{"id":602,"date":"2023-08-25T16:04:28","date_gmt":"2023-08-25T16:04:28","guid":{"rendered":"https:\/\/thronebio.baycare.com\/tb\/?page_id=602"},"modified":"2023-11-22T02:57:56","modified_gmt":"2023-11-22T02:57:56","slug":"apply-for-stem-cell-treatment-of-type-1-diabetes-adult","status":"publish","type":"page","link":"https:\/\/dev.thronebio.com\/tb\/apply-for-stem-cell-educator-treatment\/apply-for-stem-cell-treatment-of-type-1-diabetes-adult\/","title":{"rendered":"Apply For Stem Cell Treatment Of Type 1 Diabetes-Adult"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"602\" class=\"elementor elementor-602\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6cd041e elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6cd041e\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-58ac207\" data-id=\"58ac207\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-4a37a7b elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"4a37a7b\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-e37b519\" data-id=\"e37b519\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-ea4b211 elementor-widget elementor-widget-heading\" data-id=\"ea4b211\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Application For Stem Cell Treatment Of Type 1 Diabetes - Adult<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-8f40da3 elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"8f40da3\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">To initiate the application process for Throne's cord blood stem cell treatment targeting type 1 diabetes, kindly complete the following application.<\/h5>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-12a6591 elementor-widget elementor-widget-wpforms\" data-id=\"12a6591\" data-element_type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<style id=\"wpforms-css-vars-root\">\n\t\t\t\t:root {\n\t\t\t\t\t--wpforms-field-border-radius: 3px;\n--wpforms-field-background-color: #ffffff;\n--wpforms-field-border-color: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-text-color: rgba( 0, 0, 0, 0.7 );\n--wpforms-label-color: rgba( 0, 0, 0, 0.85 );\n--wpforms-label-sublabel-color: rgba( 0, 0, 0, 0.55 );\n--wpforms-label-error-color: #d63637;\n--wpforms-button-border-radius: 3px;\n--wpforms-button-background-color: #066aab;\n--wpforms-button-text-color: #ffffff;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n\n\t\t\t\t}\n\t\t\t<\/style><style id=\"wpforms-css-vars-elementor-widget-12a6591\">\n\t\t\t\t.elementor-widget-wpforms.elementor-element-12a6591 {\n\t\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n\n\t\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-599\"><form id=\"wpforms-form-599\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"599\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/tb\/wp-json\/wp\/v2\/pages\/602\" data-token=\"3cdce4caa80947df2ab7b595c477b27e\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-599-field_5-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Your Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-599-field_5\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][5][first]\" aria-errormessage=\"wpforms-599-field_5-error\" required><label for=\"wpforms-599-field_5\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-599-field_5-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][5][last]\" aria-errormessage=\"wpforms-599-field_5-last-error\" required><label for=\"wpforms-599-field_5-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-599-field_6-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"6\"><fieldset><legend class=\"wpforms-field-label\">Your Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-599-field_6\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][6][address1]\" aria-errormessage=\"wpforms-599-field_6-error\" required><label for=\"wpforms-599-field_6\" class=\"wpforms-field-sublabel after \">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-599-field_6-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][6][address2]\" aria-errormessage=\"wpforms-599-field_6-address2-error\" ><label for=\"wpforms-599-field_6-address2\" class=\"wpforms-field-sublabel after \">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-599-field_6-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][6][city]\" aria-errormessage=\"wpforms-599-field_6-city-error\" required><label for=\"wpforms-599-field_6-city\" class=\"wpforms-field-sublabel after \">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-599-field_6-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][6][state]\" placeholder=\"--- Select state ---\" aria-errormessage=\"wpforms-599-field_6-state-error\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select state ---<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-599-field_6-state\" class=\"wpforms-field-sublabel after \">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-599-field_6-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][6][postal]\" aria-errormessage=\"wpforms-599-field_6-postal-error\" required><label for=\"wpforms-599-field_6-postal\" class=\"wpforms-field-sublabel after \">Zip Code<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-599-field_9-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_9\">Your Birthdate <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-599-field_9\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-small\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][9][date]\" aria-errormessage=\"wpforms-599-field_9-error\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-599-field_7-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_7\">Your Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-599-field_7\" class=\"wpforms-field-small wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-599-field_7-error\" required><\/div><div id=\"wpforms-599-field_8-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_8\">Your Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-599-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" spellcheck=\"false\" aria-errormessage=\"wpforms-599-field_8-error\" required><\/div><div id=\"wpforms-599-field_11-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"11\"><fieldset><legend class=\"wpforms-field-label\">Have You Been Diagnosed With Type 1 Diabetes? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-599-field_11\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-599-field_11_1\" name=\"wpforms[fields][11]\" value=\"Yes, Within The Last Six Months\" aria-errormessage=\"wpforms-599-field_11_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_11_1\">Yes, Within The Last Six Months<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-599-field_11_2\" name=\"wpforms[fields][11]\" value=\"Yes, Within The Last Twelve Months\" aria-errormessage=\"wpforms-599-field_11_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_11_2\">Yes, Within The Last Twelve Months<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"radio\" id=\"wpforms-599-field_11_8\" name=\"wpforms[fields][11]\" value=\"Yes, Within The Last Twelve To Twenty Four Months Ago\" aria-errormessage=\"wpforms-599-field_11_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_11_8\">Yes, Within The Last Twelve To Twenty Four Months Ago<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-599-field_11_4\" name=\"wpforms[fields][11]\" value=\"Yes, More Than Two Years Ago\" aria-errormessage=\"wpforms-599-field_11_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_11_4\">Yes, More Than Two Years Ago<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-599-field_11_5\" name=\"wpforms[fields][11]\" value=\"Not Yet But I Am At Risk Based On Antibody Tests\" aria-errormessage=\"wpforms-599-field_11_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_11_5\">Not Yet But I Am At Risk Based On Antibody Tests<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-599-field_11_7\" name=\"wpforms[fields][11]\" value=\"Not Yet But I Am At Risk Based On Family History\" aria-errormessage=\"wpforms-599-field_11_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_11_7\">Not Yet But I Am At Risk Based On Family History<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-599-field_11_6\" name=\"wpforms[fields][11]\" value=\"No\" aria-errormessage=\"wpforms-599-field_11_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_11_6\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-599-field_12-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_12\">If You Have Been Diagnosed With Type 1 Diabetes, What Was The Date Of That Diagnosis?<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-599-field_12\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-small\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][12][date]\" aria-errormessage=\"wpforms-599-field_12-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-599-field_13-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"13\"><fieldset><legend class=\"wpforms-field-label\">What Were Your Symptoms When First Diagnosed? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-599-field_13\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_13_1\" name=\"wpforms[fields][13][]\" value=\"Frequent Urination\" aria-errormessage=\"wpforms-599-field_13_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_13_1\">Frequent Urination<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_13_2\" name=\"wpforms[fields][13][]\" value=\"Excessive Thirst\" aria-errormessage=\"wpforms-599-field_13_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_13_2\">Excessive Thirst<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_13_3\" name=\"wpforms[fields][13][]\" value=\"Excessive Appetite\" aria-errormessage=\"wpforms-599-field_13_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_13_3\">Excessive Appetite<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_13_4\" name=\"wpforms[fields][13][]\" value=\"Weight Loss\" aria-errormessage=\"wpforms-599-field_13_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_13_4\">Weight Loss<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_13_6\" name=\"wpforms[fields][13][]\" value=\"Extreme Fatigue\" aria-errormessage=\"wpforms-599-field_13_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_13_6\">Extreme Fatigue<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_13_5\" name=\"wpforms[fields][13][]\" value=\"Blurry Vision\" aria-errormessage=\"wpforms-599-field_13_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_13_5\">Blurry Vision<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_13_8\" name=\"wpforms[fields][13][]\" value=\"Other\" aria-errormessage=\"wpforms-599-field_13_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_13_8\">Other<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_13_7\" name=\"wpforms[fields][13][]\" value=\"None\" aria-errormessage=\"wpforms-599-field_13_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_13_7\">None<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-599-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_21\">How Many Units Of Long-Acting Insulin Do You Require Per Day?