/h2><\/header>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div class=\"sds-field\"><label for=\"fitter_patient\">Patient<\/label><input type=\"text\" id=\"fitter_patient\" name=\"fitter_patient\"><\/div>\n                        <div class=\"sds-field\"><label for=\"fitter_date\">Date<\/label><input type=\"date\" id=\"fitter_date\" name=\"fitter_date\"><\/div>\n                    <\/div>\n                    <div class=\"sds-field\"><label for=\"fitter_phone\">Phone<\/label><input type=\"tel\" id=\"fitter_phone\" name=\"fitter_phone\"><\/div>\n\n                    <h3 class=\"sds-box-title\">PRODUCTS AND SUPPLIES DISPENSED<\/h3>\n                    <div class=\"sds-table-wrap\"><table class=\"sds-form-table\"><thead><tr><th>Manufacturer<\/th><th>Model or Item #<\/th><th>Description<\/th><th>Number Dispensed<\/th><th>Lot # (if applicable)<\/th><\/tr><\/thead><tbody>\n                    <tr>\n                        <td><input type=\"text\" name=\"fitter_products[0][manufacturer]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[0][model_or_item]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[0][description]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[0][number_dispensed]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[0][lot]\"><\/td>\n                    <\/tr><tr>\n                        <td><input type=\"text\" name=\"fitter_products[1][manufacturer]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[1][model_or_item]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[1][description]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[1][number_dispensed]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[1][lot]\"><\/td>\n                    <\/tr><tr>\n                        <td><input type=\"text\" name=\"fitter_products[2][manufacturer]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[2][model_or_item]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[2][description]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[2][number_dispensed]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[2][lot]\"><\/td>\n                    <\/tr><tr>\n                        <td><input type=\"text\" name=\"fitter_products[3][manufacturer]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[3][model_or_item]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[3][description]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[3][number_dispensed]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[3][lot]\"><\/td>\n                    <\/tr><tr>\n                        <td><input type=\"text\" name=\"fitter_products[4][manufacturer]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[4][model_or_item]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[4][description]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[4][number_dispensed]\"><\/td>\n                        <td><input type=\"text\" name=\"fitter_products[4][lot]\"><\/td>\n                    <\/tr><\/tbody><\/table><\/div>\n\n                    <div class=\"sds-bordered-box\">\n                        <h3 class=\"sds-box-title\">PATIENT ASSESSMENT<\/h3>\n                                                    <div class=\"sds-field\"><label>Measurements and sizing of products<\/label><input type=\"text\" name=\"fitter_measurements_sizing\"><\/div>\n                                                    <div class=\"sds-field\"><label>Allergies to materials<\/label><input type=\"text\" name=\"fitter_allergies_materials\"><\/div>\n                                                    <div class=\"sds-field\"><label>Skin Condition<\/label><input type=\"text\" name=\"fitter_skin_condition\"><\/div>\n                                                    <div class=\"sds-field\"><label>Previous use of an orthoses\/prostheses<\/label><input type=\"text\" name=\"fitter_previous_orthoses_prostheses\"><\/div>\n                                                    <div class=\"sds-field\"><label>Customization of products<\/label><input type=\"text\" name=\"fitter_customization_products\"><\/div>\n                                                    <div class=\"sds-field\"><label>Recommendations to the patient<\/label><input type=\"text\" name=\"fitter_recommendations\"><\/div>\n                                            <\/div>\n\n                    <div class=\"sds-bordered-box sds-plan-copy\">\n                        <h3 class=\"sds-box-title\">PLAN OF SERVICE<\/h3>\n                        <p><u>Identified Needs\/Problems:<\/u><\/p>\n                        <ul>\n                            <li>The patient is or may be unfamiliar with use of the Fitter Service Product(s).<\/li>\n                            <li>The patient is or may be unfamiliar with Fitter Service Products that are available.<\/li>\n                            <li>The patient may require follow-up services.