<!DOCTYPE html>
<html>

<head>
    <meta charset="UTF-8">
    <title>Chagger Dental</title>
</head>

<body style="margin:0;padding:0;background:#e9ecef;font-family:Arial,Helvetica,sans-serif;">
    <table width="100%" cellpadding="0" cellspacing="0" style="background:#e9ecef;padding:30px 0;">
        <tr>
            <td align="center">
                <table width="850" cellpadding="0" cellspacing="0"
                    style="background:#ffffff;border-radius:16px;border:4px solid #2f5f9e;">
                    <tr>
                        <td align="center" style="padding:20px;">
                            <table width="100%" cellpadding="0" cellspacing="0">
                                <tr>
                                    <td align="left" style="vertical-align:top;">
                                        <img src="https://chaggerdental.com/themes/frontend/images/dental-logo.png"
                                            width="250" alt="Chagger Dental">
                                    </td>
                                    <td align="right" style="vertical-align:top;">
                                        <h1
                                            style="margin:0 0 5px 0;font-family:Arial,Helvetica,sans-serif;font-size:26px;font-weight:700;color:#001e49;letter-spacing:1px;">
                                            {{location_name}}</h1>
                                        <p style="margin:0 0 5px 0;font-size:14px;color:#434750;">{{location_address}}
                                        </p>
                                        <p style="margin:0 0 5px 0;font-size:14px;color:#434750;">
                                            <a href="mailto:{{location_email}}"
                                                style="color:#434750;text-decoration:none;">{{location_email}}</a>
                                        </p>
                                        <p style="margin:0;font-size:14px;color:#434750;">{{location_phone}}</p>
                                    </td>
                                </tr>
                                <tr>
                                    <td align="center" colspan="2">
                                        <h2
                                            style="margin:30px 0 5px 0;font-family:Arial,Helvetica,sans-serif;font-size:24px;font-weight:700;color:#001e49;letter-spacing:1px;">
                                            CHAGGER DENTAL PATIENT INFORMATION</h2>
                                    </td>
                                </tr>
                                <tr>
                                    <td align="center" colspan="2">
                                        <p style="margin:0;font-size:13px;color:#4e6072;text-align:center;">
                                            Submitted: {{submitted_at}}
                                        </p>
                                    </td>
                                </tr>
                            </table>
                        </td>
                    </tr>

                    <tr>
                        <td style="padding:0 20px 30px 20px;">
                            <table width="100%" cellpadding="0" cellspacing="0" style="border:1px solid #eae8e4;border-radius:8px;">
                                <tr><td style="background:#0e336a;padding:12px 14px;border-top-left-radius:8px;border-top-right-radius:8px;"><h3 style="margin:0;font-family:Arial,Helvetica,sans-serif;font-size:12px;color:#ffffff;letter-spacing:1px;">PATIENT PROFILE</h3></td></tr>
                                <tr><td style="padding:20px;"><table width="100%" cellpadding="10" cellspacing="0">
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Title</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{title}}</td>
</tr></table></td>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Full Name</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{full_name}}</td>
</tr></table></td>
</tr>
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Age</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{age}}</td>
</tr></table></td>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Sex</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{sex}}</td>
</tr></table></td>
</tr>
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Marital Status</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{marital_status}}</td>
</tr></table></td>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Date of Birth</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{date_of_birth}}</td>
</tr></table></td>
</tr>
<tr>
<td colspan="2" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="20.5%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Street Address</td>
<td width="79.5%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{street_address}}</td>
</tr></table></td>
</tr>
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">City</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{city}}</td>
</tr></table></td>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Province / State</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{province}}</td>
</tr></table></td>
</tr>
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Postal Code</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{postal_code}}</td>
</tr></table></td>
<td width="50%">&nbsp;</td>
</tr>
<tr>
<td colspan="2" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="20.5%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Email Address</td>
<td width="79.5%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;"><a href="mailto:{{email_address}}" style="color:#2f5f9e;">{{email_address}}</a></td>
</tr></table></td>
</tr>
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Home Phone</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{home_phone}}</td>
</tr></table></td>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Cell Phone</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{cell_phone}}</td>
</tr></table></td>
</tr>
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Occupation</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{cccupation}}</td>
</tr></table></td>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Employed By</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{employed_by}}</td>
</tr></table></td>
</tr>
</table></td></tr>
                            </table>
                        </td>
                    </tr>

