{"id":203,"date":"2020-09-25T10:12:26","date_gmt":"2020-09-25T10:12:26","guid":{"rendered":"https:\/\/scolicare.com\/east-phoenix-arizona\/?page_id=203"},"modified":"2026-05-11T15:57:12","modified_gmt":"2026-05-11T15:57:12","slug":"pro-referrers-form","status":"publish","type":"page","link":"https:\/\/scolicare.com\/east-phoenix-arizona\/pro-referrers-form\/","title":{"rendered":"How To Refer"},"content":{"rendered":"\n<section class=\"backgroundgradient\">\n<div class=\"gb-element-182e7729 grid-container\">\n<div class=\"wp-block-columns c_align_item is-layout-flex wp-container-core-columns-is-layout-9d6595d7 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:100%\">\n<h1 class=\"gb-text gb-text-c8e831a7\">How to Refer<\/h1>\n<\/div>\n<\/div>\n<\/div>\n<\/section>\n\n\n\n<section class=\"c_bread_crum\">\n<div class=\"gb-element-7f1c7953 grid-container\">\n<div class=\"wp-block-columns c_align_item is-layout-flex wp-container-core-columns-is-layout-9d6595d7 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:100%\"><\/div>\n<\/div>\n\n\n<span><span><a href=\"https:\/\/scolicare.com\/east-phoenix-arizona\/\"><svg style=\"margin-bottom: -3px; padding-right: 5px;\" width=\"18\" height=\"20\" viewBox=\"0 0 18 21\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n<path d=\"M7.54916 1.45316C8.38719 0.746164 9.61281 0.746163 10.4508 1.45316L17.2008 7.1477C17.7076 7.57521 18 8.20446 18 8.86745V18.6704C18 19.6369 17.2165 20.4204 16.25 20.4204H13.25C12.2835 20.4204 11.5 19.6369 11.5 18.6704V13.6704C11.5 13.2562 11.1642 12.9204 10.75 12.9204H7.25C6.83579 12.9204 6.5 13.2562 6.5 13.6704V18.6704C6.5 19.6369 5.7165 20.4204 4.75 20.4204H1.75C0.783502 20.4204 0 19.6369 0 18.6704V8.86745C0 8.20446 0.292405 7.57521 0.799155 7.1477L7.54916 1.45316Z\" fill=\"#00B3D7\"\/>\n<\/svg><\/a><\/span><\/span>\n<\/div>\n<\/section>\n\n\n\n<div class=\"gbp-section gb-element-8f34b589\">\n<div class=\"gbp-section__inner gb-element-9a8fffbd\">\n<div class=\"gb-element-8ee1b62e\">\n<p class=\"gb-text gbp-section__text gb-text-57cca876 P2-Regular\">We work with health professionals in all \ufb01elds to help achieve the best results for scoliosis and kyphosis patients. To directly refer a patient to this clinic, complete the form below and we will be in touch.<\/p>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"gb-element-5ac5f42c\">\n<h2 class=\"gb-text gb-text-c98063bc\">Downloadable forms (for offline referrals)<\/h2>\n<\/div>\n\n\n\n<section class=\"gb-element-5e8706e0\">\n<div class=\"gb-element-4dd0585a\">\n<div class=\"gb-element-2607206d some_practical\">\n<div class=\"gb-element-d98c220f c_some_col\">\n<img decoding=\"async\" class=\"gb-media-718da2e1\" alt=\"\" src=\"https:\/\/scolicare.com\/denver-colorado\/wp-content\/uploads\/sites\/50\/2026\/02\/scolicare-icons-18-1-scaled-1.png\" title=\"scolicare-icons-18-1-scaled\"\/>\n\n\n\n<h4 class=\"gb-text gb-text-225dada4\">Scoliosis Management<\/h4>\n\n\n\n<p class=\"gb-text gb-text-94db8a43\">Referral Form<\/p>\n\n\n\n<div class=\"wp-block-buttons c_center_mobile  jobimg is-content-justification-center is-layout-flex wp-container-core-buttons-is-layout-8057eaf3 wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button c_bg_btn_all is-style-fill\"><a class=\"wp-block-button__link has-base-3-color has-contrast-background-color has-text-color has-background has-link-color wp-element-button\" href=\"https:\/\/scolicare.com\/east-phoenix-arizona\/wp-content\/uploads\/sites\/32\/2024\/02\/Scoliosis-Management-Referral-East-Phoenix.pdf\" style=\"border-radius:6px\">Download form<img decoding=\"async\" class=\"wp-image-39470\" style=\"width: 44px\" src=\"https:\/\/scolicare.com\/wp-content\/uploads\/2025\/08\/arrow-up-outline.png\" alt=\"\"><\/a><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/section>\n\n\n\n<div class=\"gb-element-17c29cb5 mian_form\"><style>.wForm form{text-align: left;}<\/style><!-- FORM: HEAD SECTION -->\n    <meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n    <meta name=\"referrer\" content=\"no-referrer-when-downgrade\">\n    <!-- THIS SCRIPT NEEDS TO BE LOADED FIRST BEFORE wforms.js -->\n    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height: auto !important;\n                }\n            <\/style><div class=\"\"><div class=\"wForm\" id=\"5118480-WRPR\" data-language=\"en_US\" dir=\"ltr\">\n<div class=\"codesection\" id=\"code-5118480\"><\/div>\n<h3 class=\"wFormTitle\" data-testid=\"form-title\" id=\"5118480-T\">Health Professional Referral Form<\/h3>\n<form method=\"post\" action=\"https:\/\/scolicare.tfaforms.net\/api_v2\/rest\/workflow\/processor\" class=\"hintsBelow labelsAbove\" id=\"5118480\" enctype=\"multipart\/form-data\">\n<div class=\"oneField field-container-D     wf-acl-hidden\" id=\"tfa_13790-D\">\n<label id=\"tfa_13790-L\" class=\"label preField \" for=\"tfa_13790\">ScoliCare Clinic<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_13790\" name=\"tfa_13790\" title=\"ScoliCare Clinic\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_13791\" id=\"tfa_13791\" class=\"\">ScoliCare East Phoenix<\/option>\n<option value=\"tfa_13792\" id=\"tfa_13792\" class=\"\">ScoliCare Denver<\/option>\n<option value=\"tfa_13793\" id=\"tfa_13793\" class=\"\">ScoliCare Louisville<\/option>\n<option value=\"tfa_13794\" id=\"tfa_13794\" class=\"\">ScoliCare Naples<\/option>\n<option value=\"tfa_13795\" id=\"tfa_13795\" class=\"\">ScoliCare Adelaide<\/option>\n<option value=\"tfa_13796\" id=\"tfa_13796\" class=\"\">ScoliCare Brisbane<\/option>\n<option value=\"tfa_13797\" id=\"tfa_13797\" class=\"\">ScoliCare Melbourne<\/option>\n<option value=\"tfa_13798\" id=\"tfa_13798\" class=\"\">ScoliCare Sydney North<\/option>\n<option value=\"tfa_13799\" id=\"tfa_13799\" class=\"\">ScoliCare Sydney South<\/option><\/select><\/div>\n<\/div>\n<div class=\"htmlSection\" id=\"tfa_2341\"><div class=\"htmlContent\" id=\"tfa_2341-HTML\">ScoliCare welcomes referrals from other health professionals to co-manage patients with scoliosis, kyphosis, and related spinal conditions.&nbsp;<\/div><\/div>\n<fieldset id=\"tfa_5\" class=\"section\">\n<legend id=\"tfa_5-L\"><b>Referring Health Professional Details<\/b><\/legend>\n<div class=\"oneField field-container-D    \" id=\"tfa_2384-D\">\n<label id=\"tfa_2384-L\" class=\"label preField \" for=\"tfa_2384\">Title<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_2384\" name=\"tfa_2384\" title=\"Title\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_2385\" id=\"tfa_2385\" class=\"\">Dr.<\/option>\n<option value=\"tfa_2386\" id=\"tfa_2386\" class=\"\">Mr.<\/option>\n<option value=\"tfa_2387\" id=\"tfa_2387\" class=\"\">Mrs.<\/option>\n<option value=\"tfa_2388\" id=\"tfa_2388\" class=\"\">Ms.<\/option>\n<option value=\"tfa_2389\" id=\"tfa_2389\" class=\"\">Prof.<\/option><\/select><\/div>\n<\/div>\n<div id=\"tfa_2383\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_6-D\">\n<label id=\"tfa_6-L\" class=\"label preField reqMark\" for=\"tfa_6\">Referrer First Name:<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_6\" name=\"tfa_6\" value=\"\" title=\"Referrer First Name:\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2382-D\">\n<label id=\"tfa_2382-L\" class=\"label preField reqMark\" for=\"tfa_2382\">Referrer Last Name:<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_2382\" name=\"tfa_2382\" value=\"\" title=\"Referrer Last Name:\" class=\"required\"><\/div>\n<\/div>\n<\/div>\n<div id=\"tfa_2403\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_8-D\">\n<label id=\"tfa_8-L\" class=\"label preField reqMark\" for=\"tfa_8\">Profession&nbsp;<\/label><br><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_8\" name=\"tfa_8\" title=\"Profession \" class=\"required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_2391\" id=\"tfa_2391\" class=\"\">Chiropractor<\/option>\n<option value=\"tfa_2392\" id=\"tfa_2392\" class=\"\">Physical Therapist<\/option>\n<option value=\"tfa_2393\" id=\"tfa_2393\" class=\"\">Primary Care Physician<\/option>\n<option value=\"tfa_2394\" id=\"tfa_2394\" class=\"\">Orthotist\/Prosthetist<\/option>\n<option value=\"tfa_2395\" id=\"tfa_2395\" class=\"\">Clinician<\/option>\n<option value=\"tfa_3518\" id=\"tfa_3518\" class=\"\">Exercise Physiologist<\/option>\n<option value=\"tfa_2398\" id=\"tfa_2398\" class=\"\">Surgeon<\/option>\n<option value=\"tfa_2399\" id=\"tfa_2399\" class=\"\">Director<\/option>\n<option value=\"tfa_2400\" id=\"tfa_2400\" class=\"\">Clinic Manager<\/option>\n<option value=\"tfa_2401\" id=\"tfa_2401\" data-conditionals=\"#tfa_2402\" class=\"\">Other<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2402-D\">\n<label id=\"tfa_2402-L\" class=\"label preField \" for=\"tfa_2402\">Other<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_2402\" name=\"tfa_2402\" value=\"\" data-condition=\"`#tfa_2401`\" title=\"Other\" class=\"\"><\/div>\n<\/div>\n<\/div>\n<div id=\"tfa_2380\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_2180-D\">\n<label id=\"tfa_2180-L\" class=\"label preField reqMark\" for=\"tfa_2180\">Email<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_2180\" name=\"tfa_2180\" value=\"\" title=\"Email\" class=\"validate-email required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2182-D\">\n<label id=\"tfa_2182-L\" class=\"label preField \" for=\"tfa_2182\">Phone<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_2182\" name=\"tfa_2182\" value=\"\" placeholder=\"###-###-####\" title=\"Phone\" class=\"validate-custom \/^([\\(]{1}[0-9]{3}[\\)]{1}[\\.