<\/label><input type=\"text\" id=\"wpforms-599-field_21\" class=\"wpforms-field-small\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-599-field_21-error\" ><\/div><div id=\"wpforms-599-field_58-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_58\">How Many Units Of Short-Acting Insulin Do You Require Per Day?<\/label><input type=\"text\" id=\"wpforms-599-field_58\" class=\"wpforms-field-small\" name=\"wpforms[fields][58]\" aria-errormessage=\"wpforms-599-field_58-error\" ><\/div><div id=\"wpforms-599-field_57-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"57\"><fieldset><legend class=\"wpforms-field-label\">Is There A Family History Of Type 1 Diabetes?<\/legend><ul id=\"wpforms-599-field_57\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_57_1\" name=\"wpforms[fields][57][]\" value=\"One or more siblings\" aria-errormessage=\"wpforms-599-field_57_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_57_1\">One or more siblings<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_57_2\" name=\"wpforms[fields][57][]\" value=\"One or more parents\" aria-errormessage=\"wpforms-599-field_57_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_57_2\">One or more parents<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_57_3\" name=\"wpforms[fields][57][]\" value=\"One or more grandparents\" aria-errormessage=\"wpforms-599-field_57_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_57_3\">One or more grandparents<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_57_4\" name=\"wpforms[fields][57][]\" value=\"One or more first cousins\" aria-errormessage=\"wpforms-599-field_57_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_57_4\">One or more first cousins<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_57_5\" name=\"wpforms[fields][57][]\" value=\"None of the above\" aria-errormessage=\"wpforms-599-field_57_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_57_5\">None of the above<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-599-field_14-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_14\">Your Weight (in pounds) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-599-field_14\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-599-field_14-error\" required><\/div><div id=\"wpforms-599-field_18-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"18\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-599-field_18\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-25-25\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-599-field_19-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_19\">Your Height In Feet<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-599-field_19\" class=\"wpforms-field-medium\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-599-field_19-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-599-field_20-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_20\">And Inches<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-599-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" aria-errormessage=\"wpforms-599-field_20-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><\/div><\/div><div id=\"wpforms-599-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_22\">List All Of Your Prescription Medications (enter &quot;None&quot; if none)<\/label><input type=\"text\" id=\"wpforms-599-field_22\" class=\"wpforms-field-large\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-599-field_22-error\" ><\/div><div id=\"wpforms-599-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_23\">List All Of Your Allergies (enter &quot;None&quot; if none) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-599-field_23\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-599-field_23-error\" required><\/div><div id=\"wpforms-599-field_62-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"62\"><fieldset><legend class=\"wpforms-field-label\">Do You Have Any Of These Other Autoimmune Disorders? Check All That Apply. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-599-field_62\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_1\" name=\"wpforms[fields][62][]\" value=\"Gluten-Sensitive Enteropathy \/ Celiac Disease\" aria-errormessage=\"wpforms-599-field_62_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_1\">Gluten-Sensitive Enteropathy \/ Celiac Disease<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_2\" name=\"wpforms[fields][62][]\" value=\"Crohn&#039;s Disease\" aria-errormessage=\"wpforms-599-field_62_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_2\">Crohn's Disease<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_14\" name=\"wpforms[fields][62][]\" value=\"Autoimmune Hepatitis\" aria-errormessage=\"wpforms-599-field_62_14-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_14\">Autoimmune Hepatitis<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_13\" name=\"wpforms[fields][62][]\" value=\"Hyperthyroidism \/ Hashimoto&#039;s Disease\" aria-errormessage=\"wpforms-599-field_62_13-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_13\">Hyperthyroidism \/ Hashimoto's Disease<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_12\" name=\"wpforms[fields][62][]\" value=\"Hypothyroidism \/ Grave&#039;s