                    <tr>
                        <td style="padding:0 20px 30px 20px;">
                            <table width="100%" cellpadding="0" cellspacing="0" style="border:1px solid #eae8e4;border-radius:8px;">
                                <tr><td style="background:#0e336a;padding:12px 14px;border-top-left-radius:8px;border-top-right-radius:8px;"><h3 style="margin:0;font-family:Arial,Helvetica,sans-serif;font-size:12px;color:#ffffff;letter-spacing:1px;">DENTAL INSURANCE &amp; CARE PROVIDERS</h3></td></tr>
                                <tr><td style="padding:20px;"><table width="100%" cellpadding="10" cellspacing="0">
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Dental Insurance</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{dental_insurance}}</td>
</tr></table></td>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Insurance Company</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{insurance_company}}</td>
</tr></table></td>
</tr>
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Policy No.</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{policy_no}}</td>
</tr></table></td>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">ID / Certificate No.</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{certificate_no}}</td>
</tr></table></td>
</tr>
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Family Physician</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{family_physician}}</td>
</tr></table></td>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Physician Phone</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{physician_phone}}</td>
</tr></table></td>
</tr>
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Previous Dentist</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{previous_dentist}}</td>
</tr></table></td>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Previous Dentist Phone</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{previous_dentist_phone}}</td>
</tr></table></td>
</tr>
<tr>
<td colspan="2" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="20.5%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Referral Credit</td>
<td width="79.5%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{referral_credit}}</td>
</tr></table></td>
</tr>
</table></td></tr>
                            </table>
                        </td>
                    </tr>

                    <tr>
                        <td style="padding:0 20px 30px 20px;">
                            <table width="100%" cellpadding="0" cellspacing="0" style="border:1px solid #eae8e4;border-radius:8px;background:#f6f3ef;">
                                <tr><td style="background:#0e336a;padding:12px 14px;border-top-left-radius:8px;border-top-right-radius:8px;"><h3 style="margin:0;font-family:Arial,Helvetica,sans-serif;font-size:12px;color:#ffffff;letter-spacing:1px;">EMERGENCY CONTACT</h3></td></tr>
                                <tr><td style="padding:20px;"><table width="100%" cellpadding="10" cellspacing="0">
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Contact Name</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{en_contact_name}}</td>
</tr></table></td>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Relationship</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{en_relationship}}</td>
</tr></table></td>
</tr>
<tr>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Address</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{en_address}}</td>
</tr></table></td>
<td width="50%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;">
<table width="100%" cellpadding="0" cellspacing="0"><tr>
<td width="42%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;vertical-align:top;">Phone Number</td>
<td width="58%" style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#001e49;font-weight:bold;vertical-align:top;">{{en_phone_number}}</td>
</tr></table></td>
</tr>
</table></td></tr>
                            </table>
                        </td>
                    </tr>