| |\\-]{0,1}|^[0-9]{3}[\\.|\\-| ]?)?[0-9]{3}(\\.|\\-| )?[0-9]{4}$\/\"><\/div>\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2390-D\">\n<label id=\"tfa_2390-L\" class=\"label preField reqMark\" for=\"tfa_2390\">Practice\/Clinic Name<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_2390\" name=\"tfa_2390\" value=\"\" title=\"Practice\/Clinic Name\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_1863-D\">\n<label id=\"tfa_1863-L\" class=\"label preField reqMark\" for=\"tfa_1863\">Practice\/Clinic Address<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_1863\" name=\"tfa_1863\" value=\"\" title=\"Practice\/Clinic Address\" class=\"required\"><\/div>\n<\/div>\n<div id=\"tfa_2178\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_1865-D\">\n<label id=\"tfa_1865-L\" class=\"label preField reqMark\" for=\"tfa_1865\">City<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_1865\" name=\"tfa_1865\" value=\"\" title=\"City\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2177-D\">\n<label id=\"tfa_2177-L\" class=\"label preField reqMark\" for=\"tfa_2177\">Postal Code<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_2177\" name=\"tfa_2177\" value=\"\" title=\"Postal Code\" class=\"validate-integer required\"><\/div>\n<\/div>\n<\/div>\n<div id=\"tfa_2913\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_2675-D\">\n<label id=\"tfa_2675-L\" class=\"label preField reqMark\" for=\"tfa_2675\">Country<\/label><br><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_2675\" name=\"tfa_2675\" title=\"Country\" class=\"required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_2676\" id=\"tfa_2676\" class=\"\">Afghanistan<\/option>\n<option value=\"tfa_2677\" id=\"tfa_2677\" class=\"\">Albania<\/option>\n<option value=\"tfa_2678\" id=\"tfa_2678\" class=\"\">Algeria<\/option>\n<option value=\"tfa_2679\" id=\"tfa_2679\" class=\"\">American Samoa<\/option>\n<option value=\"tfa_2680\" id=\"tfa_2680\" class=\"\">Andorra<\/option>\n<option value=\"tfa_2681\" id=\"tfa_2681\" class=\"\">Angola<\/option>\n<option value=\"tfa_2682\" id=\"tfa_2682\" class=\"\">Anguilla<\/option>\n<option value=\"tfa_2683\" id=\"tfa_2683\" class=\"\">Antarctica<\/option>\n<option value=\"tfa_2684\" id=\"tfa_2684\" class=\"\">Antigua and Barbuda<\/option>\n<option value=\"tfa_2685\" id=\"tfa_2685\" class=\"\">Argentina<\/option>\n<option value=\"tfa_2686\" id=\"tfa_2686\" class=\"\">Armenia<\/option>\n<option value=\"tfa_2687\" id=\"tfa_2687\" class=\"\">Aruba<\/option>\n<option value=\"tfa_2688\" id=\"tfa_2688\" class=\"\">Australia<\/option>\n<option value=\"tfa_2689\" id=\"tfa_2689\" class=\"\">Austria<\/option>\n<option value=\"tfa_2690\" id=\"tfa_2690\" class=\"\">Azerbaijan<\/option>\n<option value=\"tfa_2691\" id=\"tfa_2691\" class=\"\">Bahamas<\/option>\n<option value=\"tfa_2692\" id=\"tfa_2692\" class=\"\">Bahrain<\/option>\n<option value=\"tfa_2693\" id=\"tfa_2693\" class=\"\">Bangladesh<\/option>\n<option value=\"tfa_2694\" id=\"tfa_2694\" class=\"\">Barbados<\/option>\n<option value=\"tfa_2695\" id=\"tfa_2695\" class=\"\">Belarus<\/option>\n<option value=\"tfa_2696\" id=\"tfa_2696\" class=\"\">Belgium<\/option>\n<option value=\"tfa_2697\" id=\"tfa_2697\" class=\"\">Belize<\/option>\n<option value=\"tfa_2698\" id=\"tfa_2698\" class=\"\">Benin<\/option>\n<option value=\"tfa_2699\" id=\"tfa_2699\" class=\"\">Bermuda<\/option>\n<option value=\"tfa_2700\" id=\"tfa_2700\" class=\"\">Bhutan<\/option>\n<option value=\"tfa_2701\" id=\"tfa_2701\" class=\"\">Bolivia<\/option>\n<option value=\"tfa_2702\" id=\"tfa_2702\" class=\"\">Bosnia and Herzegovina<\/option>\n<option value=\"tfa_2703\" id=\"tfa_2703\" class=\"\">Botswana<\/option>\n<option value=\"tfa_2704\" id=\"tfa_2704\" class=\"\">Bouvet Island<\/option>\n<option value=\"tfa_2705\" id=\"tfa_2705\" class=\"\">Brazil<\/option>\n<option value=\"tfa_2706\" id=\"tfa_2706\" class=\"\">British Indian Ocean Territory<\/option>\n<option value=\"tfa_2707\" id=\"tfa_2707\" class=\"\">Brunei<\/option>\n<option value=\"tfa_2708\" id=\"tfa_2708\" class=\"\">Bulgaria<\/option>\n<option value=\"tfa_2709\" id=\"tfa_2709\" class=\"\">Burkina Faso<\/option>\n<option value=\"tfa_2710\" id=\"tfa_2710\" class=\"\">Burundi<\/option>\n<option value=\"tfa_2711\" id=\"tfa_2711\" class=\"\">Cambodia<\/option>\n<option value=\"tfa_2712\" id=\"tfa_2712\" class=\"\">Cameroon<\/option>\n<option value=\"tfa_2713\" id=\"tfa_2713\" class=\"\">Canada<\/option>\n<option value=\"tfa_2714\" id=\"tfa_2714\" class=\"\">Cape Verde<\/option>\n<option value=\"tfa_2715\" id=\"tfa_2715\" class=\"\">Cayman Islands<\/option>\n<option value=\"tfa_2716\" id=\"tfa_2716\" class=\"\">Central African Republic<\/option>\n<option value=\"tfa_2717\" id=\"tfa_2717\" class=\"\">Chad<\/option>\n<option value=\"tfa_2718\" id=\"tfa_2718\" class=\"\">Chile<\/option>\n<option value=\"tfa_2719\" id=\"tfa_2719\" class=\"\">China<\/option>\n<option value=\"tfa_2720\" id=\"tfa_2720\" class=\"\">Christmas Island<\/option>\n<option value=\"tfa_2721\" id=\"tfa_2721\" class=\"\">Cocos ( Keeling ) Islands<\/option>\n<option value=\"tfa_2722\" id=\"tfa_2722\" class=\"\">Colombia<\/option>\n<option value=\"tfa_2723\" id=\"tfa_2723\" class=\"\">Comoros<\/option>\n<option value=\"tfa_2724\" id=\"tfa_2724\" class=\"\">Congo<\/option>\n<option value=\"tfa_2725\" id=\"tfa_2725\" class=\"\">Cook Islands<\/option>\n<option value=\"tfa_2726\" id=\"tfa_2726\" class=\"\">Costa Rica<\/option>\n<option value=\"tfa_2727\" id=\"tfa_2727\" class=\"\">C\u00f4te d ' Ivoire<\/option>\n<option value=\"tfa_2728\" id=\"tfa_2728\" class=\"\">Croatia ( Hrvatska )<\/option>\n<option value=\"tfa_2729\" id=\"tfa_2729\" class=\"\">Cuba<\/option>\n<option value=\"tfa_2730\" id=\"tfa_2730\" class=\"\">Cyprus<\/option>\n<option value=\"tfa_2731\" id=\"tfa_2731\" class=\"\">Czech Republic<\/option>\n<option value=\"tfa_2732\" id=\"tfa_2732\" class=\"\">Congo ( DRC )<\/option>\n<option value=\"tfa_2733\" id=\"tfa_2733\" class=\"\">Denmark<\/option>\n<option value=\"tfa_2734\" id=\"tfa_2734\" class=\"\">Djibouti<\/option>\n<option value=\"tfa_2735\" id=\"tfa_2735\" class=\"\">Dominica<\/option>\n<option value=\"tfa_2736\" id=\"tfa_2736\" class=\"\">Dominican Republic<\/option>\n<option value=\"tfa_2737\" id=\"tfa_2737\" class=\"\">East Timor<\/option>\n<option value=\"tfa_2738\" id=\"tfa_2738\" class=\"\">Ecuador<\/option>\n<option value=\"tfa_2739\" id=\"tfa_2739\" class=\"\">Egypt<\/option>\n<option value=\"tfa_2740\" id=\"tfa_2740\" class=\"\">El Salvador<\/option>\n<option value=\"tfa_2741\" id=\"tfa_2741\" class=\"\">Equatorial Guinea<\/option>\n<option value=\"tfa_2742\" id=\"tfa_2742\" class=\"\">Eritrea<\/option>\n<option value=\"tfa_2743\" id=\"tfa_2743\" class=\"\">Estonia<\/option>\n<option value=\"tfa_2744\" id=\"tfa_2744\" class=\"\">Ethiopia<\/option>\n<option value=\"tfa_2745\" id=\"tfa_2745\" class=\"\">Falkland Islands ( Islas Malvinas )<\/option>\n<option value=\"tfa_2746\" id=\"tfa_2746\" class=\"\">Faroe Islands<\/option>\n<option value=\"tfa_2747\" id=\"tfa_2747\" class=\"\">Fiji Islands<\/option>\n<option value=\"tfa_2748\" id=\"tfa_2748\" class=\"\">Finland<\/option>\n<option value=\"tfa_2749\" id=\"tfa_2749\" class=\"\">France<\/option>\n<option value=\"tfa_2750\" id=\"tfa_2750\" class=\"\">French Guiana<\/option>\n<option value=\"tfa_2751\" id=\"tfa_2751\" class=\"\">French Polynesia<\/option>\n<option value=\"tfa_2752\" id=\"tfa_2752\" class=\"\">French Southern and Antarctic Lands<\/option>\n<option value=\"tfa_2753\" id=\"tfa_2753\" class=\"\">Gabon<\/option>\n<option value=\"tfa_2754\" id=\"tfa_2754\" class=\"\">Gambia<\/option>\n<option value=\"tfa_2755\" id=\"tfa_2755\" class=\"\">Georgia<\/option>\n<option value=\"tfa_2756\" id=\"tfa_2756\" class=\"\">Germany<\/option>\n<option value=\"tfa_2757\" id=\"tfa_2757\" class=\"\">Ghana<\/option>\n<option value=\"tfa_2758\" id=\"tfa_2758\" class=\"\">Gibraltar<\/option>\n<option value=\"tfa_2759\" id=\"tfa_2759\" class=\"\">Greece<\/option>\n<option value=\"tfa_2760\" id=\"tfa_2760\" class=\"\">Greenland<\/option>\n<option value=\"tfa_2761\" id=\"tfa_2761\" class=\"\">Grenada<\/option>\n<option value=\"tfa_2762\" id=\"tfa_2762\" class=\"\">Guadeloupe<\/option>\n<option value=\"tfa_2763\" id=\"tfa_2763\" class=\"\">Guam<\/option>\n<option value=\"tfa_2764\" id=\"tfa_2764\" class=\"\">Guatemala<\/option>\n<option value=\"tfa_2765\" id=\"tfa_2765\" class=\"\">Guinea<\/option>\n<option