{"id":3915,"date":"2019-09-20T13:11:07","date_gmt":"2019-09-20T13:11:07","guid":{"rendered":"https:\/\/www.christusems.org\/?page_id=3915"},"modified":"2026-07-01T20:01:52","modified_gmt":"2026-07-01T20:01:52","slug":"patient-family-member-non-emergency","status":"publish","type":"page","link":"https:\/\/www.christusems.org\/?page_id=3915","title":{"rendered":"Patient\/Family Member -Non Emergency"},"content":{"rendered":"\n<h1 class=\"wp-block-heading has-text-align-center has-x-large-font-size\"><strong>FEEDBACK FORM: PATIENT\/FAMILY MEMBER<\/strong><br><strong>(NON EMERGENCY)<\/strong><\/h1>\n\n\n<style type=\"text\/css\">\n\t#ipt_fsqm_form_wrap_57 .ipt_fsqm_form_logo img,\n\t#ipt_fsqm_form_wrap_57 .ipt-eform-width-restrain,\n\t#ipt_fsqm_form_wrap_57 .ipt_fsqm_form_message_restore,\n\t#ipt_fsqm_form_wrap_57 .ipt_fsqm_form_message_success,\n\t#ipt_fsqm_form_wrap_57 .ipt_fsqm_form_message_error,\n\t#ipt_fsqm_form_wrap_57 .ipt_fsqm_form_message_process,\n\t#ipt_fsqm_form_wrap_57 .ipt_fsqm_form_validation_error,\n\t#ipt_fsqm_form_wrap_57 .eform-ui-estimator {\n\t\tmax-width: 100%;\n\t\tmin-width: 240px;\n\t}\n\n\t\/**\/\n<\/style>\n\t\t<!-- Form Created using eForm - Ultimate WordPress Form Builder https:\/\/eform.live -->\n<div\n\tid=\"ipt_fsqm_form_wrap_57\"\n\tclass=\"ipt_uif_front ipt_uif_common ipt_fsqm_form type_2 ui-front eform-ltr eform-override-element-boxy eform-override-alignment-inherit\"\n\tdata-fsqmsayt=\"{&quot;auto_save&quot;:false,&quot;show_restore&quot;:true,&quot;restore&quot;:false,&quot;admin_override&quot;:false,&quot;user_update&quot;:false,&quot;interval_save&quot;:false,&quot;interval&quot;:&quot;30&quot;}\"\n\tdata-ui-type=\"2\"\n\tdata-ui-theme=\"[&quot;https:\\\/\\\/www.christusems.org\\\/wp-content\\\/plugins\\\/wp-fsqm-pro\\\/static\\\/front\\\/css\\\/material-themes\\\/light-themes\\\/teal.css?ver=4.18.0&quot;]\"\n\tdata-ui-theme-id=\"material-default\"\n\tdata-eformanim=\"0\"\n\tdata-fsqmga=\"{&quot;enabled&quot;:false,&quot;manual_load&quot;:false,&quot;tracking_id&quot;:&quot;&quot;,&quot;cookie&quot;:&quot;auto&quot;,&quot;user_update&quot;:false,&quot;name&quot;:&quot;Patient\\\/Family Member -Non Emergency Survey&quot;,&quot;form_id&quot;:&quot;57&quot;}\"\n\tdata-fsqmreset=\"{&quot;reset&quot;:false,&quot;delay&quot;:10}\"\n\tdata-eformreg=\"{&quot;enabled&quot;:false,&quot;username_id&quot;:&quot;ipt_fsqm_form_57_pinfo_&quot;,&quot;password_id&quot;:&quot;ipt_fsqm_form_57_pinfo_&quot;,&quot;hide_pinfo&quot;:false,&quot;hide_meta&quot;:false,&quot;meta&quot;:[]}\"\n\tdata-eformscroll=\"{&quot;progress&quot;:true,&quot;message&quot;:true,&quot;offset&quot;:&quot;0&quot;,&quot;scrollOnError&quot;:true}\"\n\tdata-eform-cookie=\"0\"\n\tdata-subscription-form=\"false\"\n\tdata-instant-subscription=\"{&quot;doable&quot;:true,&quot;config&quot;:{&quot;enabled&quot;:false,&quot;min_tab&quot;:&quot;&quot;,&quot;debounce&quot;:&quot;3000&quot;},&quot;nonce&quot;:&quot;4892d06327&quot;}\"\n>\n\t\t\t\t<noscript>\n\t<div class=\"ipt_fsqm_form_message_noscript ui-widget ui-widget-content ui-corner-all\">\n\t\t<div class=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\">\n\t\t\t<div>Javascript is disabled<\/div>\n\t\t<\/div>\n\t\t<div class=\"ui-widget-content ui-corner-bottom\">\n\t\t\t<p>Javascript is disabled on your browser. 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side_margin\">\n\t\t\t\t\t\t\t\t<div class=\"ipt_uif_richtext\">\n\t\t\t\t<p>Dear Patient or Family Member:<\/p>\n<p>Recently, CHRISTUS EMS treated and transported you or a member of your family. We hope that all is well with you or your family member; the staff at CHRISTUS EMS is committed to providing excellent patient care to all of our patients.<\/p>\n<p>Please, take a moment of your time to answer these questions as your feedback will assist us in continuously improving the quality of care and services we provide.<\/p>\n\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t<\/div>\n\t\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[pinfo][0][m_type]\" id=\"ipt_fsqm_form_57_pinfo_0_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[pinfo][0][type]\" id=\"ipt_fsqm_form_57_pinfo_0_type\" value=\"f_name\" class=\"ipt_fsqm_hf_type\" \/>\n\t\t\t\t<div class=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_f_name\" id=\"ipt_fsqm_form_57_pinfo_0\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div 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class=\"clear-both\"><\/div>\t\t\t<\/div>\n<\/div>\n\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[pinfo][2][m_type]\" id=\"ipt_fsqm_form_57_pinfo_2_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[pinfo][2][type]\" id=\"ipt_fsqm_form_57_pinfo_2_type\" value=\"email\" class=\"ipt_fsqm_hf_type\" \/>\n\t\t\t\t<div class=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_email\" id=\"ipt_fsqm_form_57_pinfo_2\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div class=\"ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full\">\n\t\t<div