<\/li>\n                        <\/ul>\n                        <p><u>Expected Outcomes:<\/u><\/p>\n                        <p>Check those that apply:<\/p>\n                        <div class=\"sds-check-grid sds-check-grid-4\">\n                                                            <label><input type=\"checkbox\" name=\"fitter_expected_outcomes[]\" value=\"reduce pain\"> reduce pain<\/label>\n                                                            <label><input type=\"checkbox\" name=\"fitter_expected_outcomes[]\" value=\"increase comfort\"> increase comfort<\/label>\n                                                            <label><input type=\"checkbox\" name=\"fitter_expected_outcomes[]\" value=\"enhance function and independence\"> enhance function and independence<\/label>\n                                                            <label><input type=\"checkbox\" name=\"fitter_expected_outcomes[]\" value=\"provide joint stability\"> provide joint stability<\/label>\n                                                            <label><input type=\"checkbox\" name=\"fitter_expected_outcomes[]\" value=\"prevent deformity\"> prevent deformity<\/label>\n                                                            <label><input type=\"checkbox\" name=\"fitter_expected_outcomes[]\" value=\"increase range of motion\"> increase range of motion<\/label>\n                                                            <label><input type=\"checkbox\" name=\"fitter_expected_outcomes[]\" value=\"address cosmetic issues\"> address cosmetic issues<\/label>\n                                                            <label><input type=\"checkbox\" name=\"fitter_expected_outcomes[]\" value=\"promote healing\"> promote healing<\/label>\n                                                    <\/div>\n                        <ul>\n                            <li>The patient will be provided the Fitter Service Product(s) to comply with the physician\u2019s prescription (if required).<\/li>\n                            <li>The patient will use the Fitter Service Product(s) as prescribed by the physician.<\/li>\n                            <li>The patient will use Fitter Service Product(s) in a safe\/proper manner.<\/li>\n                            <li>The patient will communicate to the staff any Fitter Service Product(s) problems.<\/li>\n                            <li>The patient will know how to obtain follow-up services as needed.<\/li>\n                        <\/ul>\n                        <p><u>Services\/Actions to be Provided:<\/u><\/p>\n                        <ul>\n                            <li>Assess the patient and fit the Product(s).<\/li>\n                            <li>Provide training in use of the Fitter Service Product(s).<\/li>\n                            <li>Provide training and written handout in patient rights and responsibilities, supplier standards, home safety, HIPAA Privacy standards, emergency planning and provide financial responsibilities.<\/li>\n                            <li>Demonstrate cleaning and care of the products provided.<\/li>\n                            <li>Provide written instructions for use of the Fitter Service Product(s).<\/li>\n                            <li>Provide written instructions for obtaining follow-up services.<\/li>\n                        <\/ul>\n                        <label class=\"sds-checkline\"><input type=\"checkbox\" name=\"fitter_warranty_information_given\" value=\"Yes\"> Check that the warranty information was given to the patient.<\/label>\n                    <\/div>\n                    <p class=\"sds-acknowledgement\">I acknowledge training in the use of the products provided and the performance of the Fitter Services Admission Assessment and Plan of Service on the date noted.<\/p>\n                    <div class=\"sds-grid sds-grid-3\">\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Patient Signature<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"fitter_patient_signature\" aria-label=\"Patient Signature\"><\/canvas>\n        <input type=\"hidden\" name=\"fitter_patient_signature\" id=\"fitter_patient_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                        <div class=\"sds-field\"><label for=\"fitter_ack_date\">Date<\/label><input type=\"date\" id=\"fitter_ack_date\" name=\"fitter_ack_date\"><\/div>\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Fitter Service Technician Signature<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"fitter_technician_signature\" aria-label=\"Fitter Service Technician Signature\"><\/canvas>\n        <input type=\"hidden\" name=\"fitter_technician_signature\" id=\"fitter_technician_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                    <\/div>\n                        <div class=\"sds-source-footer\">\n        <div class=\"sds-footer-top\">\n            <span>\u00a9 All Rights Reserved.<br><strong>ACHCU<\/strong><\/span>\n            <span>VERSION 2019.3<\/span>\n            <span>8<\/span>\n        <\/div>\n        <div class=\"sds-footer-company\">\n            <strong>SDS Medical Supplies Inc.<\/strong> | 2375 Wall Street SE, Suite 240 Rm 50, Conyers, GA 30013<br>\n            Office: (770) 285-4104 | Fax: (770) 285-4152 | Monday-Friday 10:00am to 4:00pm\n        <\/div>\n    <\/div>\n                    <\/div>\n            <\/section>\n\n            <!