value=\"tfa_2766\" id=\"tfa_2766\" class=\"\">Guinea-Bissau<\/option>\n<option value=\"tfa_2767\" id=\"tfa_2767\" class=\"\">Guyana<\/option>\n<option value=\"tfa_2768\" id=\"tfa_2768\" class=\"\">Haiti<\/option>\n<option value=\"tfa_2769\" id=\"tfa_2769\" class=\"\">Heard Island and McDonald Islands<\/option>\n<option value=\"tfa_2770\" id=\"tfa_2770\" class=\"\">Honduras<\/option>\n<option value=\"tfa_2771\" id=\"tfa_2771\" class=\"\">Hong Kong SAR<\/option>\n<option value=\"tfa_2772\" id=\"tfa_2772\" class=\"\">Hungary<\/option>\n<option value=\"tfa_2773\" id=\"tfa_2773\" class=\"\">Iceland<\/option>\n<option value=\"tfa_2774\" id=\"tfa_2774\" class=\"\">India<\/option>\n<option value=\"tfa_2775\" id=\"tfa_2775\" class=\"\">Indonesia<\/option>\n<option value=\"tfa_2776\" id=\"tfa_2776\" class=\"\">Iran<\/option>\n<option value=\"tfa_2777\" id=\"tfa_2777\" class=\"\">Iraq<\/option>\n<option value=\"tfa_2778\" id=\"tfa_2778\" class=\"\">Ireland<\/option>\n<option value=\"tfa_2779\" id=\"tfa_2779\" class=\"\">Israel<\/option>\n<option value=\"tfa_2780\" id=\"tfa_2780\" class=\"\">Italy<\/option>\n<option value=\"tfa_2781\" id=\"tfa_2781\" class=\"\">Jamaica<\/option>\n<option value=\"tfa_2782\" id=\"tfa_2782\" class=\"\">Japan<\/option>\n<option value=\"tfa_2783\" id=\"tfa_2783\" class=\"\">Jordan<\/option>\n<option value=\"tfa_2784\" id=\"tfa_2784\" class=\"\">Kazakhstan<\/option>\n<option value=\"tfa_2785\" id=\"tfa_2785\" class=\"\">Kenya<\/option>\n<option value=\"tfa_2786\" id=\"tfa_2786\" class=\"\">Kiribati<\/option>\n<option value=\"tfa_2787\" id=\"tfa_2787\" class=\"\">Korea<\/option>\n<option value=\"tfa_2788\" id=\"tfa_2788\" class=\"\">Kuwait<\/option>\n<option value=\"tfa_2789\" id=\"tfa_2789\" class=\"\">Kyrgyzstan<\/option>\n<option value=\"tfa_2790\" id=\"tfa_2790\" class=\"\">Laos<\/option>\n<option value=\"tfa_2791\" id=\"tfa_2791\" class=\"\">Latvia<\/option>\n<option value=\"tfa_2792\" id=\"tfa_2792\" class=\"\">Lebanon<\/option>\n<option value=\"tfa_2793\" id=\"tfa_2793\" class=\"\">Lesotho<\/option>\n<option value=\"tfa_2794\" id=\"tfa_2794\" class=\"\">Liberia<\/option>\n<option value=\"tfa_2795\" id=\"tfa_2795\" class=\"\">Libya<\/option>\n<option value=\"tfa_2796\" id=\"tfa_2796\" class=\"\">Liechtenstein<\/option>\n<option value=\"tfa_2797\" id=\"tfa_2797\" class=\"\">Lithuania<\/option>\n<option value=\"tfa_2798\" id=\"tfa_2798\" class=\"\">Luxembourg<\/option>\n<option value=\"tfa_2799\" id=\"tfa_2799\" class=\"\">Macao SAR<\/option>\n<option value=\"tfa_2800\" id=\"tfa_2800\" class=\"\">Macedonia, Former Yugoslav Republic of<\/option>\n<option value=\"tfa_2801\" id=\"tfa_2801\" class=\"\">Madagascar<\/option>\n<option value=\"tfa_2802\" id=\"tfa_2802\" class=\"\">Malawi<\/option>\n<option value=\"tfa_2803\" id=\"tfa_2803\" class=\"\">Malaysia<\/option>\n<option value=\"tfa_2804\" id=\"tfa_2804\" class=\"\">Maldives<\/option>\n<option value=\"tfa_2805\" id=\"tfa_2805\" class=\"\">Mali<\/option>\n<option value=\"tfa_2806\" id=\"tfa_2806\" class=\"\">Malta<\/option>\n<option value=\"tfa_2807\" id=\"tfa_2807\" class=\"\">Marshall Islands<\/option>\n<option value=\"tfa_2808\" id=\"tfa_2808\" class=\"\">Martinique<\/option>\n<option value=\"tfa_2809\" id=\"tfa_2809\" class=\"\">Mauritania<\/option>\n<option value=\"tfa_2810\" id=\"tfa_2810\" class=\"\">Mauritius<\/option>\n<option value=\"tfa_2811\" id=\"tfa_2811\" class=\"\">Mayotte<\/option>\n<option value=\"tfa_2812\" id=\"tfa_2812\" class=\"\">Mexico<\/option>\n<option value=\"tfa_2813\" id=\"tfa_2813\" class=\"\">Micronesia<\/option>\n<option value=\"tfa_2814\" id=\"tfa_2814\" class=\"\">Moldova<\/option>\n<option value=\"tfa_2815\" id=\"tfa_2815\" class=\"\">Monaco<\/option>\n<option value=\"tfa_2816\" id=\"tfa_2816\" class=\"\">Mongolia<\/option>\n<option value=\"tfa_2817\" id=\"tfa_2817\" class=\"\">Montserrat<\/option>\n<option value=\"tfa_2818\" id=\"tfa_2818\" class=\"\">Morocco<\/option>\n<option value=\"tfa_2819\" id=\"tfa_2819\" class=\"\">Mozambique<\/option>\n<option value=\"tfa_2820\" id=\"tfa_2820\" class=\"\">Myanmar<\/option>\n<option value=\"tfa_2821\" id=\"tfa_2821\" class=\"\">Namibia<\/option>\n<option value=\"tfa_2822\" id=\"tfa_2822\" class=\"\">Nauru<\/option>\n<option value=\"tfa_2823\" id=\"tfa_2823\" class=\"\">Nepal<\/option>\n<option value=\"tfa_2824\" id=\"tfa_2824\" class=\"\">Netherlands<\/option>\n<option value=\"tfa_2825\" id=\"tfa_2825\" class=\"\">Netherlands Antilles<\/option>\n<option value=\"tfa_2826\" id=\"tfa_2826\" class=\"\">New Caledonia<\/option>\n<option value=\"tfa_2827\" id=\"tfa_2827\" class=\"\">New Zealand<\/option>\n<option value=\"tfa_2828\" id=\"tfa_2828\" class=\"\">Nicaragua<\/option>\n<option value=\"tfa_2829\" id=\"tfa_2829\" class=\"\">Niger<\/option>\n<option value=\"tfa_2830\" id=\"tfa_2830\" class=\"\">Nigeria<\/option>\n<option value=\"tfa_2831\" id=\"tfa_2831\" class=\"\">Niue<\/option>\n<option value=\"tfa_2832\" id=\"tfa_2832\" class=\"\">Norfolk Island<\/option>\n<option value=\"tfa_2833\" id=\"tfa_2833\" class=\"\">North Korea<\/option>\n<option value=\"tfa_2834\" id=\"tfa_2834\" class=\"\">Northern Mariana Islands<\/option>\n<option value=\"tfa_2835\" id=\"tfa_2835\" class=\"\">Norway<\/option>\n<option value=\"tfa_2836\" id=\"tfa_2836\" class=\"\">Oman<\/option>\n<option value=\"tfa_2837\" id=\"tfa_2837\" class=\"\">Pakistan<\/option>\n<option value=\"tfa_2838\" id=\"tfa_2838\" class=\"\">Palau<\/option>\n<option value=\"tfa_2839\" id=\"tfa_2839\" class=\"\">Panama<\/option>\n<option value=\"tfa_2840\" id=\"tfa_2840\" class=\"\">Papua New Guinea<\/option>\n<option value=\"tfa_2841\" id=\"tfa_2841\" class=\"\">Paraguay<\/option>\n<option value=\"tfa_2842\" id=\"tfa_2842\" class=\"\">Peru<\/option>\n<option value=\"tfa_2843\" id=\"tfa_2843\" class=\"\">Philippines<\/option>\n<option value=\"tfa_2844\" id=\"tfa_2844\" class=\"\">Pitcairn Islands<\/option>\n<option value=\"tfa_2845\" id=\"tfa_2845\" class=\"\">Poland<\/option>\n<option value=\"tfa_2846\" id=\"tfa_2846\" class=\"\">Portugal<\/option>\n<option value=\"tfa_2847\" id=\"tfa_2847\" class=\"\">Puerto Rico<\/option>\n<option value=\"tfa_2848\" id=\"tfa_2848\" class=\"\">Qatar<\/option>\n<option value=\"tfa_2849\" id=\"tfa_2849\" class=\"\">Reunion<\/option>\n<option value=\"tfa_2850\" id=\"tfa_2850\" class=\"\">Romania<\/option>\n<option value=\"tfa_2851\" id=\"tfa_2851\" class=\"\">Russia<\/option>\n<option value=\"tfa_2852\" id=\"tfa_2852\" class=\"\">Rwanda<\/option>\n<option value=\"tfa_2853\" id=\"tfa_2853\" class=\"\">Samoa<\/option>\n<option value=\"tfa_2854\" id=\"tfa_2854\" class=\"\">San Marino<\/option>\n<option value=\"tfa_2855\" id=\"tfa_2855\" class=\"\">S\u00e3o Tom\u00e9 and Pr\u00ecncipe<\/option>\n<option value=\"tfa_2856\" id=\"tfa_2856\" class=\"\">Saudi Arabia<\/option>\n<option value=\"tfa_2857\" id=\"tfa_2857\" class=\"\">Senegal<\/option>\n<option value=\"tfa_2858\" id=\"tfa_2858\" class=\"\">Serbia and Montenegro<\/option>\n<option value=\"tfa_2859\" id=\"tfa_2859\" class=\"\">Seychelles<\/option>\n<option value=\"tfa_2860\" id=\"tfa_2860\" class=\"\">Sierra Leone<\/option>\n<option value=\"tfa_2861\" id=\"tfa_2861\" class=\"\">Singapore<\/option>\n<option value=\"tfa_2862\" id=\"tfa_2862\" class=\"\">Slovakia<\/option>\n<option value=\"tfa_2863\" id=\"tfa_2863\" class=\"\">Slovenia<\/option>\n<option value=\"tfa_2864\" id=\"tfa_2864\" class=\"\">Solomon Islands<\/option>\n<option value=\"tfa_2865\" id=\"tfa_2865\" class=\"\">Somalia<\/option>\n<option value=\"tfa_2866\" id=\"tfa_2866\" class=\"\">South Africa<\/option>\n<option value=\"tfa_2867\" id=\"tfa_2867\" class=\"\">South Georgia and the South Sandwich Islands<\/option>\n<option value=\"tfa_2868\" id=\"tfa_2868\" class=\"\">Spain<\/option>\n<option value=\"tfa_2869\" id=\"tfa_2869\" class=\"\">Sri Lanka<\/option>\n<option value=\"tfa_2870\" id=\"tfa_2870\" class=\"\">St. Helena<\/option>\n<option value=\"tfa_2871\" id=\"tfa_2871\" class=\"\">St. Kitts and Nevis<\/option>\n<option value=\"tfa_2872\" id=\"tfa_2872\" class=\"\">St. Lucia<\/option>\n<option value=\"tfa_2873\" id=\"tfa_2873\" class=\"\">St. Pierre and Miquelon<\/option>\n<option value=\"tfa_2874\" id=\"tfa_2874\" class=\"\">St. Vincent and the Grenadines<\/option>\n<option value=\"tfa_2875\" id=\"tfa_2875\" class=\"\">Sudan<\/option>\n<option value=\"tfa_2876\" id=\"tfa_2876\" class=\"\">Suriname<\/option>\n<option value=\"tfa_2877\" id=\"tfa_2877\" class=\"\">Svalbard and Jan Mayen<\/option>\n<option value=\"tfa_2878\" id=\"tfa_2878\" class=\"\">Swaziland<\/option>\n<option value=\"tfa_2879\" id=\"tfa_2879\" class=\"\">Sweden<\/option>\n<option value=\"tfa_2880\" id=\"tfa_2880\" class=\"\">Switzerland<\/option>\n<option value=\"tfa_2881\" id=\"tfa_2881\" class=\"\">Syria<\/option>\n<option value=\"tfa_2882\" id=\"tfa_2882\" class=\"\">Taiwan<\/option>\n<option value=\"tfa_2883\" id=\"tfa_2883\" class=\"\">Tajikistan<\/option>\n<option