class=\"ipt_uif_question_content\">\n\t\t\t\t<div class=\"input-field has-icon\">\n\t<input class=\" check_me validate[custom[email]] 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id=\"ipt_fsqm_form_57_pinfo_3\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div class=\"ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full\">\n\t\t<div class=\"ipt_uif_question_content\">\n\t\t\t\t<div class=\"input-field has-icon\">\n\t<input class=\" check_me validate[custom[phone]] ipt_uif_text\"\n\t\t\t\t\t\t\t\t\t\ttype=\"tel\"\n\t\t\t\tname=\"ipt_fsqm_form_57[pinfo][3][value]\"\n\t\tid=\"ipt_fsqm_form_57_pinfo_3_value\"\n\t\tmaxlength=\"\"\t\tvalue=\"\" \/>\n\t<i title=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe08c;\"><\/i>\n\t\t\t\t\t<label for=\"ipt_fsqm_form_57_pinfo_3_value\">Phone (Leave blank if you wish to remain anonymous)<\/label>\n\t<\/div>\n\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t<\/div>\n<\/div>\n\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][0][m_type]\" id=\"ipt_fsqm_form_57_mcq_0_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][0][type]\" id=\"ipt_fsqm_form_57_mcq_0_type\" value=\"radio\" class=\"ipt_fsqm_hf_type\" \/>\n\t\t\t\t<div class=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio\" id=\"ipt_fsqm_form_57_mcq_0\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div class=\"ipt_uif_question ipt_uif_question_vertical\">\n\t\t\t<div class=\"ipt_uif_question_label\">\n\t\t\t<label class=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_57_mcq_0\">When you called for service, the Dispatcher on the phone was courteous and helpful.<span class=\"ipt_uif_question_required\">*<\/span><\/label>\n\t\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"ipt_uif_question_content\">\n\t\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input checked=\"checked\"\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][0][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_0_options__0\"\n\t\tvalue=\"0\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_0_options__0\" data-labelcon=\"&#xe18e;\">\n\t\t Agree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][0][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_0_options__1\"\n\t\tvalue=\"1\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_0_options__1\" data-labelcon=\"&#xe18e;\">\n\t\t Neutral\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][0][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_0_options__2\"\n\t\tvalue=\"2\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_0_options__2\" data-labelcon=\"&#xe18e;\">\n\t\t Disagree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][0][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_0_options__3\"\n\t\tvalue=\"3\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_0_options__3\" data-labelcon=\"&#xe18e;\">\n\t\t Don&#8217;t Know\t<\/label>\n<\/div>\n\t\t\t<div class=\"clear-both\"><\/div>\t\t<div class=\"clear-both\"><\/div>\t\t\t<\/div>\n<\/div>\n\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][17][m_type]\" id=\"ipt_fsqm_form_57_mcq_17_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][17][type]\" id=\"ipt_fsqm_form_57_mcq_17_type\" value=\"radio\" class=\"ipt_fsqm_hf_type\" \/>\n\t\t\t\t<div class=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio\" id=\"ipt_fsqm_form_57_mcq_17\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div class=\"ipt_uif_question ipt_uif_question_vertical\">\n\t\t\t<div class=\"ipt_uif_question_label\">\n\t\t\t<label class=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_57_mcq_17\">CHRISTUS EMS arrived at the appointed time.<span class=\"ipt_uif_question_required\">*<\/span><\/label>\n\t\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"ipt_uif_question_content\">\n\t\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input checked=\"checked\"\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][17][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_17_options__0\"\n\t\tvalue=\"0\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_17_options__0\" data-labelcon=\"&#xe18e;\">\n\t\t Agree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][17][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_17_options__1\"\n\t\tvalue=\"1\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_17_options__1\" data-labelcon=\"&#xe18e;\">\n\t\t Neutral\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][17][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_17_options__2\"\n\t\tvalue=\"2\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_17_options__2\" data-labelcon=\"&#xe18e;\">\n\t\t Disagree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][17][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_17_options__3\"\n\t\tvalue=\"3\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_17_options__3\" data-labelcon=\"&#xe18e;\">\n\t\t Don&#8217;t Know\t<\/label>\n<\/div>\n\t\t\t<div class=\"clear-both\"><\/div>\t\t<div class=\"clear-both\"><\/div>\t\t\t<\/div>\n<\/div>\n\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][16][m_type]\" id=\"ipt_fsqm_form_57_mcq_16_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][16][type]\" id=\"ipt_fsqm_form_57_mcq_16_type\" value=\"radio\" class=\"ipt_fsqm_hf_type\" \/>\n\t\t\t\t<div class=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio\" id=\"ipt_fsqm_form_57_mcq_16\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div class=\"ipt_uif_question ipt_uif_question_vertical\">\n\t\t\t<div class=\"ipt_uif_question_label\">\n\t\t\t<label class=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_57_mcq_16\">The CHRISTUS EMS personnel acted in a compassionate and caring manner.