-- PAGE 9: MEDICARE CAPPED RENTAL -->\n            <section class=\"sds-step\" data-step=\"9\">\n                <div class=\"sds-document-card\">\n                    <header class=\"sds-doc-header\"><div class=\"sds-brand\">SDS Medical Supplies<\/div><h2>MEDICARE CAPPED RENTAL AND INEXPENSIVE OR ROUTINELY<br>PURCHASED ITEMS NOTIFICATION<\/h2><\/header>\n                    <div class=\"sds-legal-copy sds-large-copy\">\n                        <p>I received instructions and understand that Medicare defines the <input class=\"sds-inline-input\" type=\"text\" name=\"medicare_item_received\" aria-label=\"Medicare item received\"> that I received as being either a capped rental or an inexpensive or routinely purchased item.<\/p>\n                        <h3>FOR CAPPED RENTAL ITEMS:<\/h3>\n                        <p>Medicare will pay a monthly rental fee for a period not to exceed 13 months, after which ownership of the equipment is transferred to the Medicare beneficiary.<\/p>\n                        <p>After ownership of the equipment is transferred to the Medicare beneficiary, it is the beneficiary's responsibility to arrange for any required equipment service or repair.<\/p>\n                        <p>Examples of this type of equipment include: Hospital beds, wheelchairs, alternating pressure pads, air-fluidized beds, nebulizers, suction pumps, continuous airway pressure (CPAP) devices, patient lifts, and trapeze bars.<\/p>\n                        <h3>FOR INEXPENSIVE OR ROUTINELY PURCHASED ITEMS:<\/h3>\n                        <p>Equipment in this category can be purchased or rented; however, the total amount paid for monthly rentals cannot exceed the fee schedule purchase amount.<\/p>\n                        <p>Examples of this type of equipment include: Canes, walkers, crutches, commode chairs, low pressure and positioning equalization pads, home blood glucose monitors, seat lift mechanisms, pneumatic compressors (lymphedema pumps), bed side rails, and traction equipment.<\/p>\n                        <p>I select the:<\/p>\n                        <div class=\"sds-block-options sds-inline-options\">\n                            <label><input type=\"radio\" name=\"medicare_option\" value=\"Purchase Option\"> Purchase Option<\/label>\n                            <label><input type=\"radio\" name=\"medicare_option\" value=\"Rental Option\"> Rental Option<\/label>\n                        <\/div>\n                    <\/div>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Beneficiary Signature<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"medicare_beneficiary_signature\" aria-label=\"Beneficiary Signature\"><\/canvas>\n        <input type=\"hidden\" name=\"medicare_beneficiary_signature\" id=\"medicare_beneficiary_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                        <div class=\"sds-field\"><label for=\"medicare_date\">Date<\/label><input type=\"date\" id=\"medicare_date\" name=\"medicare_date\"><\/div>\n                    <\/div>\n                        <div class=\"sds-source-footer\">\n        <div class=\"sds-footer-top\">\n            <span>\u00a9 All Rights Reserved.<br><strong>ACHCU<\/strong><\/span>\n            <span>VERSION 2019.3<\/span>\n            <span>9<\/span>\n        <\/div>\n        <div class=\"sds-footer-company\">\n            <strong>SDS Medical Supplies Inc.<\/strong> | 2375 Wall Street SE, Suite 240 Rm 50, Conyers, GA 30013<br>\n            Office: (770) 285-4104 | Fax: (770) 285-4152 | Monday-Friday 10:00am to 4:00pm\n        <\/div>\n    <\/div>\n                    <\/div>\n            <\/section>\n\n            <!-- PAGE 10: WARRANTY -->\n            <section class=\"sds-step\" data-step=\"10\">\n                <div class=\"sds-document-card\">\n                    <header class=\"sds-doc-header\"><div class=\"sds-brand\">SDS Medical Supplies<\/div><h2>EQUIPMENT WARRANTY INFORMATION FORM<\/h2><\/header>\n                    <div class=\"sds-legal-copy sds-large-copy\">\n                        <p>Every product sold or rented by our company carries a 1-year manufacturer's warranty. SDS Medical Supplies will notify all Medicare beneficiaries of the warranty coverage, and we will honor all warranties under applicable law.<\/p>\n                        <p>SDS Medical Supplies will repair or replace, free of charge, Medicare-covered equipment that is under warranty. In addition, an owner's manual with warranty information will be provided to beneficiaries for all durable medical equipment where this manual is available.<\/p>\n                        <p>I have been instructed and understand the warranty coverage on the product I have received.<\/p>\n                    <\/div>\n                    <div class=\"sds-grid sds-grid-2\">\n                        <div>    <div class=\"sds-signature-wrap\">\n        <label>Beneficiary&#039;s Signature<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"warranty_beneficiary_signature\" aria-label=\"Beneficiary&#039;s Signature\"><\/canvas>\n        <input type=\"hidden\" name=\"warranty_beneficiary_signature\" id=\"warranty_beneficiary_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                        <div class=\"sds-field\"><label for=\"warranty_date\">Date<\/label><input type=\"date\" id=\"warranty_date\" name=\"warranty_date\"><\/div>\n                    <\/div>\n                        <div class=\"sds-source-footer\">\n        <div class=\"sds-footer-top\">\n            <span>\u00a9 All Rights Reserved.