value=\"tfa_2884\" id=\"tfa_2884\" class=\"\">Tanzania<\/option>\n<option value=\"tfa_2885\" id=\"tfa_2885\" class=\"\">Thailand<\/option>\n<option value=\"tfa_2886\" id=\"tfa_2886\" class=\"\">Togo<\/option>\n<option value=\"tfa_2887\" id=\"tfa_2887\" class=\"\">Tokelau<\/option>\n<option value=\"tfa_2888\" id=\"tfa_2888\" class=\"\">Tonga<\/option>\n<option value=\"tfa_2889\" id=\"tfa_2889\" class=\"\">Trinidad and Tobago<\/option>\n<option value=\"tfa_2890\" id=\"tfa_2890\" class=\"\">Tunisia<\/option>\n<option value=\"tfa_2891\" id=\"tfa_2891\" class=\"\">Turkey<\/option>\n<option value=\"tfa_2892\" id=\"tfa_2892\" class=\"\">Turkmenistan<\/option>\n<option value=\"tfa_2893\" id=\"tfa_2893\" class=\"\">Turks and Caicos Islands<\/option>\n<option value=\"tfa_2894\" id=\"tfa_2894\" class=\"\">Tuvalu<\/option>\n<option value=\"tfa_2895\" id=\"tfa_2895\" class=\"\">Uganda<\/option>\n<option value=\"tfa_2896\" id=\"tfa_2896\" class=\"\">Ukraine<\/option>\n<option value=\"tfa_2897\" id=\"tfa_2897\" class=\"\">United Arab Emirates<\/option>\n<option value=\"tfa_2898\" id=\"tfa_2898\" class=\"\">United Kingdom<\/option>\n<option value=\"tfa_2899\" id=\"tfa_2899\" data-conditionals=\"#tfa_2617\" class=\"\" selected data-default-value=\"true\">United States<\/option>\n<option value=\"tfa_2900\" id=\"tfa_2900\" class=\"\">United States Minor Outlying Islands<\/option>\n<option value=\"tfa_2901\" id=\"tfa_2901\" class=\"\">Uruguay<\/option>\n<option value=\"tfa_2902\" id=\"tfa_2902\" class=\"\">Uzbekistan<\/option>\n<option value=\"tfa_2903\" id=\"tfa_2903\" class=\"\">Vanuatu<\/option>\n<option value=\"tfa_2904\" id=\"tfa_2904\" class=\"\">Vatican City<\/option>\n<option value=\"tfa_2905\" id=\"tfa_2905\" class=\"\">Venezuela<\/option>\n<option value=\"tfa_2906\" id=\"tfa_2906\" class=\"\">Viet Nam<\/option>\n<option value=\"tfa_2907\" id=\"tfa_2907\" class=\"\">Virgin Islands ( British )<\/option>\n<option value=\"tfa_2908\" id=\"tfa_2908\" class=\"\">Virgin Islands<\/option>\n<option value=\"tfa_2909\" id=\"tfa_2909\" class=\"\">Wallis and Futuna<\/option>\n<option value=\"tfa_2910\" id=\"tfa_2910\" class=\"\">Yemen<\/option>\n<option value=\"tfa_2911\" id=\"tfa_2911\" class=\"\">Zambia<\/option>\n<option value=\"tfa_2912\" id=\"tfa_2912\" class=\"\">Zimbabwe<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2617-D\">\n<label id=\"tfa_2617-L\" class=\"label preField reqMark\" for=\"tfa_2617\">State<\/label><br><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_2617\" name=\"tfa_2617\" data-condition=\"`#tfa_2899`\" title=\"State\" class=\"required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_2618\" id=\"tfa_2618\" class=\"\">Alabama<\/option>\n<option value=\"tfa_2619\" id=\"tfa_2619\" class=\"\">Alaska<\/option>\n<option value=\"tfa_2620\" id=\"tfa_2620\" class=\"\">Arizona<\/option>\n<option value=\"tfa_2621\" id=\"tfa_2621\" class=\"\">Arkansas<\/option>\n<option value=\"tfa_2622\" id=\"tfa_2622\" class=\"\">California<\/option>\n<option value=\"tfa_2623\" id=\"tfa_2623\" class=\"\">Colorado<\/option>\n<option value=\"tfa_2624\" id=\"tfa_2624\" class=\"\">Connecticut<\/option>\n<option value=\"tfa_2625\" id=\"tfa_2625\" class=\"\">Delaware<\/option>\n<option value=\"tfa_2626\" id=\"tfa_2626\" class=\"\">District Of Columbia<\/option>\n<option value=\"tfa_2627\" id=\"tfa_2627\" class=\"\">Florida<\/option>\n<option value=\"tfa_2628\" id=\"tfa_2628\" class=\"\">Georgia<\/option>\n<option value=\"tfa_2629\" id=\"tfa_2629\" class=\"\">Hawaii<\/option>\n<option value=\"tfa_2630\" id=\"tfa_2630\" class=\"\">Idaho<\/option>\n<option value=\"tfa_2631\" id=\"tfa_2631\" class=\"\">Illinois<\/option>\n<option value=\"tfa_2632\" id=\"tfa_2632\" class=\"\">Indiana<\/option>\n<option value=\"tfa_2633\" id=\"tfa_2633\" class=\"\">Iowa<\/option>\n<option value=\"tfa_2634\" id=\"tfa_2634\" class=\"\">Kansas<\/option>\n<option value=\"tfa_2635\" id=\"tfa_2635\" class=\"\">Kentucky<\/option>\n<option value=\"tfa_2636\" id=\"tfa_2636\" class=\"\">Louisiana<\/option>\n<option value=\"tfa_2637\" id=\"tfa_2637\" class=\"\">Maine<\/option>\n<option value=\"tfa_2638\" id=\"tfa_2638\" class=\"\">Maryland<\/option>\n<option value=\"tfa_2639\" id=\"tfa_2639\" class=\"\">Massachusetts<\/option>\n<option value=\"tfa_2640\" id=\"tfa_2640\" class=\"\">Michigan<\/option>\n<option value=\"tfa_2641\" id=\"tfa_2641\" class=\"\">Minnesota<\/option>\n<option value=\"tfa_2642\" id=\"tfa_2642\" class=\"\">Mississippi<\/option>\n<option value=\"tfa_2643\" id=\"tfa_2643\" class=\"\">Missouri<\/option>\n<option value=\"tfa_2644\" id=\"tfa_2644\" class=\"\">Montana<\/option>\n<option value=\"tfa_2645\" id=\"tfa_2645\" class=\"\">Nebraska<\/option>\n<option value=\"tfa_2646\" id=\"tfa_2646\" class=\"\">Nevada<\/option>\n<option value=\"tfa_2647\" id=\"tfa_2647\" class=\"\">New Hampshire<\/option>\n<option value=\"tfa_2648\" id=\"tfa_2648\" class=\"\">New Jersey<\/option>\n<option value=\"tfa_2649\" id=\"tfa_2649\" class=\"\">New Mexico<\/option>\n<option value=\"tfa_2650\" id=\"tfa_2650\" class=\"\">New York<\/option>\n<option value=\"tfa_2651\" id=\"tfa_2651\" class=\"\">North Carolina<\/option>\n<option value=\"tfa_2652\" id=\"tfa_2652\" class=\"\">North Dakota<\/option>\n<option value=\"tfa_2653\" id=\"tfa_2653\" class=\"\">Ohio<\/option>\n<option value=\"tfa_2654\" id=\"tfa_2654\" class=\"\">Oklahoma<\/option>\n<option value=\"tfa_2655\" id=\"tfa_2655\" class=\"\">Oregon<\/option>\n<option value=\"tfa_2656\" id=\"tfa_2656\" class=\"\">Pennsylvania<\/option>\n<option value=\"tfa_2657\" id=\"tfa_2657\" class=\"\">Rhode Island<\/option>\n<option value=\"tfa_2658\" id=\"tfa_2658\" class=\"\">South Carolina<\/option>\n<option value=\"tfa_2659\" id=\"tfa_2659\" class=\"\">South Dakota<\/option>\n<option value=\"tfa_2660\" id=\"tfa_2660\" class=\"\">Tennessee<\/option>\n<option value=\"tfa_2661\" id=\"tfa_2661\" class=\"\">Texas<\/option>\n<option value=\"tfa_2662\" id=\"tfa_2662\" class=\"\">Utah<\/option>\n<option value=\"tfa_2663\" id=\"tfa_2663\" class=\"\">Vermont<\/option>\n<option value=\"tfa_2664\" id=\"tfa_2664\" class=\"\">Virginia<\/option>\n<option value=\"tfa_2665\" id=\"tfa_2665\" class=\"\">Washington<\/option>\n<option value=\"tfa_2666\" id=\"tfa_2666\" class=\"\">West Virginia<\/option>\n<option value=\"tfa_2667\" id=\"tfa_2667\" class=\"\">Wisconsin<\/option>\n<option value=\"tfa_2668\" id=\"tfa_2668\" class=\"\">Wyoming<\/option>\n<option value=\"tfa_2669\" id=\"tfa_2669\" class=\"\">Puerto Rico<\/option>\n<option value=\"tfa_2670\" id=\"tfa_2670\" class=\"\">Virgin Island<\/option>\n<option value=\"tfa_2671\" id=\"tfa_2671\" class=\"\">Northern Mariana Islands<\/option>\n<option value=\"tfa_2672\" id=\"tfa_2672\" class=\"\">Guam<\/option>\n<option value=\"tfa_2673\" id=\"tfa_2673\" class=\"\">American Samoa<\/option>\n<option value=\"tfa_2674\" id=\"tfa_2674\" class=\"\">Palau<\/option><\/select><\/div>\n<\/div>\n<\/div>\n<div id=\"tfa_3517\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_3506-D\">\n<label id=\"tfa_3506-L\" class=\"label preField reqMark\" for=\"tfa_3506\">How did you hear about ScoliCare?<\/label><br><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_3506\" name=\"tfa_3506\" title=\"How did you hear about ScoliCare?\" class=\"required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3512\" id=\"tfa_3512\" class=\"\">Google or other search engine<\/option>\n<option value=\"tfa_3513\" id=\"tfa_3513\" class=\"\">Social media<\/option>\n<option value=\"tfa_3514\" id=\"tfa_3514\" class=\"\">Word of mouth<\/option>\n<option value=\"tfa_3515\" id=\"tfa_3515\" class=\"\">Industry body or association<\/option>\n<option value=\"tfa_3516\" id=\"tfa_3516\" data-conditionals=\"#tfa_3510\" class=\"\">Other<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3510-D\">\n<label id=\"tfa_3510-L\" class=\"label preField reqMark\" for=\"tfa_3510\">Other<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_3510\" name=\"tfa_3510\" value=\"\" data-condition=\"`#tfa_3516`\" title=\"Other\" class=\"required\"><\/div>\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_13800-D\" role=\"group\" aria-labelledby=\"tfa_13800-L\" data-tfa-labelledby=\"-L tfa_13800-L\"><div class=\"inputWrapper\"><span id=\"tfa_13800\" class=\"choices vertical \"><span class=\"oneChoice\"><input type=\"checkbox\" value=\"tfa_13801\" class=\"\" id=\"tfa_13801\" name=\"tfa_13801\" aria-labelledby=\"tfa_13801-L\" data-tfa-labelledby=\"tfa_13800-L tfa_13801-L\" data-tfa-parent-id=\"tfa_13800\"><label class=\"label postField\" id=\"tfa_13801-L\" for=\"tfa_13801\"><span class=\"input-checkbox-faux\"><\/span><div class=\"inputWrapper\" style=\"font-family: Montserrat, sans-serif, sans-serif;\"><div class=\"inputContainer\" data-contentid=\"tfa_13865\" data-contenttype=\"checkbox\"><span id=\"tfa_13865\" class=\"choices vertical\"><span class=\"oneChoice\"><div class=\"label postField\" id=\"tfa_13866-L\"><div class=\"editableText\" id=\"tfa_13866-LTXT\" data-contentid=\"tfa_13865\" data-contenttype=\"\"><span style=\"color: rgb(0, 0, 0); font-family: -webkit-standard; font-size: medium; caret-color: rgb(0, 0, 0);\">I agree to receive SMS messages from ScoliCare regarding my enquiry, consultation scheduling, appointments, services, treatment updates, and other relevant communications.