Disease\" aria-errormessage=\"wpforms-599-field_62_12-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_12\">Hypothyroidism \/ Grave's Disease<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_11\" name=\"wpforms[fields][62][]\" value=\"Adrenal Insufficiency \/ Addison&#039;s Disease\" aria-errormessage=\"wpforms-599-field_62_11-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_11\">Adrenal Insufficiency \/ Addison's Disease<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_10\" name=\"wpforms[fields][62][]\" value=\"Rheumatoid Arthritis \/ Idiopathic Arthritis\" aria-errormessage=\"wpforms-599-field_62_10-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_10\">Rheumatoid Arthritis \/ Idiopathic Arthritis<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_9\" name=\"wpforms[fields][62][]\" value=\"Psoriasis \/ Psoriatic Arthritis\" aria-errormessage=\"wpforms-599-field_62_9-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_9\">Psoriasis \/ Psoriatic Arthritis<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_8\" name=\"wpforms[fields][62][]\" value=\"Dermatoid Arthritis\" aria-errormessage=\"wpforms-599-field_62_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_8\">Dermatoid Arthritis<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_7\" name=\"wpforms[fields][62][]\" value=\"Dermatomyositis\" aria-errormessage=\"wpforms-599-field_62_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_7\">Dermatomyositis<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_6\" name=\"wpforms[fields][62][]\" value=\"Lupus\" aria-errormessage=\"wpforms-599-field_62_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_6\">Lupus<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_5\" name=\"wpforms[fields][62][]\" value=\"Scleroderma\" aria-errormessage=\"wpforms-599-field_62_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_5\">Scleroderma<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_4\" name=\"wpforms[fields][62][]\" value=\"Sj\u00f6gren syndrome\" aria-errormessage=\"wpforms-599-field_62_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_4\">Sj\u00f6gren syndrome<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_24\" name=\"wpforms[fields][62][]\" value=\"Alopecia Areata\" aria-errormessage=\"wpforms-599-field_62_24-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_24\">Alopecia Areata<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_18\" name=\"wpforms[fields][62][]\" value=\"Parkinson&#039;s Disease\" aria-errormessage=\"wpforms-599-field_62_18-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_18\">Parkinson's Disease<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_17\" name=\"wpforms[fields][62][]\" value=\"Alzheimer&#039;s Disease\" aria-errormessage=\"wpforms-599-field_62_17-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_17\">Alzheimer's Disease<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_16\" name=\"wpforms[fields][62][]\" value=\"Myasthenia gravis\" aria-errormessage=\"wpforms-599-field_62_16-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_16\">Myasthenia gravis<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_15\" name=\"wpforms[fields][62][]\" value=\"Multiple Sclerosis\" aria-errormessage=\"wpforms-599-field_62_15-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_15\">Multiple Sclerosis<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_22\" name=\"wpforms[fields][62][]\" value=\"Autism\" aria-errormessage=\"wpforms-599-field_62_22-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_22\">Autism<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_21\" name=\"wpforms[fields][62][]\" value=\"Pernicious anemia\" aria-errormessage=\"wpforms-599-field_62_21-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_21\">Pernicious anemia<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_20\" name=\"wpforms[fields][62][]\" value=\"Other (list below)\" aria-errormessage=\"wpforms-599-field_62_20-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_20\">Other (list below)<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_23\" name=\"wpforms[fields][62][]\" value=\"Possibly (list below)\" aria-errormessage=\"wpforms-599-field_62_23-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_23\">Possibly (list below)<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-599-field_62_19\" name=\"wpforms[fields][62][]\" value=\"None Of The Above\" aria-errormessage=\"wpforms-599-field_62_19-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_62_19\">None Of The Above<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-599-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_25\">List All Other Chronic Illnesses Or Disorders, Especially If Autoimmune, (enter &quot;None&quot; If none) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-599-field_25\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][25]\" aria-errormessage=\"wpforms-599-field_25-error\" required><\/div><div id=\"wpforms-599-field_24-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_24\">List All Vaccinations For Which You Have Records And Age When Vaccinated <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-599-field_24\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][24]\" aria-errormessage=\"wpforms-599-field_24-error\" required><\/textarea><\/div><div id=\"wpforms-599-field_26-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"26\"><h3 id=\"wpforms-599-field_26\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-599-field_26-error\">If