<br><strong>ACHCU<\/strong><\/span>\n            <span>VERSION 2019.3<\/span>\n            <span>10<\/span>\n        <\/div>\n        <div class=\"sds-footer-company\">\n            <strong>SDS Medical Supplies Inc.<\/strong> | 2375 Wall Street SE, Suite 240 Rm 50, Conyers, GA 30013<br>\n            Office: (770) 285-4104 | Fax: (770) 285-4152 | Monday-Friday 10:00am to 4:00pm\n        <\/div>\n    <\/div>\n                    <\/div>\n            <\/section>\n\n            <!-- PAGE 11: SATISFACTION SURVEY -->\n            <section class=\"sds-step\" data-step=\"11\">\n                <div class=\"sds-document-card\">\n                    <header class=\"sds-doc-header\"><div class=\"sds-brand\">SDS Medical Supplies<\/div><h2>PATIENT SATISFACTION SURVEY<\/h2><\/header>\n                    <div class=\"sds-field\"><label for=\"survey_date\">Date<\/label><input type=\"date\" id=\"survey_date\" name=\"survey_date\"><\/div>\n                    <div class=\"sds-legal-copy\">\n                        <p>Dear Patient,<\/p>\n                        <p>It is our desire to provide you with the best quality services available. In order to help us maintain our high standards, please take a few moments to tell us how we are doing. Please complete this form and mail it back to us. Thank you.<\/p>\n                    <\/div>\n                                        <div class=\"sds-survey-table\">\n                                                    <div class=\"sds-survey-row\">\n                                <div class=\"sds-survey-question\">Was your equipment (and supplies if applicable) delivered on time?<\/div>\n                                <label><input type=\"radio\" name=\"survey_delivered_on_time\" value=\"YES\"> YES<\/label>\n                                <label><input type=\"radio\" name=\"survey_delivered_on_time\" value=\"NO\"> NO<\/label>\n                            <\/div>\n                                                    <div class=\"sds-survey-row\">\n                                <div class=\"sds-survey-question\">Was the equipment (and supplies if applicable) delivered \/ dispensed accurately?<\/div>\n                                <label><input type=\"radio\" name=\"survey_delivered_accurately\" value=\"YES\"> YES<\/label>\n                                <label><input type=\"radio\" name=\"survey_delivered_accurately\" value=\"NO\"> NO<\/label>\n                            <\/div>\n                                                    <div class=\"sds-survey-row\">\n                                <div class=\"sds-survey-question\">Was the training and consultations effective in educating you or your caregiver on your equipment (and supplies if applicable)?<\/div>\n                                <label><input type=\"radio\" name=\"survey_training_effective\" value=\"YES\"> YES<\/label>\n                                <label><input type=\"radio\" name=\"survey_training_effective\" value=\"NO\"> NO<\/label>\n                            <\/div>\n                                                    <div class=\"sds-survey-row\">\n                                <div class=\"sds-survey-question\">Was the educational materials and instructions provided adequate to educate you or your caregiver on the product(s) provided?<\/div>\n                                <label><input type=\"radio\" name=\"survey_materials_adequate\" value=\"YES\"> YES<\/label>\n                                <label><input type=\"radio\" name=\"survey_materials_adequate\" value=\"NO\"> NO<\/label>\n                            <\/div>\n                                                    <div class=\"sds-survey-row\">\n                                <div class=\"sds-survey-question\">Was the company staff courteous and helpful?<\/div>\n                                <label><input type=\"radio\" name=\"survey_staff_courteous\" value=\"YES\"> YES<\/label>\n                                <label><input type=\"radio\" name=\"survey_staff_courteous\" value=\"NO\"> NO<\/label>\n                            <\/div>\n                                                    <div class=\"sds-survey-row\">\n                                <div class=\"sds-survey-question\">Was your financial responsibilities explained to you?<\/div>\n                                <label><input type=\"radio\" name=\"survey_financial_explained\" value=\"YES\"> YES<\/label>\n                                <label><input type=\"radio\" name=\"survey_financial_explained\" value=\"NO\"> NO<\/label>\n                            <\/div>\n                                                    <div class=\"sds-survey-row\">\n                                <div class=\"sds-survey-question\">Did you receive advice or help when requested?<\/div>\n                                <label><input type=\"radio\" name=\"survey_advice_received\" value=\"YES\"> YES<\/label>\n                                <label><input type=\"radio\" name=\"survey_advice_received\" value=\"NO\"> NO<\/label>\n                            <\/div>\n                                                    <div class=\"sds-survey-row\">\n                                <div class=\"sds-survey-question\">Did the services provided make a positive impact on the outcome of your care?