<\/span><span style=\"font-size: 14.4px; caret-color: rgb(0, 0, 0);\">&nbsp;Message and data rates may apply. Message frequency varies. Reply STOP to opt out. View our<span>&nbsp;<\/span><a href=\"https:\/\/scolicare.com\/patients-scolicare-privacy-policy\/\" target=\"_blank\" style=\"box-sizing: inherit; -webkit-font-smoothing: antialiased; background-color: transparent; color: rgb(0, 179, 215); text-decoration: none; transition: color 0.1s linear; cursor: pointer; font-weight: 400; vertical-align: top;\">Privacy Policy<\/a><span>&nbsp;<\/span>and<span>&nbsp;<\/span><a href=\"https:\/\/scolicare.com\/patients-terms-conditions\/\" target=\"_blank\" style=\"box-sizing: inherit; -webkit-font-smoothing: antialiased; background-color: transparent; color: rgb(0, 179, 215); text-decoration: none; transition: color 0.1s linear; cursor: pointer; font-weight: 400; vertical-align: top;\">Terms &amp; Conditions<\/a>.<\/span><\/div><\/div><\/span><\/span><\/div><\/div><\/label><\/span><\/span><\/div><\/div>\n<\/fieldset>\n<fieldset id=\"tfa_2253\" class=\"section\">\n<legend id=\"tfa_2253-L\"><b>Patient Details<\/b><\/legend>\n<div id=\"tfa_2254\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_2255-D\">\n<label id=\"tfa_2255-L\" class=\"label preField reqMark\" for=\"tfa_2255\">Patient First Name:<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_2255\" name=\"tfa_2255\" value=\"\" title=\"Patient First Name:\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2256-D\">\n<label id=\"tfa_2256-L\" class=\"label preField reqMark\" for=\"tfa_2256\">Patient Last Name:<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_2256\" name=\"tfa_2256\" value=\"\" title=\"Patient Last Name:\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2257-D\">\n<label id=\"tfa_2257-L\" class=\"label preField reqMark\" for=\"tfa_2257\">Email<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_2257\" name=\"tfa_2257\" value=\"\" title=\"Email\" class=\"validate-email required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2258-D\">\n<label id=\"tfa_2258-L\" class=\"label preField \" for=\"tfa_2258\">Phone<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_2258\" name=\"tfa_2258\" value=\"\" autoformat=\"###-###-####\" title=\"Phone\" class=\"\"><\/div>\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2408-D\">\n<label id=\"tfa_2408-L\" class=\"label preField reqMark\" for=\"tfa_2408\">Birthdate<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_2408\" name=\"tfa_2408\" value=\"\" autocomplete=\"off\" title=\"Birthdate\" class=\"validate-datecal required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2259-D\">\n<label id=\"tfa_2259-L\" class=\"label preField \" for=\"tfa_2259\">Patient Address<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_2259\" name=\"tfa_2259\" value=\"\" title=\"Patient Address\" class=\"\"><\/div>\n<\/div>\n<div id=\"tfa_2260\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_2261-D\">\n<label id=\"tfa_2261-L\" class=\"label preField \" for=\"tfa_2261\">City<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_2261\" name=\"tfa_2261\" value=\"\" title=\"City\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2320-D\">\n<label id=\"tfa_2320-L\" class=\"label preField \" for=\"tfa_2320\">Postal Code<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_2320\" name=\"tfa_2320\" value=\"\" title=\"Postal Code\" class=\"validate-integer\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3152-D\">\n<label id=\"tfa_3152-L\" class=\"label preField reqMark\" for=\"tfa_3152\">Country<\/label><br><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_3152\" name=\"tfa_3152\" title=\"Country\" class=\"required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3153\" id=\"tfa_3153\" class=\"\">Afghanistan<\/option>\n<option value=\"tfa_3154\" id=\"tfa_3154\" class=\"\">Albania<\/option>\n<option value=\"tfa_3155\" id=\"tfa_3155\" class=\"\">Algeria<\/option>\n<option value=\"tfa_3156\" id=\"tfa_3156\" class=\"\">American Samoa<\/option>\n<option value=\"tfa_3157\" id=\"tfa_3157\" class=\"\">Andorra<\/option>\n<option value=\"tfa_3158\" id=\"tfa_3158\" class=\"\">Angola<\/option>\n<option value=\"tfa_3159\" id=\"tfa_3159\" class=\"\">Anguilla<\/option>\n<option value=\"tfa_3160\" id=\"tfa_3160\" class=\"\">Antarctica<\/option>\n<option value=\"tfa_3161\" id=\"tfa_3161\" class=\"\">Antigua and Barbuda<\/option>\n<option value=\"tfa_3162\" id=\"tfa_3162\" class=\"\">Argentina<\/option>\n<option value=\"tfa_3163\" id=\"tfa_3163\" class=\"\">Armenia<\/option>\n<option value=\"tfa_3164\" id=\"tfa_3164\" class=\"\">Aruba<\/option>\n<option value=\"tfa_3165\" id=\"tfa_3165\" class=\"\">Australia<\/option>\n<option value=\"tfa_3166\" id=\"tfa_3166\" class=\"\">Austria<\/option>\n<option value=\"tfa_3167\" id=\"tfa_3167\" class=\"\">Azerbaijan<\/option>\n<option value=\"tfa_3168\" id=\"tfa_3168\" class=\"\">Bahamas<\/option>\n<option value=\"tfa_3169\" id=\"tfa_3169\" class=\"\">Bahrain<\/option>\n<option value=\"tfa_3170\" id=\"tfa_3170\" class=\"\">Bangladesh<\/option>\n<option value=\"tfa_3171\" id=\"tfa_3171\" class=\"\">Barbados<\/option>\n<option value=\"tfa_3172\" id=\"tfa_3172\" class=\"\">Belarus<\/option>\n<option value=\"tfa_3173\" id=\"tfa_3173\" class=\"\">Belgium<\/option>\n<option value=\"tfa_3174\" id=\"tfa_3174\" class=\"\">Belize<\/option>\n<option value=\"tfa_3175\" id=\"tfa_3175\" class=\"\">Benin<\/option>\n<option value=\"tfa_3176\" id=\"tfa_3176\" class=\"\">Bermuda<\/option>\n<option value=\"tfa_3177\" id=\"tfa_3177\" class=\"\">Bhutan<\/option>\n<option value=\"tfa_3178\" id=\"tfa_3178\" class=\"\">Bolivia<\/option>\n<option value=\"tfa_3179\" id=\"tfa_3179\" class=\"\">Bosnia and Herzegovina<\/option>\n<option value=\"tfa_3180\" id=\"tfa_3180\" class=\"\">Botswana<\/option>\n<option value=\"tfa_3181\" id=\"tfa_3181\" class=\"\">Bouvet Island<\/option>\n<option value=\"tfa_3182\" id=\"tfa_3182\" class=\"\">Brazil<\/option>\n<option value=\"tfa_3183\" id=\"tfa_3183\" class=\"\">British Indian Ocean Territory<\/option>\n<option value=\"tfa_3184\" id=\"tfa_3184\" class=\"\">Brunei<\/option>\n<option value=\"tfa_3185\" id=\"tfa_3185\" class=\"\">Bulgaria<\/option>\n<option value=\"tfa_3186\" id=\"tfa_3186\" class=\"\">Burkina Faso<\/option>\n<option value=\"tfa_3187\" id=\"tfa_3187\" class=\"\">Burundi<\/option>\n<option value=\"tfa_3188\" id=\"tfa_3188\" class=\"\">Cambodia<\/option>\n<option value=\"tfa_3189\" id=\"tfa_3189\" class=\"\">Cameroon<\/option>\n<option value=\"tfa_3190\" id=\"tfa_3190\" class=\"\">Canada<\/option>\n<option value=\"tfa_3191\" id=\"tfa_3191\" class=\"\">Cape Verde<\/option>\n<option value=\"tfa_3192\" id=\"tfa_3192\" class=\"\">Cayman Islands<\/option>\n<option value=\"tfa_3193\" id=\"tfa_3193\" class=\"\">Central African Republic<\/option>\n<option value=\"tfa_3194\" id=\"tfa_3194\" class=\"\">Chad<\/option>\n<option value=\"tfa_3195\" id=\"tfa_3195\" class=\"\">Chile<\/option>\n<option value=\"tfa_3196\" id=\"tfa_3196\" class=\"\">China<\/option>\n<option value=\"tfa_3197\" id=\"tfa_3197\" class=\"\">Christmas Island<\/option>\n<option value=\"tfa_3198\" id=\"tfa_3198\" class=\"\">Cocos ( Keeling ) Islands<\/option>\n<option value=\"tfa_3199\" id=\"tfa_3199\" class=\"\">Colombia<\/option>\n<option value=\"tfa_3200\" id=\"tfa_3200\" class=\"\">Comoros<\/option>\n<option value=\"tfa_3201\" id=\"tfa_3201\" class=\"\">Congo<\/option>\n<option value=\"tfa_3202\" id=\"tfa_3202\" class=\"\">Cook Islands<\/option>\n<option value=\"tfa_3203\" id=\"tfa_3203\" class=\"\">Costa Rica<\/option>\n<option value=\"tfa_3204\" id=\"tfa_3204\" class=\"\">C\u00f4te d ' Ivoire<\/option>\n<option value=\"tfa_3205\" id=\"tfa_3205\" class=\"\">Croatia ( Hrvatska )<\/option>\n<option value=\"tfa_3206\" id=\"tfa_3206\" class=\"\">Cuba<\/option>\n<option value=\"tfa_3207\" id=\"tfa_3207\" class=\"\">Cyprus<\/option>\n<option value=\"tfa_3208\" id=\"tfa_3208\" class=\"\">Czech Republic<\/option>\n<option value=\"tfa_3209\" id=\"tfa_3209\" class=\"\">Congo ( DRC )<\/option>\n<option value=\"tfa_3210\" id=\"tfa_3210\" class=\"\">Denmark<\/option>\n<option value=\"tfa_3211\" id=\"tfa_3211\" class=\"\">Djibouti<\/option>\n<option value=\"tfa_3212\" id=\"tfa_3212\" class=\"\">Dominica<\/option>\n<option value=\"tfa_3213\" id=\"tfa_3213\" class=\"\">Dominican Republic<\/option>\n<option value=\"tfa_3214\" id=\"tfa_3214\" class=\"\">East Timor<\/option>\n<option value=\"tfa_3215\" id=\"tfa_3215\" class=\"\">Ecuador<\/option>\n<option value=\"tfa_3216\" id=\"tfa_3216\" class=\"\">Egypt<\/option>\n<option value=\"tfa_3217\" id=\"tfa_3217\" class=\"\">El