Data Array:
Array
(
[chronoform] => ortho_adult
[event] => submit
[text1] => manny
[text4] =>
[text21] => test
[text23] => test
[text24] => test
[text25] => test
[text26] => test
[text27] => test
[text32] => test
[text36] => manny@mdtechteam.com
[text37] =>
[text38] =>
[text40] =>
[text41] =>
[text42] =>
[text43] =>
[text44] =>
[text45] =>
[text46] =>
[text47] =>
[text48] =>
[text49] =>
[radio129] => No
[text50] =>
[text51] =>
[text52] =>
[text53] =>
[text54] =>
[text55] =>
[text56] =>
[text57] =>
[text62] =>
[text63] =>
[text64] =>
[text65] =>
[text66] =>
[text67] =>
[text68] =>
[text69] =>
[text74] =>
[text75] =>
[text84] =>
[text86] =>
[text87] =>
[text93] =>
[text123] =>
[text99] =>
[text101] =>
[text100] =>
[text102] =>
[text104] =>
[text106] =>
[text110] => test on sunday
[text111] => first test
[recaptcha_challenge_field] => 03AHJ_VuvAFJZ5uMIN3CDvBdVv37A47orT1V2GSaI5r3kTwQnItncyj0A4xfx-bwSbge-Mi6svVw_TY3gjudnjgUMUj7rBYXm2r5r9kJmUiApyZqE_KtgInwyhai2V6a1jpbZsb92JAFirlFRtCd0-wvC_AN43t_62FfaDjP9sMXPfecz64jljPngQ13xkeH9Q-DEVEVUouwny
[recaptcha_response_field] => 643
[button114] => Submit Patient Form
[ip_address] => 24.147.88.250
[id] => 58
)
Debug Info:
Array
(
[6] => Array
(
[Email] => Array
(
[0] => An email with the details below was sent successfully:
[1] => To:manny@mdtechteam.com, info@yanniorthodontics.com
[2] => Subject:New Adult Patient Form
[3] => From name:Patient Forms
[4] => From email:info@yanniorthodontics.com
[5] => CC:
[6] => BCC:
[7] => Reply name:
[8] => Reply email:
[9] => Attachments:
[10] => Array
(
)
[11] => Body:
<table>
<tr><td></td><td></td></tr>
<tr><td>Patient Name:</td><td>manny</td></tr>
<tr><td>Gender:</td><td></td></tr>
<tr><td>Social Security Number:</td><td></td></tr>
<tr><td> Birth Date:</td><td>test</td></tr>
<tr><td>Home Address: </td><td>test</td></tr>
<tr><td>City:</td><td>test</td></tr>
<tr><td>State:</td><td>test</td></tr>
<tr><td>Zip: </td><td>test</td></tr>
<tr><td>Home Phone:</td><td>test</td></tr>
<tr><td>Cell Phone: </td><td>test</td></tr>
<tr><td>Would you like to receive appointment reminders via text message?</td><td></td></tr>
<tr><td>E-mail:</td><td>manny@mdtechteam.com</td></tr>
<tr><td>Would you like to receive appointment reminders via email?</td><td></td></tr>
<tr><td>Employer's Name:</td><td></td></tr>
<tr><td>Occupation:</td><td></td></tr>
<tr><td>Marital Status</td><td></td></tr>
<tr><td>Spouse/Partner's Name:</td><td></td></tr>
<tr><td>Emergency Contact Name:</td><td></td></tr>
<tr><td>Phone Number:</td><td></td></tr>
<tr><td>Relation:</td><td></td></tr>
<tr><td>Address:</td><td></td></tr>
<tr><td>City:</td><td></td></tr>
<tr><td>State:</td><td></td></tr>
<tr><td> Zip:</td><td></td></tr>
<tr><td>Person(s) to whom we may release your appointment or medical information:</td><td></td></tr>
<tr><td>Relation(s):</td><td></td></tr>
<tr><td>Do You Have Dental Insurance?</td><td>No</td></tr>
<tr><td>Primary Dental Insurance Company:</td><td></td></tr>
<tr><td>Phone Number:</td><td></td></tr>
<tr><td>Group Number:</td><td></td></tr>
<tr><td>Policy Number:</td><td></td></tr>
<tr><td>Policy Holder's Name:</td><td></td></tr>
<tr><td>Relation:</td><td></td></tr>
<tr><td>Policy Holder's Social Security Number:</td><td></td></tr>
<tr><td>Policy Holder's Date of Birth:</td><td></td></tr>
<tr><td>Secondary Dental Insurance Company:</td><td></td></tr>
<tr><td>Phone Number:</td><td></td></tr>