<\/div>\n                                <label><input type=\"radio\" name=\"survey_positive_impact\" value=\"YES\"> YES<\/label>\n                                <label><input type=\"radio\" name=\"survey_positive_impact\" value=\"NO\"> NO<\/label>\n                            <\/div>\n                                                    <div class=\"sds-survey-row\">\n                                <div class=\"sds-survey-question\">Would you recommend our services to friends and family?<\/div>\n                                <label><input type=\"radio\" name=\"survey_recommend\" value=\"YES\"> YES<\/label>\n                                <label><input type=\"radio\" name=\"survey_recommend\" value=\"NO\"> NO<\/label>\n                            <\/div>\n                                                    <div class=\"sds-survey-row\">\n                                <div class=\"sds-survey-question\">Did the services provided meet your needs and expectations?<\/div>\n                                <label><input type=\"radio\" name=\"survey_needs_expectations\" value=\"YES\"> YES<\/label>\n                                <label><input type=\"radio\" name=\"survey_needs_expectations\" value=\"NO\"> NO<\/label>\n                            <\/div>\n                                            <\/div>\n                    <div class=\"sds-field\"><label for=\"survey_comments\">COMMENTS (OPTIONAL)<\/label><textarea id=\"survey_comments\" name=\"survey_comments\" rows=\"7\"><\/textarea><\/div>\n                    <div>    <div class=\"sds-signature-wrap\">\n        <label>Signature (optional)<\/label>\n        <canvas class=\"sds-signature-pad\" data-target=\"survey_signature\" aria-label=\"Signature (optional)\"><\/canvas>\n        <input type=\"hidden\" name=\"survey_signature\" id=\"survey_signature\" value=\"\">\n        <button type=\"button\" class=\"sds-clear-signature\">Clear Signature<\/button>\n    <\/div>\n    <\/div>\n                    <p class=\"sds-form-revised\">Form Revised: 06\/11\/2019<\/p>\n                        <div class=\"sds-source-footer\">\n        <div class=\"sds-footer-top\">\n            <span>\u00a9 All Rights Reserved.<br><strong>ACHCU<\/strong><\/span>\n            <span>VERSION 2019.3<\/span>\n            <span>11<\/span>\n        <\/div>\n        <div class=\"sds-footer-company\">\n            <strong>SDS Medical Supplies Inc.<\/strong> | 2375 Wall Street SE, Suite 240 Rm 50, Conyers, GA 30013<br>\n            Office: (770) 285-4104 | Fax: (770) 285-4152 | Monday-Friday 10:00am to 4:00pm\n        <\/div>\n    <\/div>\n                    <\/div>\n            <\/section>\n\n            <div class=\"sds-form-nav\">\n                <button type=\"button\" class=\"sds-btn sds-btn-secondary sds-prev\" hidden>Previous<\/button>\n                <button type=\"button\" class=\"sds-btn sds-next\">Next<\/button>\n                <button type=\"submit\" class=\"sds-btn sds-submit\" hidden>Submit Patient Form<\/button>\n            <\/div>\n        <\/form>\n    <\/div>\n\n    <style>\n    .sds-patient-form-shell{--sds-border:#202020;--sds-muted:#667085;--sds-bg:#f5f7fa;--sds-accent:#1d4f7a;--sds-accent-2:#163c5e;font-family:Arial,Helvetica,sans-serif;color:#111;max-width:1120px;margin:0 auto;padding:16px}\n    .sds-patient-form *{box-sizing:border-box}\n    .sds-progress{position:sticky;top:0;z-index:20;background:#fff;padding:12px 0 14px;margin-bottom:18px;border-bottom:1px solid #e6e7ea}\n    .sds-progress-bar{height:8px;background:#e9edf2;border-radius:20px;overflow:hidden}.sds-progress-bar span{display:block;height:100%;width:9.09%;background:var(--sds-accent);transition:width .25s ease}\n    .sds-progress-text{margin-top:8px;font-size:13px;font-weight:700;color:#475467;text-align:right}\n    .sds-step{display:none}.sds-step.is-active{display:block}\n    .sds-document-card{background:#fff;border:1px solid #d9dde3;border-radius:14px;padding:32px;box-shadow:0 8px 28px rgba(16,24,40,.06)}\n    .sds-doc-header{text-align:center;margin-bottom:28px}.sds-brand{font-size:24px;font-weight:800}.sds-doc-header h2{margin:4px 0 0;font-size:25px;line-height:1.18;font-weight:800}\n    .sds-section-title,.sds-box-title{font-size:16px;font-weight:800;margin:22px 0 10px}.sds-box-title{text-align:center;background:#f8fafc;border:1px solid var(--sds-border);padding:7px;margin-bottom:0}\n    .sds-grid{display:grid;gap:14px;margin-bottom:14px}.sds-grid-2{grid-template-columns:repeat(2,minmax(0,1fr))}.sds-grid-3{grid-template-columns:repeat(3,minmax(0,1fr))}.sds-grid-4{grid-template-columns:repeat(4,minmax(0,1fr))}.sds-grid-5{grid-template-columns:1.1fr .8fr 1.1fr .8fr 2fr}\n    .sds-field{margin-bottom:14px}.sds-field label,.sds-label{display:block;font-size:14px;font-weight:700;margin-bottom:6px}.sds-field small{font-weight:400;color:var(--sds-muted)}\n    .sds-field input[type=text],.sds-field input[type=email],.sds-field input[type=tel],.sds-field input[type=date],.sds-field input[type=time],.sds-field textarea,.sds-bordered-box textarea,.sds-form-table input{width:100%;border:1px solid #98a2b3;background:#fff;border-radius:6px;padding:10px 11px;font:inherit;min-height:42px;outline:none}\n    .sds-field input:focus,.sds-field textarea:focus,.sds-form-table input:focus,.sds-bordered-box