Salvador<\/option>\n<option value=\"tfa_3218\" id=\"tfa_3218\" class=\"\">Equatorial Guinea<\/option>\n<option value=\"tfa_3219\" id=\"tfa_3219\" class=\"\">Eritrea<\/option>\n<option value=\"tfa_3220\" id=\"tfa_3220\" class=\"\">Estonia<\/option>\n<option value=\"tfa_3221\" id=\"tfa_3221\" class=\"\">Ethiopia<\/option>\n<option value=\"tfa_3222\" id=\"tfa_3222\" class=\"\">Falkland Islands ( Islas Malvinas )<\/option>\n<option value=\"tfa_3223\" id=\"tfa_3223\" class=\"\">Faroe Islands<\/option>\n<option value=\"tfa_3224\" id=\"tfa_3224\" class=\"\">Fiji Islands<\/option>\n<option value=\"tfa_3225\" id=\"tfa_3225\" class=\"\">Finland<\/option>\n<option value=\"tfa_3226\" id=\"tfa_3226\" class=\"\">France<\/option>\n<option value=\"tfa_3227\" id=\"tfa_3227\" class=\"\">French Guiana<\/option>\n<option value=\"tfa_3228\" id=\"tfa_3228\" class=\"\">French Polynesia<\/option>\n<option value=\"tfa_3229\" id=\"tfa_3229\" class=\"\">French Southern and Antarctic Lands<\/option>\n<option value=\"tfa_3230\" id=\"tfa_3230\" class=\"\">Gabon<\/option>\n<option value=\"tfa_3231\" id=\"tfa_3231\" class=\"\">Gambia<\/option>\n<option value=\"tfa_3232\" id=\"tfa_3232\" class=\"\">Georgia<\/option>\n<option value=\"tfa_3233\" id=\"tfa_3233\" class=\"\">Germany<\/option>\n<option value=\"tfa_3234\" id=\"tfa_3234\" class=\"\">Ghana<\/option>\n<option value=\"tfa_3235\" id=\"tfa_3235\" class=\"\">Gibraltar<\/option>\n<option value=\"tfa_3236\" id=\"tfa_3236\" class=\"\">Greece<\/option>\n<option value=\"tfa_3237\" id=\"tfa_3237\" class=\"\">Greenland<\/option>\n<option value=\"tfa_3238\" id=\"tfa_3238\" class=\"\">Grenada<\/option>\n<option value=\"tfa_3239\" id=\"tfa_3239\" class=\"\">Guadeloupe<\/option>\n<option value=\"tfa_3240\" id=\"tfa_3240\" class=\"\">Guam<\/option>\n<option value=\"tfa_3241\" id=\"tfa_3241\" class=\"\">Guatemala<\/option>\n<option value=\"tfa_3242\" id=\"tfa_3242\" class=\"\">Guinea<\/option>\n<option value=\"tfa_3243\" id=\"tfa_3243\" class=\"\">Guinea-Bissau<\/option>\n<option value=\"tfa_3244\" id=\"tfa_3244\" class=\"\">Guyana<\/option>\n<option value=\"tfa_3245\" id=\"tfa_3245\" class=\"\">Haiti<\/option>\n<option value=\"tfa_3246\" id=\"tfa_3246\" class=\"\">Heard Island and McDonald Islands<\/option>\n<option value=\"tfa_3247\" id=\"tfa_3247\" class=\"\">Honduras<\/option>\n<option value=\"tfa_3248\" id=\"tfa_3248\" class=\"\">Hong Kong SAR<\/option>\n<option value=\"tfa_3249\" id=\"tfa_3249\" class=\"\">Hungary<\/option>\n<option value=\"tfa_3250\" id=\"tfa_3250\" class=\"\">Iceland<\/option>\n<option value=\"tfa_3251\" id=\"tfa_3251\" class=\"\">India<\/option>\n<option value=\"tfa_3252\" id=\"tfa_3252\" class=\"\">Indonesia<\/option>\n<option value=\"tfa_3253\" id=\"tfa_3253\" class=\"\">Iran<\/option>\n<option value=\"tfa_3254\" id=\"tfa_3254\" class=\"\">Iraq<\/option>\n<option value=\"tfa_3255\" id=\"tfa_3255\" class=\"\">Ireland<\/option>\n<option value=\"tfa_3256\" id=\"tfa_3256\" class=\"\">Israel<\/option>\n<option value=\"tfa_3257\" id=\"tfa_3257\" class=\"\">Italy<\/option>\n<option value=\"tfa_3258\" id=\"tfa_3258\" class=\"\">Jamaica<\/option>\n<option value=\"tfa_3259\" id=\"tfa_3259\" class=\"\">Japan<\/option>\n<option value=\"tfa_3260\" id=\"tfa_3260\" class=\"\">Jordan<\/option>\n<option value=\"tfa_3261\" id=\"tfa_3261\" class=\"\">Kazakhstan<\/option>\n<option value=\"tfa_3262\" id=\"tfa_3262\" class=\"\">Kenya<\/option>\n<option value=\"tfa_3263\" id=\"tfa_3263\" class=\"\">Kiribati<\/option>\n<option value=\"tfa_3264\" id=\"tfa_3264\" class=\"\">Korea<\/option>\n<option value=\"tfa_3265\" id=\"tfa_3265\" class=\"\">Kuwait<\/option>\n<option value=\"tfa_3266\" id=\"tfa_3266\" class=\"\">Kyrgyzstan<\/option>\n<option value=\"tfa_3267\" id=\"tfa_3267\" class=\"\">Laos<\/option>\n<option value=\"tfa_3268\" id=\"tfa_3268\" class=\"\">Latvia<\/option>\n<option value=\"tfa_3269\" id=\"tfa_3269\" class=\"\">Lebanon<\/option>\n<option value=\"tfa_3270\" id=\"tfa_3270\" class=\"\">Lesotho<\/option>\n<option value=\"tfa_3271\" id=\"tfa_3271\" class=\"\">Liberia<\/option>\n<option value=\"tfa_3272\" id=\"tfa_3272\" class=\"\">Libya<\/option>\n<option value=\"tfa_3273\" id=\"tfa_3273\" class=\"\">Liechtenstein<\/option>\n<option value=\"tfa_3274\" id=\"tfa_3274\" class=\"\">Lithuania<\/option>\n<option value=\"tfa_3275\" id=\"tfa_3275\" class=\"\">Luxembourg<\/option>\n<option value=\"tfa_3276\" id=\"tfa_3276\" class=\"\">Macao SAR<\/option>\n<option value=\"tfa_3277\" id=\"tfa_3277\" class=\"\">Macedonia, Former Yugoslav Republic of<\/option>\n<option value=\"tfa_3278\" id=\"tfa_3278\" class=\"\">Madagascar<\/option>\n<option value=\"tfa_3279\" id=\"tfa_3279\" class=\"\">Malawi<\/option>\n<option value=\"tfa_3280\" id=\"tfa_3280\" class=\"\">Malaysia<\/option>\n<option value=\"tfa_3281\" id=\"tfa_3281\" class=\"\">Maldives<\/option>\n<option value=\"tfa_3282\" id=\"tfa_3282\" class=\"\">Mali<\/option>\n<option value=\"tfa_3283\" id=\"tfa_3283\" class=\"\">Malta<\/option>\n<option value=\"tfa_3284\" id=\"tfa_3284\" class=\"\">Marshall Islands<\/option>\n<option value=\"tfa_3285\" id=\"tfa_3285\" class=\"\">Martinique<\/option>\n<option value=\"tfa_3286\" id=\"tfa_3286\" class=\"\">Mauritania<\/option>\n<option value=\"tfa_3287\" id=\"tfa_3287\" class=\"\">Mauritius<\/option>\n<option value=\"tfa_3288\" id=\"tfa_3288\" class=\"\">Mayotte<\/option>\n<option value=\"tfa_3289\" id=\"tfa_3289\" class=\"\">Mexico<\/option>\n<option value=\"tfa_3290\" id=\"tfa_3290\" class=\"\">Micronesia<\/option>\n<option value=\"tfa_3291\" id=\"tfa_3291\" class=\"\">Moldova<\/option>\n<option value=\"tfa_3292\" id=\"tfa_3292\" class=\"\">Monaco<\/option>\n<option value=\"tfa_3293\" id=\"tfa_3293\" class=\"\">Mongolia<\/option>\n<option value=\"tfa_3294\" id=\"tfa_3294\" class=\"\">Montserrat<\/option>\n<option value=\"tfa_3295\" id=\"tfa_3295\" class=\"\">Morocco<\/option>\n<option value=\"tfa_3296\" id=\"tfa_3296\" class=\"\">Mozambique<\/option>\n<option value=\"tfa_3297\" id=\"tfa_3297\" class=\"\">Myanmar<\/option>\n<option value=\"tfa_3298\" id=\"tfa_3298\" class=\"\">Namibia<\/option>\n<option value=\"tfa_3299\" id=\"tfa_3299\" class=\"\">Nauru<\/option>\n<option value=\"tfa_3300\" id=\"tfa_3300\" class=\"\">Nepal<\/option>\n<option value=\"tfa_3301\" id=\"tfa_3301\" class=\"\">Netherlands<\/option>\n<option value=\"tfa_3302\" id=\"tfa_3302\" class=\"\">Netherlands Antilles<\/option>\n<option value=\"tfa_3303\" id=\"tfa_3303\" class=\"\">New Caledonia<\/option>\n<option value=\"tfa_3304\" id=\"tfa_3304\" class=\"\">New Zealand<\/option>\n<option value=\"tfa_3305\" id=\"tfa_3305\" class=\"\">Nicaragua<\/option>\n<option value=\"tfa_3306\" id=\"tfa_3306\" class=\"\">Niger<\/option>\n<option value=\"tfa_3307\" id=\"tfa_3307\" class=\"\">Nigeria<\/option>\n<option value=\"tfa_3308\" id=\"tfa_3308\" class=\"\">Niue<\/option>\n<option value=\"tfa_3309\" id=\"tfa_3309\" class=\"\">Norfolk Island<\/option>\n<option value=\"tfa_3310\" id=\"tfa_3310\" class=\"\">North Korea<\/option>\n<option value=\"tfa_3311\" id=\"tfa_3311\" class=\"\">Northern Mariana Islands<\/option>\n<option value=\"tfa_3312\" id=\"tfa_3312\" class=\"\">Norway<\/option>\n<option value=\"tfa_3313\" id=\"tfa_3313\" class=\"\">Oman<\/option>\n<option value=\"tfa_3314\" id=\"tfa_3314\" class=\"\">Pakistan<\/option>\n<option value=\"tfa_3315\" id=\"tfa_3315\" class=\"\">Palau<\/option>\n<option value=\"tfa_3316\" id=\"tfa_3316\" class=\"\">Panama<\/option>\n<option value=\"tfa_3317\" id=\"tfa_3317\" class=\"\">Papua New Guinea<\/option>\n<option value=\"tfa_3318\" id=\"tfa_3318\" class=\"\">Paraguay<\/option>\n<option value=\"tfa_3319\" id=\"tfa_3319\" class=\"\">Peru<\/option>\n<option value=\"tfa_3320\" id=\"tfa_3320\" class=\"\">Philippines<\/option>\n<option value=\"tfa_3321\" id=\"tfa_3321\" class=\"\">Pitcairn Islands<\/option>\n<option value=\"tfa_3322\" id=\"tfa_3322\" class=\"\">Poland<\/option>\n<option value=\"tfa_3323\" id=\"tfa_3323\" class=\"\">Portugal<\/option>\n<option value=\"tfa_3324\" id=\"tfa_3324\" class=\"\">Puerto Rico<\/option>\n<option value=\"tfa_3325\" id=\"tfa_3325\" class=\"\">Qatar<\/option>\n<option value=\"tfa_3326\" id=\"tfa_3326\" class=\"\">Reunion<\/option>\n<option value=\"tfa_3327\" id=\"tfa_3327\" class=\"\">Romania<\/option>\n<option value=\"tfa_3328\" id=\"tfa_3328\" class=\"\">Russia<\/option>\n<option value=\"tfa_3329\" id=\"tfa_3329\" class=\"\">Rwanda<\/option>\n<option value=\"tfa_3330\" id=\"tfa_3330\" class=\"\">Samoa<\/option>\n<option value=\"tfa_3331\" id=\"tfa_3331\" class=\"\">San Marino<\/option>\n<option value=\"tfa_3332\" id=\"tfa_3332\" class=\"\">S\u00e3o Tom\u00e9 and Pr\u00ecncipe<\/option>\n<option value=\"tfa_3333\" id=\"tfa_3333\" class=\"\">Saudi Arabia<\/option>\n<option value=\"tfa_3334\" id=\"tfa_3334\" class=\"\">Senegal<\/option>\n<option value=\"tfa_3335\" id=\"tfa_3335\" class=\"\">Serbia and Montenegro<\/option>\n<option value=\"tfa_3336\" id=\"tfa_3336\" class=\"\">Seychelles<\/option>\n<option