                    <tr>
                        <td style="padding:0 20px 30px 20px;">
                            <table width="100%" cellpadding="0" cellspacing="0" style="border:1px solid #eae8e4;border-radius:8px;">
                                <tr><td style="background:#0e336a;padding:12px 14px;border-top-left-radius:8px;border-top-right-radius:8px;"><h3 style="margin:0;font-family:Arial,Helvetica,sans-serif;font-size:12px;color:#ffffff;letter-spacing:1px;">CONFIDENTIAL MEDICAL HISTORY</h3></td></tr>
                                <tr><td style="padding:20px;"><table width="100%" cellpadding="10" cellspacing="0">
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">1. Date of last complete physical examination</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{dlcp_examination}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">2. Are you currently under a physician's care?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{cup_care}}</p><p style="margin:4px 0 0 0;font-size:12px;color:#4e6072;"><strong>Specify:</strong> {{cup_care_specify}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">3. Do you have frequent headaches?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{frequent_headaches}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">4. Do you smoke?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{smoke}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">5. Do you drink alcohol?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{drink_alcohol}}</p><p style="margin:4px 0 0 0;font-size:12px;color:#4e6072;"><strong>Specify:</strong> {{drink_alcohol_specify}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">6. Do you do recreational drugs?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{recreational_drugs}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">7. Do you routinely take vitamins, herbal substances, or natural products?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{herbal_substances}}</p><p style="margin:4px 0 0 0;font-size:12px;color:#4e6072;"><strong>Specify:</strong> {{herbal_substances_specify}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">8. Are you taking any medications?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{any_medications}}</p><p style="margin:4px 0 0 0;font-size:12px;color:#4e6072;"><strong>Specify:</strong> {{any_medications_specify}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">9. Have you taken any prolonged medication in the past?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{prolonged_medication}}</p><p style="margin:4px 0 0 0;font-size:12px;color:#4e6072;"><strong>Specify:</strong> {{prolonged_medication_specify}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">10. Have you taken cortisone or steroids?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{cortisone}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">11. Have you ever been hospitalized for any surgery?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{any_surgery}}</p><p style="margin:4px 0 0 0;font-size:12px;color:#4e6072;"><strong>Specify:</strong> {{any_surgery_specify}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">12. Are your ankles often swollen?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{ankles_swollen}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">13. Have you gained or lost excessive weight recently?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{gained_lost_weight}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">14. Are you pregnant?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{pregnant}}</p><p style="margin:4px 0 0 0;font-size:12px;color:#4e6072;"><strong>Specify:</strong> {{pregnant_weeks}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">15. Sensitive / adverse reactions</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{adverse_reaction}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">16. Allergies / adverse reactions</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{allergic_adverse_reaction}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">17. Allergic or adverse reactions to any other drugs?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{adverse_reactions}}</p><p style="margin:4px 0 0 0;font-size:12px;color:#4e6072;"><strong>Specify:</strong> {{adverse_reactions_specify}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">18. Treated for or told you have any of the following</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{treated}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">19. Have you ever experienced heavy bleeding?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{heavy_bleeding}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">20. Is there anything else we should know?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{anything_else_know}}</p><p style="margin:4px 0 0 0;font-size:12px;color:#4e6072;"><strong>Specify:</strong> {{anything_else_know_specify}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">21. Have you been diagnosed with any other disease, condition or problem?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{other_disease}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">22. Is there anything about your health we should be aware of?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{anything_about_health}}</p><p style="margin:4px 0 0 0;font-size:12px;color:#4e6072;"><strong>Specify:</strong> {{anything_about_health_specify}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">23. Do you wish to speak to the doctor privately?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{speak_doctor_privately}}</p>
</td></tr>
</table></td></tr>
                            </table>
                        </td>
                    </tr>