textarea:focus{border-color:var(--sds-accent);box-shadow:0 0 0 3px rgba(29,79,122,.12)}\n    .sds-required{color:#b42318}.sds-inline-options{display:flex;gap:18px;align-items:center;flex-wrap:wrap}.sds-inline-options label,.sds-checkline,.sds-check-grid label{font-weight:500;font-size:14px}.sds-inline-options input,.sds-checkline input,.sds-check-grid input{margin-right:6px}\n    .sds-block-options{margin:12px 0 22px;gap:30px}.sds-question-row{display:flex;align-items:center;gap:16px;flex-wrap:wrap}.sds-question-row .sds-label{margin-bottom:0}.sds-question-row small{color:#475467}\n    .sds-subcard,.sds-bordered-box{border:1px solid var(--sds-border);padding:14px;margin-bottom:16px}.sds-subcard-title{font-weight:800;margin-bottom:10px}\n    .sds-legal-copy{font-size:14px;line-height:1.45}.sds-legal-copy p{margin:0 0 16px}.sds-legal-copy h3{font-size:17px;margin:24px 0 12px}.sds-large-copy{font-size:16px}.sds-plan-copy{font-size:13px;line-height:1.34}.sds-plan-copy p{margin:5px 0}.sds-plan-copy ul{margin:4px 0 8px 22px;padding:0}\n    .sds-initials-row{display:flex;gap:12px;align-items:center;margin:10px 0 18px}.sds-initials-row .sds-field{width:140px;margin:0}.sds-initials-row p{margin:0;flex:1}\n    .sds-table-wrap{overflow-x:auto;margin-bottom:16px;-webkit-overflow-scrolling:touch}.sds-form-table{width:100%;border-collapse:collapse;min-width:760px}.sds-form-table th,.sds-form-table td{border:1px solid var(--sds-border);padding:0;text-align:center}.sds-form-table th{font-size:13px;padding:8px 6px;background:#f8fafc}.sds-form-table input{border:0;border-radius:0;min-height:46px;padding:7px}\n    .sds-bordered-box .sds-box-title{border:0;background:transparent;padding:0;margin:0 0 12px}.sds-check-grid{display:grid;grid-template-columns:repeat(3,minmax(0,1fr));gap:8px 16px;margin-top:8px}.sds-check-grid-4{grid-template-columns:repeat(4,minmax(0,1fr))}.sds-centered-check{justify-content:center;text-align:center;display:flex}.sds-center-text{text-align:center;font-size:13px}.sds-acknowledgement{font-size:14px;line-height:1.4;margin:22px 0 14px}\n    .sds-signature-wrap{margin-bottom:14px}.sds-signature-wrap>label{display:block;font-size:14px;font-weight:700;margin-bottom:6px}.sds-signature-pad{display:block;width:100%;height:120px;border:1px solid #98a2b3;border-radius:6px;background:#fff;touch-action:none;cursor:crosshair}.sds-clear-signature{margin-top:6px;border:0;background:transparent;color:var(--sds-accent);font-weight:700;padding:4px 0;cursor:pointer}\n    .sds-inline-input{border:0;border-bottom:1px solid #111;border-radius:0;min-width:300px;padding:3px 5px;font:inherit;background:transparent}\n    .sds-survey-table{border:1px solid var(--sds-border);margin:18px 0}.sds-survey-row{display:grid;grid-template-columns:1fr 105px 105px;border-bottom:1px solid var(--sds-border)}.sds-survey-row:last-child{border-bottom:0}.sds-survey-question{padding:10px 12px}.sds-survey-row label{display:flex;align-items:center;justify-content:center;gap:5px;border-left:1px solid var(--sds-border);padding:10px 6px}.sds-form-revised{font-size:12px;margin-top:20px}\n    .sds-source-footer{margin-top:55px;padding-top:18px;font-size:11px;color:#555}.sds-footer-top{display:flex;justify-content:space-between;align-items:flex-end}.sds-footer-top strong{color:#32628c;font-size:13px}.sds-footer-company{text-align:center;font-weight:600;color:#777;margin-top:6px;line-height:1.25}\n    .sds-form-nav{display:flex;justify-content:space-between;gap:12px;margin:20px 0 4px}.sds-btn{appearance:none;border:0;border-radius:8px;background:var(--sds-accent);color:#fff;padding:13px 22px;font-size:15px;font-weight:800;cursor:pointer}.sds-btn:hover{background:var(--sds-accent-2)}.sds-btn:disabled{opacity:.45;cursor:not-allowed}.sds-btn-secondary{background:#eef2f6;color:#344054}.sds-btn-secondary:hover{background:#e4e9ef}.sds-next,.sds-submit{margin-left:auto}.sds-prev[hidden],.sds-next[hidden],.sds-submit[hidden]{display:none!important}.sds-form-message{display:none;margin:0 0 18px;padding:14px;border-radius:8px;font-weight:700}.sds-form-message.is-success{display:block;background:#ecfdf3;color:#027a48;border:1px solid #abefc6}.sds-form-message.is-error{display:block;background:#fef3f2;color:#b42318;border:1px solid #fecdca}.sds-hp{display:none!important;position:absolute!important;left:-99999px!important;width:1px!important;height:1px!important;overflow:hidden!important;pointer-events:none!important}\n    .sds-lined-textarea{line-height:38px;background-image:linear-gradient(to bottom,transparent 37px,#b8bec6 38px);background-size:100% 38px;resize:vertical}\n    @media(max-width:900px){.sds-grid-4,.sds-grid-5{grid-template-columns:repeat(2,minmax(0,1fr))}.sds-check-grid-4{grid-template-columns:repeat(2,minmax(0,1fr))}}\n    @media(max-width:700px){.sds-patient-form-shell{padding:8px}.sds-document-card{padding:20px 14px;border-radius:10px}.sds-brand{font-size:20px}.sds-doc-header h2{font-size:20px}.sds-grid-2,.sds-grid-3,.sds-grid-4,.sds-grid-5{grid-template-columns:1fr}.sds-check-grid,.sds-check-grid-4{grid-template-columns:1fr}.sds-survey-row{grid-template-columns:minmax(0,1fr) 64px 64px;font-size:12px}.sds-survey-question{padding:9px 8px;overflow-wrap:anywhere}.sds-survey-row label{padding:9px 