<span class=\"ipt_uif_question_required\">*<\/span><\/label>\n\t\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"ipt_uif_question_content\">\n\t\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input checked=\"checked\"\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][16][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_16_options__0\"\n\t\tvalue=\"0\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_16_options__0\" data-labelcon=\"&#xe18e;\">\n\t\t Agree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][16][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_16_options__1\"\n\t\tvalue=\"1\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_16_options__1\" data-labelcon=\"&#xe18e;\">\n\t\t Neutral\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][16][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_16_options__2\"\n\t\tvalue=\"2\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_16_options__2\" data-labelcon=\"&#xe18e;\">\n\t\t Disagree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][16][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_16_options__3\"\n\t\tvalue=\"3\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_16_options__3\" data-labelcon=\"&#xe18e;\">\n\t\t Don&#8217;t Know\t<\/label>\n<\/div>\n\t\t\t<div class=\"clear-both\"><\/div>\t\t<div class=\"clear-both\"><\/div>\t\t\t<\/div>\n<\/div>\n\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][15][m_type]\" id=\"ipt_fsqm_form_57_mcq_15_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][15][type]\" id=\"ipt_fsqm_form_57_mcq_15_type\" value=\"radio\" class=\"ipt_fsqm_hf_type\" \/>\n\t\t\t\t<div class=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio\" id=\"ipt_fsqm_form_57_mcq_15\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div class=\"ipt_uif_question ipt_uif_question_vertical\">\n\t\t\t<div class=\"ipt_uif_question_label\">\n\t\t\t<label class=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_57_mcq_15\">The CHRISTUS EMS personnel told me or a family member what they were doing and listened to me.<span class=\"ipt_uif_question_required\">*<\/span><\/label>\n\t\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"ipt_uif_question_content\">\n\t\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input checked=\"checked\"\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][15][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_15_options__0\"\n\t\tvalue=\"0\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_15_options__0\" data-labelcon=\"&#xe18e;\">\n\t\t Agree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][15][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_15_options__1\"\n\t\tvalue=\"1\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_15_options__1\" data-labelcon=\"&#xe18e;\">\n\t\t Neutral\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][15][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_15_options__2\"\n\t\tvalue=\"2\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_15_options__2\" data-labelcon=\"&#xe18e;\">\n\t\t Disagree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][15][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_15_options__3\"\n\t\tvalue=\"3\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_15_options__3\" data-labelcon=\"&#xe18e;\">\n\t\t Don&#8217;t Know\t<\/label>\n<\/div>\n\t\t\t<div class=\"clear-both\"><\/div>\t\t<div class=\"clear-both\"><\/div>\t\t\t<\/div>\n<\/div>\n\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][14][m_type]\" id=\"ipt_fsqm_form_57_mcq_14_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][14][type]\" id=\"ipt_fsqm_form_57_mcq_14_type\" value=\"radio\" class=\"ipt_fsqm_hf_type\" \/>\n\t\t\t\t<div class=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio\" id=\"ipt_fsqm_form_57_mcq_14\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div class=\"ipt_uif_question ipt_uif_question_vertical\">\n\t\t\t<div class=\"ipt_uif_question_label\">\n\t\t\t<label class=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_57_mcq_14\">The CHRISTUS EMS personnel were polite and respectful.