                    <tr>
                        <td style="padding:0 20px 30px 20px;">
                            <table width="100%" cellpadding="0" cellspacing="0" style="border:1px solid #eae8e4;border-radius:8px;">
                                <tr><td style="background:#0e336a;padding:12px 14px;border-top-left-radius:8px;border-top-right-radius:8px;"><h3 style="margin:0;font-family:Arial,Helvetica,sans-serif;font-size:12px;color:#ffffff;letter-spacing:1px;">DENTAL HISTORY</h3></td></tr>
                                <tr><td style="padding:20px;"><table width="100%" cellpadding="10" cellspacing="0">
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">24. Date of last complete exam</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{date_last_complete_exam}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">25. Date of last cleaning</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{date_last_cleaning}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">26. Date of last x-rays</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{date_last_x_rays}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">27. Did you see your last dentist regularly?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{last_dentist_regularly}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">28. How often did you see your last dentist?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{last_dentist}}</p><p style="margin:4px 0 0 0;font-size:12px;color:#4e6072;"><strong>Specify:</strong> {{last_dentist_description}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">29. Have you ever been advised to take antibiotics?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{antibiotics}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">30. Heavy bleeding following extractions?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{heavy_bleeding_extractions}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">31. Have you ever had gum treatment or surgery?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{gum_treatment}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">32. Have you had any orthodontic treatment?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{orthodontic_treatment}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">33. Have you ever had an unpleasant dental experience?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{unpleasant_dental_experience}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">34. How can we make your dental experience more pleasant?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{pleasant_dental_experience}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">35. Is there anything else we should know?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{anything_else_should_know}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">36. What brings you to the office today?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{brings_office_today}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">37. Are you in any discomfort?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{any_discomfort}}</p><p style="margin:4px 0 0 0;font-size:12px;color:#4e6072;"><strong>Specify:</strong> {{any_discomfort_specify}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">38. Do you have or have you experienced</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{have_experienced}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">39. Does food get caught between your teeth?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{food_teeth}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">40. Do you have any sore spots in your mouth?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{sore_spots}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">41. Have you had any teeth replaced?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{teeth_replaced}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">42. Interested in permanent tooth replacement?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{permanent_tooth_replacement}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">43. Have you ever been given local anesthesia?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{local_anesthesia}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">44. Have you ever been given general anesthesia?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{general_anesthesia}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">45. Are you satisfied with the appearance of your teeth?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{satisfied_appearance_teeth}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">46. Are you anxious to keep your natural teeth?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{keep_natural_teeth}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">47. Are you tense during dental visits?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{tense_dental_visits}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">48. Interested in a method to calm your nerves?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{calm_nerves}}</p>
</td></tr>
<tr><td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#4e6072;letter-spacing:1px;vertical-align:top;border-bottom:1px solid #f0ede9;">
<p style="margin:0 0 5px 0;">49. How can we help you today?</p>
<p style="margin:0;font-weight:bold;color:#001e49;">{{describe}}</p>
</td></tr>
</table></td></tr>
                            </table>
                        </td>
                    </tr>
                    <tr>
                        <td style="padding:0 20px 30px 20px;">
                            <table width="100%" cellpadding="0" cellspacing="0"
                                style="background:#0e336a; border-radius:16px;">
                                <tr>
                                    <td colspan="2" style="padding:12px 14px;">
                                        <h3
                                            style="margin:15px 0 5px 15px;font-family:Arial,Helvetica,sans-serif;font-size:16px;color:#ffffff;letter-spacing:1px;">
                                            Patient Consent</h3>
                                        <p
                                            style="margin:0 0 0 15px;font-family:Arial,Helvetica,sans-serif;font-size:12px;color:#ffffff;letter-spacing:1px;">
                                            Verified & Authorized Digital Copy</p>
                                    </td>
                                </tr>
                                <tr>
                                    <td width="60%" style="padding:0 20px 20px 20px;vertical-align: top;">
                                        <table width="100%" cellpadding="0" cellspacing="0">
                                            <tr>
                                                <td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#ffffff;letter-spacing:1px;vertical-align:top;">
                                                    <p style="margin:0 0 10px 15px;">{{consent_privacy_patient_icon}}&nbsp;&nbsp;I agree to the privacy policy regarding medical records.</p>
                                                </td>
                                            </tr>
                                            <tr>
                                                <td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#ffffff;letter-spacing:1px;vertical-align:top;">
                                                    <p style="margin:0 0 0 15px;">{{consent_newsletter_icon}}&nbsp;&nbsp;I consent to receiving emails and newsletters.</p>
                                                </td>
                                            </tr>
                                        </table>
                                    </td>
                                    <td width="40%" style="padding:0 20px 20px 20px;vertical-align: top;">
                                        <table width="100%" cellpadding="0" cellspacing="0">
                                            <tr>
                                                <td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#ffffff;letter-spacing:1px;vertical-align:top;">
                                                    <p style="margin:0 0 5px 0;">SIGNATURE</p>
                                                    <img src="{{signature}}" alt="Signature" style="max-width: 150px; max-height: 70px; border: 1px solid #ccc; padding: 4px; background: #fff;margin: 0 0 20px 0;">
                                                </td>
                                            </tr>
                                            <tr>
                                                <td style="font-family:Arial,Helvetica,sans-serif;font-size:13px;color:#ffffff;letter-spacing:1px;vertical-align:top;">
                                                    <p style="margin:0 0 5px 0;">PRINT NAME</p>
                                                    <p style="margin:0;">{{print_name}}</p>
                                                </td>
                                            </tr>
                                        </table>
                                    </td>
                                </tr>
                            </table>
                        </td>
                    </tr>
                    <tr>
                        <td style="border-top: 1px solid #eae8e4;">
                            &nbsp;
                        </td>
                    </tr>
                    <tr>
                        <td align="center">
                            <img src="https://chaggerdental.com/themes/frontend/images/dental-logo.png"
                                width="250" alt="Chagger Dental">
                        </td>
                    </tr>
                    <tr>
                        <td align="center" style="padding:18px;font-size:13px;color:#434750;">
                            &copy; {{year}} Chagger Dental &bull; Confidential Medical Record
                        </td>
                    </tr>
                </table>
            </td>
        </tr>
        <tr>
            <td align="center" style="padding:20px;font-size:14px;">
                <b>Note:</b> Please do not reply to this email.
            </td>
        </tr>
    </table>
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