3px}.sds-initials-row{align-items:flex-end;flex-wrap:wrap}.sds-inline-input{min-width:0;width:100%;display:block;margin-top:8px}.sds-source-footer{margin-top:34px}.sds-footer-top{font-size:10px}.sds-footer-company{font-size:10px}.sds-form-nav{position:sticky;bottom:0;background:#fff;padding:12px 0;z-index:15}.sds-btn{flex:1;padding:12px 10px;min-width:0}.sds-next,.sds-submit{margin-left:0}}\n    @media(max-width:380px){.sds-survey-row{grid-template-columns:minmax(0,1fr) 52px 52px}.sds-survey-row label{font-size:11px}.sds-document-card{padding-left:10px;padding-right:10px}}\n    @media print{.sds-progress,.sds-form-nav,.sds-clear-signature,.sds-form-message{display:none!important}.sds-step{display:block!important;page-break-after:always}.sds-document-card{border:0;box-shadow:none;border-radius:0;padding:0}.sds-patient-form-shell{max-width:none;padding:0}.sds-source-footer{margin-top:28px}}\n    <\/style>\n\n    <script>\n    (function(){\n        const form = document.getElementById('sds-patient-form');\n        if (!form || form.dataset.initialized === '1') return;\n        form.dataset.initialized = '1';\n\n        const steps = Array.from(form.querySelectorAll('.sds-step'));\n        const prevBtn = form.querySelector('.sds-prev');\n        const nextBtn = form.querySelector('.sds-next');\n        const submitBtn = form.querySelector('.sds-submit');\n        const progressBar = form.querySelector('.sds-progress-bar span');\n        const progressText = form.querySelector('.sds-progress-text');\n        const message = form.querySelector('#sds-form-message');\n        let current = 0;\n        let firstRender = true;\n\n        function updateStep(){\n            steps.forEach((step, i) => step.classList.toggle('is-active', i === current));\n            prevBtn.hidden = current === 0;\n            prevBtn.disabled = current === 0;\n            nextBtn.hidden = current === steps.length - 1;\n            submitBtn.hidden = current !== steps.length - 1;\n            const pct = ((current + 1) \/ steps.length) * 100;\n            progressBar.style.width = pct + '%';\n            progressText.textContent = 'Step ' + (current + 1) + ' of ' + steps.length;\n            setTimeout(() => {\n                steps[current].querySelectorAll('.sds-signature-pad').forEach(canvas => {\n                    if (typeof canvas._sdsResize === 'function') canvas._sdsResize();\n                });\n            }, 40);\n            if (!firstRender) {\n                window.scrollTo({top: form.getBoundingClientRect().top + window.scrollY - 90, behavior:'smooth'});\n            }\n            firstRender = false;\n        }\n\n        function validateCurrentStep(){\n            const required = Array.from(steps[current].querySelectorAll('[required]'));\n            for (const field of required){\n                if (!field.checkValidity()){\n                    field.reportValidity();\n                    field.focus({preventScroll:false});\n                    return false;\n                }\n            }\n            return true;\n        }\n\n        function patientName(){\n            const first = form.querySelector('[name=\"first_name\"]')?.value.trim() || '';\n            const last = form.querySelector('[name=\"last_name\"]')?.value.trim() || '';\n            return (first + ' ' + last).trim();\n        }\n\n        function syncPatientFields(){\n            const name = patientName();\n            const phone = form.querySelector('[name=\"phone\"]')?.value.trim() || '';\n            ['notes_patient','service_patient_name','delivery_patient','maintenance_patient','pickup_patient','management_patient','fitter_patient'].forEach(key => {\n                const el = form.querySelector('[name=\"' + key + '\"]');\n                if (el && !el.value && name) el.value = name;\n            });\n            ['delivery_phone','maintenance_phone','pickup_phone','management_phone','fitter_phone'].forEach(key => {\n                const el = form.querySelector('[name=\"' + key + '\"]');\n                if (el && !el.value && phone) el.value = phone;\n            });\n        }\n\n        nextBtn.addEventListener('click', function(){\n            if (!validateCurrentStep()) return;\n            syncPatientFields();\n            if (current < steps.length - 1){ current++; updateStep(); }\n        });\n        prevBtn.addEventListener('click', function(){ if (current > 0){ current--; updateStep(); } });\n\n        \/\/ Signature pads.\n        form.querySelectorAll('.sds-signature-pad').forEach(canvas => {\n            const ctx = canvas.getContext('2d');\n            let drawing = false;\n            let hasInk = false;\n\n            function resizeCanvas(){\n                const rect = canvas.getBoundingClientRect();\n                const ratio = Math.max(window.devicePixelRatio || 1, 1);\n                const saved = hasInk ? canvas.toDataURL('image\/png') : null;\n                canvas.width = Math.floor(rect.width * ratio);\n                canvas.height = Math.floor(120 * ratio);\n                ctx.setTransform(ratio,0,0,ratio,0,0);\n                ctx.lineWidth = 2;\n                ctx.lineCap = 'round';\n                ctx.strokeStyle = '#111';\n                if (saved){\n                    const img = new Image();\n                    