<tr><td>Group Number:</td><td></td></tr>
<tr><td>Policy Number:</td><td></td></tr>
<tr><td>Policy Holder's Name:</td><td></td></tr>
<tr><td>Relation:</td><td></td></tr>
<tr><td>Policy Holder's Social Security Number:</td><td></td></tr>
<tr><td>Policy Holder's Date of Birth:</td><td></td></tr>
<tr><td>General Dentist:</td><td></td></tr>
<tr><td>Last Visit:</td><td></td></tr>
<tr><td>How did you hear about our Practice?</td><td></td></tr>
<tr><td>Name of person referring (if applicable) :</td><td></td></tr>
<tr><td>Have you visited an orthodontist before?</td><td></td></tr>
<tr><td>When:</td><td></td></tr>
<tr><td>Reason:</td><td></td></tr>
<tr><td>Have your tonsils or adenoids been removed?</td><td></td></tr>
<tr><td>Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)?</td><td></td></tr>
<tr><td>Do you have any missing or extra permanent teeth?</td><td></td></tr>
<tr><td>Have you ever had an injury to (select all that apply):</td><td></td></tr>
<tr><td>Do you have speech problems?</td><td></td></tr>
<tr><td>If so, explain:</td><td></td></tr>
<tr><td>Do your gums bleed?</td><td></td></tr>
<tr><td>Do you smoke?</td><td></td></tr>
<tr><td>Do you like your smile?</td><td></td></tr>
<tr><td>Do you currently or have you ever had any of the following habits (check all that apply)</td><td></td></tr>
<tr><td>Is this habit past or present?</td><td></td></tr>
<tr><td>Has menses begun?</td><td></td></tr>
<tr><td>If yes, what year (approximately)?</td><td></td></tr>
<tr><td>Are you currently being treated by a physician for a medical condition?</td><td></td></tr>
<tr><td>Reason:</td><td></td></tr>
<tr><td>Last Visit:</td><td></td></tr>
<tr><td>Physician Name:</td><td></td></tr>
<tr><td>Phone:</td><td></td></tr>
<tr><td>Do you have any allergies/sensitivities to medications or latex?</td><td></td></tr>
<tr><td>If yes, please list:</td><td></td></tr>
<tr><td>Are you currently taking any prescription or over-the-counter medications?</td><td></td></tr>
<tr><td>Please list, with dosage:</td><td></td></tr>
<tr><td>Are you pregnant?</td><td></td></tr>
<tr><td>I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.</td><td></td></tr>
<tr><td>Submitted by:</td><td>test on sunday</td></tr>
<tr><td> Date:</td><td>first test</td></tr>
<tr><td>Enter Code</td><td></td></tr>
</table><br /><br />IP: 24.147.88.250
)
)
[9] => Array
(
[DB Save] => Array
(
[Queries] => Array
(
[0] => INSERT INTO `datatable_ortho_adult` (`text1`, `text4`, `text21`, `text23`, `text24`, `text25`, `text26`, `text27`, `text32`, `text36`, `text37`, `text38`, `text40`, `text41`, `text42`, `text43`, `text44`, `text45`, `text46`, `text47`, `text48`, `text49`, `radio129`, `text50`, `text51`, `text52`, `text53`, `text54`, `text55`, `text56`, `text57`, `text62`, `text63`, `text64`, `text65`, `text66`, `text67`, `text68`, `text69`, `text74`, `text75`, `text84`, `text86`, `text87`, `text93`, `text123`, `text99`, `text101`, `text100`, `text102`, `text104`, `text106`, `text110`, `text111`, `button114`, `user_id`, `uniq_id`, `created`) values ('manny', '', 'test', 'test', 'test', 'test', 'test', 'test', 'test', 'manny@mdtechteam.com', '', '', '', '', '', '', '', '', '', '', '', '', 'No', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', 'test on sunday', 'first test', 'Submit Patient Form', '0', '548743111bde79ffcdd13d96b252b17f1bbf4122', '2016-05-29 09:58:36');
)
)
)
)