You Have Recent Blood Test Results, Please Enter Them Below<\/h3><\/div><div id=\"wpforms-599-field_39-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"39\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-599-field_39\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_40-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_40\">IA2 Antibody Result<\/label><input type=\"text\" id=\"wpforms-599-field_40\" class=\"wpforms-field-medium\" name=\"wpforms[fields][40]\" aria-errormessage=\"wpforms-599-field_40-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_49-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_49\">Date Of Result<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-599-field_49\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][49][date]\" aria-errormessage=\"wpforms-599-field_49-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-599-field_27-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"27\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-599-field_27\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_28-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_28\">Fasting Blood Sugar Result<\/label><input type=\"text\" id=\"wpforms-599-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-599-field_28-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_45-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_45\">Date Of Result<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-599-field_45\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][45][date]\" aria-errormessage=\"wpforms-599-field_45-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-599-field_30-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"30\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-599-field_30\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_31\">Hemoglobin A1C Result<\/label><input type=\"text\" id=\"wpforms-599-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" aria-errormessage=\"wpforms-599-field_31-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_46-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_46\">Date Of Result<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-599-field_46\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][46][date]\" aria-errormessage=\"wpforms-599-field_46-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-599-field_33-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"33\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-599-field_33\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_34\">C-Peptide Result<\/label><input type=\"text\" id=\"wpforms-599-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" aria-errormessage=\"wpforms-599-field_34-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_47-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_47\">Date Of Result<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-599-field_47\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][47][date]\" aria-errormessage=\"wpforms-599-field_47-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-599-field_36-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"36\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-599-field_36\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_37-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_37\">GAD Antibody Result<\/label><input type=\"text\" id=\"wpforms-599-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\" aria-errormessage=\"wpforms-599-field_37-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_48-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_48\">Date Of Result<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-599-field_48\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][48][date]\" aria-errormessage=\"wpforms-599-field_48-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-599-field_42-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"42\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-599-field_42\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_43-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_43\">ICA Antibody Result<\/label><input type=\"text\" id=\"wpforms-599-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-599-field_43-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_44-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_44\">Date Of Result<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-599-field_44\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][44][date]\" aria-errormessage=\"wpforms-599-field_44-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-599-field_50-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"50\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-599-field_50\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_51-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_51\">IAA Antibody Result<\/label><input type=\"text\" id=\"wpforms-599-field_51\" class=\"wpforms-field-medium\" name=\"wpforms[fields][51]\" aria-errormessage=\"wpforms-599-field_51-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-599-field_52-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_52\">Date Of Result<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-599-field_52\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][52][date]\" aria-errormessage=\"wpforms-599-field_52-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-599-field_53-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_53\">Enter The Name, Address, Phone Number, And Email Address Of The Doctor And\/Or Clinic That Provides Your Diabetes Care<\/label><textarea id=\"wpforms-599-field_53\" class=\"wpforms-field-medium\" name=\"wpforms[fields][53]\" aria-errormessage=\"wpforms-599-field_53-error\" ><\/textarea><\/div><div id=\"wpforms-599-field_54-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"54\"><fieldset><legend class=\"wpforms-field-label\">Email Communication Authorization: I give permission for Throne Biotechnology And Its Doctors To Communicate With Me Regarding My Care By Telephone, Text Message, or Email. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-599-field_54\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-599-field_54_1\" name=\"wpforms[fields][54]\" value=\"Yes\" aria-errormessage=\"wpforms-599-field_54_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_54_1\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-599-field_55-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"55\"><fieldset><legend class=\"wpforms-field-label\">Required HIPPA Privacy Practices Notice (To See A Copy Of Our HIPPA Privacy Practices, See Next The Paragraph) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-599-field_55\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-599-field_55_1\" name=\"wpforms[fields][55]\" value=\"Yes, I have been shown a copy of this office&#039;s HIPPA Privacy Practices Notice.\" aria-errormessage=\"wpforms-599-field_55_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-599-field_55_1\">Yes, I have been shown a copy of this office's HIPPA Privacy Practices Notice.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-599-field_61-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"61\"><div id=\"wpforms-599-field_61\" aria-errormessage=\"wpforms-599-field_61-error\">Click <a href=\"https:\/\/dev.thronebio.com\/tb\/wp-content\/uploads\/2023\/09\/HIPPA-Notice-Throne-9-18-2023.pdf\">here<\/a> to review our HIPPA Privacy Policy.<\/div><\/div><div id=\"wpforms-599-field_59-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-599-field_59\">The Throne Stem Cell Treatment Is A Two Day Procedure. Please Enter Your Preferred Date To Begin The Procedure.<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-599-field_59\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-small\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][59][date]\" aria-errormessage=\"wpforms-599-field_59-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"599\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-599\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/dev.thronebio.com\/tb\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-ef32917 elementor-widget elementor-widget-text-editor\" data-id=\"ef32917\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<h6 id=\"wpforms-599-field_60\" aria-errormessage=\"wpforms-599-field_60-error\">Thank you for your interest in the Throne Stem Cell Treatment. We will respond to your application within the next two business days.<\/h6>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-edf82bc elementor-widget elementor-widget-spacer\" data-id=\"edf82bc\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-a8922b9 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"a8922b9\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-19ab1ae\" data-id=\"19ab1ae\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-ffd1894 elementor-widget elementor-widget-text-editor\" data-id=\"ffd1894\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Throne Biotechnologies, 10 Forest Avenue, Suite 110, Paramus, NJ 07652<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Application For Stem Cell Treatment Of Type 1 Diabetes &#8211; Adult To initiate the application process for Throne&#8217;s cord blood stem cell treatment targeting type 1 diabetes, kindly complete the following application. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Your Name * FirstLast&hellip;&nbsp;<a href=\"https:\/\/dev.thronebio.com\/tb\/apply-for-stem-cell-educator-treatment\/apply-for-stem-cell-treatment-of-type-1-diabetes-adult\/\" rel=\"bookmark\">Read More &raquo;<span class=\"screen-reader-text\">Apply For Stem Cell Treatment Of Type 1 Diabetes-Adult<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":2115,"menu_order":1,"comment_status":"closed","ping_status":"closed","template":"page-templates\/template-pagebuilder-full-width.php","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"class_list":["post-602","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/dev.thronebio.com\/tb\/wp-json\/wp\/v2\/pages\/602","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/dev.thronebio.com\/tb\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dev.thronebio.com\/tb\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dev.thronebio.com\/tb\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/dev.thronebio.com\/tb\/wp-json\/wp\/v2\/comments?post=602"}],"version-history":[{"count":18,"href":"https:\/\/dev.thronebio.com\/tb\/wp-json\/wp\/v2\/pages\/602\/revisions"}],"predecessor-version":[{"id":2482,"href":"https:\/\/dev.thronebio.com\/tb\/wp-json\/wp\/v2\/pages\/602\/revisions\/2482"}],"up":[{"embeddable":true,"href":"https:\/\/dev.thronebio.com\/tb\/wp-json\/wp\/v2\/pages\/2115"}],"wp:attachment":[{"href":"https:\/\/dev.thronebio.com\/tb\/wp-json\/wp\/v2\/media?parent=602"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}