img.onload = function(){ ctx.drawImage(img,0,0,rect.width,120); };\n                    img.src = saved;\n                }\n            }\n            canvas._sdsResize = resizeCanvas;\n            resizeCanvas();\n\n            function point(e){\n                const r = canvas.getBoundingClientRect();\n                return {x:e.clientX-r.left, y:e.clientY-r.top};\n            }\n            canvas.addEventListener('pointerdown', e => {\n                drawing = true; hasInk = true; canvas.setPointerCapture(e.pointerId);\n                const p = point(e); ctx.beginPath(); ctx.moveTo(p.x,p.y);\n            });\n            canvas.addEventListener('pointermove', e => {\n                if (!drawing) return; const p = point(e); ctx.lineTo(p.x,p.y); ctx.stroke();\n            });\n            function finish(){\n                if (!drawing) return; drawing = false;\n                const target = document.getElementById(canvas.dataset.target);\n                if (target && hasInk) target.value = canvas.toDataURL('image\/png');\n            }\n            canvas.addEventListener('pointerup', finish);\n            canvas.addEventListener('pointercancel', finish);\n            canvas.closest('.sds-signature-wrap').querySelector('.sds-clear-signature').addEventListener('click', function(){\n                ctx.clearRect(0,0,canvas.width,canvas.height); hasInk = false;\n                const target = document.getElementById(canvas.dataset.target); if (target) target.value = '';\n            });\n            window.addEventListener('resize', resizeCanvas);\n        });\n\n        form.addEventListener('submit', async function(e){\n            e.preventDefault();\n            syncPatientFields();\n            if (!form.checkValidity()){\n                const invalid = form.querySelector(':invalid');\n                if (invalid){\n                    const step = invalid.closest('.sds-step');\n                    const idx = steps.indexOf(step);\n                    if (idx >= 0) current = idx;\n                    updateStep();\n                    setTimeout(() => { invalid.reportValidity(); invalid.focus(); }, 250);\n                }\n                return;\n            }\n\n            \/\/ Ensure every drawn signature is copied into its hidden field.\n            form.querySelectorAll('.sds-signature-pad').forEach(canvas => {\n                const target = document.getElementById(canvas.dataset.target);\n                if (target && target.value === '') {\n                    \/\/ Blank canvases remain blank; nonblank ones are captured on pointer-up.\n                }\n            });\n\n            submitBtn.disabled = true;\n            submitBtn.textContent = 'Submitting...';\n            message.className = 'sds-form-message';\n            message.textContent = '';\n\n            try {\n                const response = await fetch(form.dataset.ajaxUrl, { method:'POST', body:new FormData(form), credentials:'same-origin' });\n                const data = await response.json();\n                if (!data.success) throw new Error(data?.data?.message || 'Submission failed. Please try again.');\n                message.className = 'sds-form-message is-success';\n                message.textContent = data.data.message || 'Your form has been submitted successfully.';\n                form.querySelectorAll('input:not([type=\"hidden\"]), textarea').forEach(el => {\n                    if (el.type === 'radio' || el.type === 'checkbox') el.checked = false; else el.value = '';\n                });\n                form.querySelectorAll('.sds-signature-pad').forEach(canvas => canvas.getContext('2d').clearRect(0,0,canvas.width,canvas.height));\n                form.querySelectorAll('input[type=\"hidden\"][name$=\"_signature\"]').forEach(el => el.value = '');\n                current = 0; updateStep();\n            } catch(err){\n                message.className = 'sds-form-message is-error';\n                message.textContent = err.message || 'Unable to submit the form. Please try again.';\n            } finally {\n                submitBtn.disabled = false;\n                submitBtn.textContent = 'Submit Patient Form';\n            }\n        });\n\n        updateStep();\n    })();\n    <\/script>\n    <\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-7191","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/onlinedemoserver10.com\/kenneth\/wp-json\/wp\/v2\/pages\/7191","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/onlinedemoserver10.com\/kenneth\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/onlinedemoserver10.com\/kenneth\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/onlinedemoserver10.com\/kenneth\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/onlinedemoserver10.com\/kenneth\/wp-json\/wp\/v2\/comments?post=7191"}],"version-history":[{"count":10,"href":"https:\/\/onlinedemoserver10.com\/kenneth\/wp-json\/wp\/v2\/pages\/7191\/revisions"}],"predecessor-version":[{"id":7203,"href":"https:\/\/onlinedemoserver10.com\/kenneth\/wp-json\/wp\/v2\/pages\/7191\/revisions\/7203"}],"wp:attachment":[{"href":"https:\/\/onlinedemoserver10.com\/kenneth\/wp-json\/wp\/v2\/media?parent=7191"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}