value=\"tfa_3337\" id=\"tfa_3337\" class=\"\">Sierra Leone<\/option>\n<option value=\"tfa_3338\" id=\"tfa_3338\" class=\"\">Singapore<\/option>\n<option value=\"tfa_3339\" id=\"tfa_3339\" class=\"\">Slovakia<\/option>\n<option value=\"tfa_3340\" id=\"tfa_3340\" class=\"\">Slovenia<\/option>\n<option value=\"tfa_3341\" id=\"tfa_3341\" class=\"\">Solomon Islands<\/option>\n<option value=\"tfa_3342\" id=\"tfa_3342\" class=\"\">Somalia<\/option>\n<option value=\"tfa_3343\" id=\"tfa_3343\" class=\"\">South Africa<\/option>\n<option value=\"tfa_3344\" id=\"tfa_3344\" class=\"\">South Georgia and the South Sandwich Islands<\/option>\n<option value=\"tfa_3345\" id=\"tfa_3345\" class=\"\">Spain<\/option>\n<option value=\"tfa_3346\" id=\"tfa_3346\" class=\"\">Sri Lanka<\/option>\n<option value=\"tfa_3347\" id=\"tfa_3347\" class=\"\">St. Helena<\/option>\n<option value=\"tfa_3348\" id=\"tfa_3348\" class=\"\">St. Kitts and Nevis<\/option>\n<option value=\"tfa_3349\" id=\"tfa_3349\" class=\"\">St. Lucia<\/option>\n<option value=\"tfa_3350\" id=\"tfa_3350\" class=\"\">St. Pierre and Miquelon<\/option>\n<option value=\"tfa_3351\" id=\"tfa_3351\" class=\"\">St. Vincent and the Grenadines<\/option>\n<option value=\"tfa_3352\" id=\"tfa_3352\" class=\"\">Sudan<\/option>\n<option value=\"tfa_3353\" id=\"tfa_3353\" class=\"\">Suriname<\/option>\n<option value=\"tfa_3354\" id=\"tfa_3354\" class=\"\">Svalbard and Jan Mayen<\/option>\n<option value=\"tfa_3355\" id=\"tfa_3355\" class=\"\">Swaziland<\/option>\n<option value=\"tfa_3356\" id=\"tfa_3356\" class=\"\">Sweden<\/option>\n<option value=\"tfa_3357\" id=\"tfa_3357\" class=\"\">Switzerland<\/option>\n<option value=\"tfa_3358\" id=\"tfa_3358\" class=\"\">Syria<\/option>\n<option value=\"tfa_3359\" id=\"tfa_3359\" class=\"\">Taiwan<\/option>\n<option value=\"tfa_3360\" id=\"tfa_3360\" class=\"\">Tajikistan<\/option>\n<option value=\"tfa_3361\" id=\"tfa_3361\" class=\"\">Tanzania<\/option>\n<option value=\"tfa_3362\" id=\"tfa_3362\" class=\"\">Thailand<\/option>\n<option value=\"tfa_3363\" id=\"tfa_3363\" class=\"\">Togo<\/option>\n<option value=\"tfa_3364\" id=\"tfa_3364\" class=\"\">Tokelau<\/option>\n<option value=\"tfa_3365\" id=\"tfa_3365\" class=\"\">Tonga<\/option>\n<option value=\"tfa_3366\" id=\"tfa_3366\" class=\"\">Trinidad and Tobago<\/option>\n<option value=\"tfa_3367\" id=\"tfa_3367\" class=\"\">Tunisia<\/option>\n<option value=\"tfa_3368\" id=\"tfa_3368\" class=\"\">Turkey<\/option>\n<option value=\"tfa_3369\" id=\"tfa_3369\" class=\"\">Turkmenistan<\/option>\n<option value=\"tfa_3370\" id=\"tfa_3370\" class=\"\">Turks and Caicos Islands<\/option>\n<option value=\"tfa_3371\" id=\"tfa_3371\" class=\"\">Tuvalu<\/option>\n<option value=\"tfa_3372\" id=\"tfa_3372\" class=\"\">Uganda<\/option>\n<option value=\"tfa_3373\" id=\"tfa_3373\" class=\"\">Ukraine<\/option>\n<option value=\"tfa_3374\" id=\"tfa_3374\" class=\"\">United Arab Emirates<\/option>\n<option value=\"tfa_3375\" id=\"tfa_3375\" class=\"\">United Kingdom<\/option>\n<option value=\"tfa_3376\" id=\"tfa_3376\" data-conditionals=\"#tfa_3448\" class=\"\" selected data-default-value=\"true\">United States<\/option>\n<option value=\"tfa_3377\" id=\"tfa_3377\" class=\"\">United States Minor Outlying Islands<\/option>\n<option value=\"tfa_3378\" id=\"tfa_3378\" class=\"\">Uruguay<\/option>\n<option value=\"tfa_3379\" id=\"tfa_3379\" class=\"\">Uzbekistan<\/option>\n<option value=\"tfa_3380\" id=\"tfa_3380\" class=\"\">Vanuatu<\/option>\n<option value=\"tfa_3381\" id=\"tfa_3381\" class=\"\">Vatican City<\/option>\n<option value=\"tfa_3382\" id=\"tfa_3382\" class=\"\">Venezuela<\/option>\n<option value=\"tfa_3383\" id=\"tfa_3383\" class=\"\">Viet Nam<\/option>\n<option value=\"tfa_3384\" id=\"tfa_3384\" class=\"\">Virgin Islands ( British )<\/option>\n<option value=\"tfa_3385\" id=\"tfa_3385\" class=\"\">Virgin Islands<\/option>\n<option value=\"tfa_3386\" id=\"tfa_3386\" class=\"\">Wallis and Futuna<\/option>\n<option value=\"tfa_3387\" id=\"tfa_3387\" class=\"\">Yemen<\/option>\n<option value=\"tfa_3388\" id=\"tfa_3388\" class=\"\">Zambia<\/option>\n<option value=\"tfa_3389\" id=\"tfa_3389\" class=\"\">Zimbabwe<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_3448-D\">\n<label id=\"tfa_3448-L\" class=\"label preField reqMark\" for=\"tfa_3448\">State<\/label><br><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_3448\" name=\"tfa_3448\" data-condition=\"`#tfa_3376`\" title=\"State\" class=\"required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_3449\" id=\"tfa_3449\" class=\"\">Alabama<\/option>\n<option value=\"tfa_3450\" id=\"tfa_3450\" class=\"\">Alaska<\/option>\n<option value=\"tfa_3451\" id=\"tfa_3451\" class=\"\">Arizona<\/option>\n<option value=\"tfa_3452\" id=\"tfa_3452\" class=\"\">Arkansas<\/option>\n<option value=\"tfa_3453\" id=\"tfa_3453\" class=\"\">California<\/option>\n<option value=\"tfa_3454\" id=\"tfa_3454\" class=\"\">Colorado<\/option>\n<option value=\"tfa_3455\" id=\"tfa_3455\" class=\"\">Connecticut<\/option>\n<option value=\"tfa_3456\" id=\"tfa_3456\" class=\"\">Delaware<\/option>\n<option value=\"tfa_3457\" id=\"tfa_3457\" class=\"\">District Of Columbia<\/option>\n<option value=\"tfa_3458\" id=\"tfa_3458\" class=\"\">Florida<\/option>\n<option value=\"tfa_3459\" id=\"tfa_3459\" class=\"\">Georgia<\/option>\n<option value=\"tfa_3460\" id=\"tfa_3460\" class=\"\">Hawaii<\/option>\n<option value=\"tfa_3461\" id=\"tfa_3461\" class=\"\">Idaho<\/option>\n<option value=\"tfa_3462\" id=\"tfa_3462\" class=\"\">Illinois<\/option>\n<option value=\"tfa_3463\" id=\"tfa_3463\" class=\"\">Indiana<\/option>\n<option value=\"tfa_3464\" id=\"tfa_3464\" class=\"\">Iowa<\/option>\n<option value=\"tfa_3465\" id=\"tfa_3465\" class=\"\">Kansas<\/option>\n<option value=\"tfa_3466\" id=\"tfa_3466\" class=\"\">Kentucky<\/option>\n<option value=\"tfa_3467\" id=\"tfa_3467\" class=\"\">Louisiana<\/option>\n<option value=\"tfa_3468\" id=\"tfa_3468\" class=\"\">Maine<\/option>\n<option value=\"tfa_3469\" id=\"tfa_3469\" class=\"\">Maryland<\/option>\n<option value=\"tfa_3470\" id=\"tfa_3470\" class=\"\">Massachusetts<\/option>\n<option value=\"tfa_3471\" id=\"tfa_3471\" class=\"\">Michigan<\/option>\n<option value=\"tfa_3472\" id=\"tfa_3472\" class=\"\">Minnesota<\/option>\n<option value=\"tfa_3473\" id=\"tfa_3473\" class=\"\">Mississippi<\/option>\n<option value=\"tfa_3474\" id=\"tfa_3474\" class=\"\">Missouri<\/option>\n<option value=\"tfa_3475\" id=\"tfa_3475\" class=\"\">Montana<\/option>\n<option value=\"tfa_3476\" id=\"tfa_3476\" class=\"\">Nebraska<\/option>\n<option value=\"tfa_3477\" id=\"tfa_3477\" class=\"\">Nevada<\/option>\n<option value=\"tfa_3478\" id=\"tfa_3478\" class=\"\">New Hampshire<\/option>\n<option value=\"tfa_3479\" id=\"tfa_3479\" class=\"\">New Jersey<\/option>\n<option value=\"tfa_3480\" id=\"tfa_3480\" class=\"\">New Mexico<\/option>\n<option value=\"tfa_3481\" id=\"tfa_3481\" class=\"\">New York<\/option>\n<option value=\"tfa_3482\" id=\"tfa_3482\" class=\"\">North Carolina<\/option>\n<option value=\"tfa_3483\" id=\"tfa_3483\" class=\"\">North Dakota<\/option>\n<option value=\"tfa_3484\" id=\"tfa_3484\" class=\"\">Ohio<\/option>\n<option value=\"tfa_3485\" id=\"tfa_3485\" class=\"\">Oklahoma<\/option>\n<option value=\"tfa_3486\" id=\"tfa_3486\" class=\"\">Oregon<\/option>\n<option value=\"tfa_3487\" id=\"tfa_3487\" class=\"\">Pennsylvania<\/option>\n<option value=\"tfa_3488\" id=\"tfa_3488\" class=\"\">Rhode Island<\/option>\n<option value=\"tfa_3489\" id=\"tfa_3489\" class=\"\">South Carolina<\/option>\n<option value=\"tfa_3490\" id=\"tfa_3490\" class=\"\">South Dakota<\/option>\n<option value=\"tfa_3491\" id=\"tfa_3491\" class=\"\">Tennessee<\/option>\n<option value=\"tfa_3492\" id=\"tfa_3492\" class=\"\">Texas<\/option>\n<option value=\"tfa_3493\" id=\"tfa_3493\" class=\"\">Utah<\/option>\n<option value=\"tfa_3494\" id=\"tfa_3494\" class=\"\">Vermont<\/option>\n<option value=\"tfa_3495\" id=\"tfa_3495\" class=\"\">Virginia<\/option>\n<option value=\"tfa_3496\" id=\"tfa_3496\" class=\"\" selected data-default-value=\"true\">Washington<\/option>\n<option value=\"tfa_3497\" id=\"tfa_3497\" class=\"\">West Virginia<\/option>\n<option value=\"tfa_3498\" id=\"tfa_3498\" class=\"\">Wisconsin<\/option>\n<option value=\"tfa_3499\" id=\"tfa_3499\" class=\"\">Wyoming<\/option>\n<option value=\"tfa_3500\" id=\"tfa_3500\" class=\"\">Puerto Rico<\/option>\n<option value=\"tfa_3501\" id=\"tfa_3501\" class=\"\">Virgin Island<\/option>\n<option value=\"tfa_3502\" id=\"tfa_3502\" class=\"\">Northern Mariana Islands<\/option>\n<option value=\"tfa_3503\" id=\"tfa_3503\" class=\"\">Guam<\/option>\n<option value=\"tfa_3504\" id=\"tfa_3504\" class=\"\">American Samoa<\/option>\n<option value=\"tfa_3505\" id=\"tfa_3505\" class=\"\">Palau<\/option><\/select><\/div>\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2368-D\" role=\"group\" aria-labelledby=\"tfa_2368-L\" data-tfa-labelledby=\"-L tfa_2368-L\">\n<label id=\"tfa_2368-L\" class=\"label preField reqMark\" data-tfa-check-label-for=\"tfa_2368\" aria-label=\"Referral for: \u00a0 required\">Referral for:<\/label><br><div class=\"inputWrapper\"><table id=\"tfa_2368\" class=\"choices columns2 required\">\n<tr>\n<td><span class=\"oneChoice\"><input type=\"checkbox\" value=\"tfa_2369\" class=\"\" id=\"tfa_2369\" name=\"tfa_2369\" aria-labelledby=\"tfa_2369-L\" data-tfa-labelledby=\"tfa_2368-L tfa_2369-L\" data-tfa-parent-id=\"tfa_2368\"><label class=\"label postField\" id=\"tfa_2369-L\" for=\"tfa_2369\"><span class=\"input-checkbox-faux\"><\/span>Scoliosis<\/label><\/span><\/td>\n<td><span class=\"oneChoice\"><input type=\"checkbox\" value=\"tfa_2370\" class=\"\" id=\"tfa_2370\" name=\"tfa_2370\" aria-labelledby=\"tfa_2370-L\" data-tfa-labelledby=\"tfa_2368-L tfa_2370-L\" data-tfa-parent-id=\"tfa_2368\"><label class=\"label postField\" id=\"tfa_2370-L\" for=\"tfa_2370\"><span class=\"input-checkbox-faux\"><\/span>Kyphosis<\/label><\/span><\/td>\n<\/tr>\n<tr>\n<td><span class=\"oneChoice\"><input type=\"checkbox\" value=\"tfa_2371\" class=\"\" id=\"tfa_2371\" name=\"tfa_2371\" aria-labelledby=\"tfa_2371-L\" data-tfa-labelledby=\"tfa_2368-L tfa_2371-L\" data-tfa-parent-id=\"tfa_2368\"><label class=\"label postField\" id=\"tfa_2371-L\" for=\"tfa_2371\"><span class=\"input-checkbox-faux\"><\/span>Exercise program<\/label><\/span><\/td>\n<td><span class=\"oneChoice\"><input type=\"checkbox\" value=\"tfa_2372\" class=\"\" id=\"tfa_2372\" name=\"tfa_2372\" aria-labelledby=\"tfa_2372-L\" data-tfa-labelledby=\"tfa_2368-L tfa_2372-L\" data-tfa-parent-id=\"tfa_2368\"><label class=\"label postField\" id=\"tfa_2372-L\" for=\"tfa_2372\"><span class=\"input-checkbox-faux\"><\/span>Brace assessment<\/label><\/span><\/td>\n<\/tr>\n<tr><td><span class=\"oneChoice\"><input type=\"checkbox\" value=\"tfa_2373\" class=\"\" id=\"tfa_2373\" name=\"tfa_2373\" aria-labelledby=\"tfa_2373-L\" data-tfa-labelledby=\"tfa_2368-L tfa_2373-L\" data-tfa-parent-id=\"tfa_2368\"><label class=\"label postField\" id=\"tfa_2373-L\" for=\"tfa_2373\"><span class=\"input-checkbox-faux\"><\/span>Shoe Lift<\/label><\/span><\/td><\/tr>\n<\/table><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2321-D\">\n<label id=\"tfa_2321-L\" class=\"label preField \" for=\"tfa_2321\">Details:<\/label><br><div class=\"inputWrapper\"><textarea id=\"tfa_2321\" name=\"tfa_2321\" title=\"Details:\" class=\"\"><\/textarea><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2358-D\" role=\"radiogroup\" aria-labelledby=\"tfa_2358-L\" data-tfa-labelledby=\"-L tfa_2358-L\">\n<label id=\"tfa_2358-L\" class=\"label preField reqMark\" data-tfa-check-label-for=\"tfa_2358\">The patient\/parent\/carer has given permission for ScoliCare to contact them about making an appointment<\/label><br><div class=\"inputWrapper\"><table id=\"tfa_2358\" class=\"choices columns2 required\"><tr>\n<td><span class=\"oneChoice\"><input type=\"radio\" value=\"tfa_2359\" class=\"\" id=\"tfa_2359\" name=\"tfa_2358\" aria-required=\"true\" aria-labelledby=\"tfa_2359-L\" data-tfa-labelledby=\"tfa_2358-L tfa_2359-L\" data-tfa-parent-id=\"tfa_2358\"><label class=\"label postField\" id=\"tfa_2359-L\" for=\"tfa_2359\"><span class=\"input-radio-faux\"><\/span>Yes<\/label><\/span><\/td>\n<td><span class=\"oneChoice\"><input type=\"radio\" value=\"tfa_2375\" class=\"\" id=\"tfa_2375\" name=\"tfa_2358\" aria-required=\"true\" aria-labelledby=\"tfa_2375-L\" data-tfa-labelledby=\"tfa_2358-L tfa_2375-L\" data-tfa-parent-id=\"tfa_2358\"><label class=\"label postField\" id=\"tfa_2375-L\" for=\"tfa_2375\"><span class=\"input-radio-faux\"><\/span>No (Please ask patient to contact the clinic)<\/label><\/span><\/td>\n<\/tr><\/table><\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"tfa_2322\" class=\"section\">\n<legend id=\"tfa_2322-L\"><b>Health Summary<\/b><\/legend>\n<div class=\"oneField field-container-D    \" id=\"tfa_2323-D\">\n<label id=\"tfa_2323-L\" class=\"label preField \" for=\"tfa_2323\">What symptoms is the patient experiencing?<\/label><br><div class=\"inputWrapper\"><textarea id=\"tfa_2323\" name=\"tfa_2323\" title=\"What symptoms is the patient experiencing?\" class=\"\"><\/textarea><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2329-D\">\n<label id=\"tfa_2329-L\" class=\"label preField \" for=\"tfa_2329\">Please list any past diagnoses and relevant medical history:<\/label><br><div class=\"inputWrapper\"><textarea id=\"tfa_2329\" name=\"tfa_2329\" title=\"Please list any past diagnoses and relevant medical history:\" class=\"\"><\/textarea><\/div>\n<\/div>\n<\/fieldset>\n<div class=\"oneField field-container-D    \" id=\"tfa_2376-D\">\n<label id=\"tfa_2376-L\" class=\"label preField \" for=\"tfa_2376\">Attach File 1 (e.g. AP\/PA x-ray)<\/label><br><div class=\"inputWrapper\"><input type=\"file\" id=\"tfa_2376\" name=\"tfa_2376\" size=\"\" title=\"Attach File 1 (e.g. AP\/PA x-ray)\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_2378-D\">\n<label id=\"tfa_2378-L\" class=\"label preField \" for=\"tfa_2378\">Attach File 2 (e.g. Lateral x-ray)<\/label><br><div class=\"inputWrapper\"><input type=\"file\" id=\"tfa_2378\" name=\"tfa_2378\" size=\"\" title=\"Attach File 2 (e.g. Lateral x-ray)\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D     wf-acl-hidden\" id=\"tfa_2405-D\" role=\"radiogroup\" aria-labelledby=\"tfa_2405-L\" data-tfa-labelledby=\"-L tfa_2405-L\">\n<label id=\"tfa_2405-L\" class=\"label preField \" data-tfa-check-label-for=\"tfa_2405\"><span style=\"font-size: 14.4px;\">Please send me email updates on scoliosis related information, including education, research, products and events<\/span><\/label><br><div class=\"inputWrapper\"><span id=\"tfa_2405\" class=\"choices vertical \"><span class=\"oneChoice\"><input type=\"radio\" value=\"tfa_3519\" class=\"\" checked data-default-value=\"true\" id=\"tfa_3519\" name=\"tfa_2405\" aria-labelledby=\"tfa_3519-L\" data-tfa-labelledby=\"tfa_2405-L tfa_3519-L\" data-tfa-parent-id=\"tfa_2405\"><label class=\"label postField\" id=\"tfa_3519-L\" for=\"tfa_3519\"><span class=\"input-radio-faux\"><\/span>Opt-in<\/label><\/span><span class=\"oneChoice\"><input type=\"radio\" value=\"tfa_3520\" class=\"\" id=\"tfa_3520\" name=\"tfa_2405\" aria-labelledby=\"tfa_3520-L\" data-tfa-labelledby=\"tfa_2405-L tfa_3520-L\" data-tfa-parent-id=\"tfa_2405\"><label class=\"label postField\" id=\"tfa_3520-L\" for=\"tfa_3520\"><span class=\"input-radio-faux\"><\/span>Opt-out<\/label><\/span><\/span><\/div>\n<\/div>\n<div class=\"actions\" id=\"5118480-A\" data-contentid=\"submit_button\"><input type=\"submit\" data-label=\"Submit\" class=\"primaryAction\" id=\"submit_button\" value=\"Submit\"><\/div>\n<div style=\"clear:both\"><\/div>\n<input type=\"hidden\" value=\"364-9a4b2a18313c87fcd41491f8e4a9940b\" name=\"tfa_dbCounters\" id=\"tfa_dbCounters\" autocomplete=\"off\"><input type=\"hidden\" value=\"5118480\" name=\"tfa_dbFormId\" id=\"tfa_dbFormId\"><input type=\"hidden\" value=\"\" name=\"tfa_dbResponseId\" id=\"tfa_dbResponseId\"><input type=\"hidden\" value=\"c2d4a37609848f5fc2134fe1767fc290\" name=\"tfa_dbControl\" id=\"tfa_dbControl\"><input type=\"hidden\" value=\"\" name=\"tfa_dbWorkflowSessionUuid\" id=\"tfa_dbWorkflowSessionUuid\"><input type=\"hidden\" value=\"1779707721\" name=\"tfa_dbTimeStarted\" id=\"tfa_dbTimeStarted\" autocomplete=\"off\"><input type=\"hidden\" value=\"5\" name=\"tfa_dbVersionId\" id=\"tfa_dbVersionId\"><input type=\"hidden\" value=\"\" name=\"tfa_switchedoff\" id=\"tfa_switchedoff\">\n<\/form>\n<\/div><\/div><div class=\"wFormFooter\"><p class=\"supportInfo\"><br><\/p><\/div>\n  <p class=\"supportInfo\" >\n      <\/p>\n <\/div>\n\n<script\n    id=\"analytics-collector-script\"\n    type=\"text\/javascript\"\n    src=\"https:\/\/scolicare.tfaforms.net\/dist\/analytics\/data-collector.f9f54c12ade21135b7c2.js\"\n    data-customer-id=\"72074\"\n    data-endpoint=\"https:\/\/analytics.formassembly.com\/v1\/traces\"\n><\/script>\n\n\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>How to Refer We work with health professionals in all \ufb01elds to help achieve the best results for scoliosis and &#8230; <a title=\"How To Refer\" class=\"read-more\" href=\"https:\/\/scolicare.com\/east-phoenix-arizona\/pro-referrers-form\/\" aria-label=\"Read more about How To Refer\">Read more<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-203","page","type-page","status-publish"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Refer your patients for scoliosis treatment East Phoenix Arizona<\/title>\n<meta name=\"description\" content=\"ScoliCare work with health professionals to provide great scoliosis treatment outcomes for our co-managed scoliosis patients.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/scolicare.com\/pro-how-to-refer\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Refer 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