<span class=\"ipt_uif_question_required\">*<\/span><\/label>\n\t\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"ipt_uif_question_content\">\n\t\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input checked=\"checked\"\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][14][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_14_options__0\"\n\t\tvalue=\"0\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_14_options__0\" data-labelcon=\"&#xe18e;\">\n\t\t Agree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][14][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_14_options__1\"\n\t\tvalue=\"1\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_14_options__1\" data-labelcon=\"&#xe18e;\">\n\t\t Neutral\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][14][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_14_options__2\"\n\t\tvalue=\"2\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_14_options__2\" data-labelcon=\"&#xe18e;\">\n\t\t Disagree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][14][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_14_options__3\"\n\t\tvalue=\"3\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_14_options__3\" data-labelcon=\"&#xe18e;\">\n\t\t Don&#8217;t Know\t<\/label>\n<\/div>\n\t\t\t<div class=\"clear-both\"><\/div>\t\t<div class=\"clear-both\"><\/div>\t\t\t<\/div>\n<\/div>\n\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][13][m_type]\" id=\"ipt_fsqm_form_57_mcq_13_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][13][type]\" id=\"ipt_fsqm_form_57_mcq_13_type\" value=\"radio\" class=\"ipt_fsqm_hf_type\" \/>\n\t\t\t\t<div class=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio\" id=\"ipt_fsqm_form_57_mcq_13\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div class=\"ipt_uif_question ipt_uif_question_vertical\">\n\t\t\t<div class=\"ipt_uif_question_label\">\n\t\t\t<label class=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_57_mcq_13\">The CHRISTUS EMS personnel were professional in conduct and appearance.<span class=\"ipt_uif_question_required\">*<\/span><\/label>\n\t\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"ipt_uif_question_content\">\n\t\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input checked=\"checked\"\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][13][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_13_options__0\"\n\t\tvalue=\"0\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_13_options__0\" data-labelcon=\"&#xe18e;\">\n\t\t Agree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][13][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_13_options__1\"\n\t\tvalue=\"1\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_13_options__1\" data-labelcon=\"&#xe18e;\">\n\t\t Neutral\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][13][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_13_options__2\"\n\t\tvalue=\"2\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_13_options__2\" data-labelcon=\"&#xe18e;\">\n\t\t Disagree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][13][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_13_options__3\"\n\t\tvalue=\"3\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_13_options__3\" data-labelcon=\"&#xe18e;\">\n\t\t Don&#8217;t Know\t<\/label>\n<\/div>\n\t\t\t<div class=\"clear-both\"><\/div>\t\t<div class=\"clear-both\"><\/div>\t\t\t<\/div>\n<\/div>\n\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][12][m_type]\" id=\"ipt_fsqm_form_57_mcq_12_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][12][type]\" id=\"ipt_fsqm_form_57_mcq_12_type\" value=\"radio\" class=\"ipt_fsqm_hf_type\" \/>\n\t\t\t\t<div class=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio\" id=\"ipt_fsqm_form_57_mcq_12\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div class=\"ipt_uif_question ipt_uif_question_vertical\">\n\t\t\t<div class=\"ipt_uif_question_label\">\n\t\t\t<label class=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_57_mcq_12\">The overall quality of care i received from CHRISTUS EMS was excellent.<span class=\"ipt_uif_question_required\">*<\/span><\/label>\n\t\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"ipt_uif_question_content\">\n\t\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input checked=\"checked\"\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][12][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_12_options__0\"\n\t\tvalue=\"0\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_12_options__0\" data-labelcon=\"&#xe18e;\">\n\t\t Agree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][12][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_12_options__1\"\n\t\tvalue=\"1\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_12_options__1\" data-labelcon=\"&#xe18e;\">\n\t\t Neutral\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][12][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_12_options__2\"\n\t\tvalue=\"2\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_12_options__2\" data-labelcon=\"&#xe18e;\">\n\t\t Disagree\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][12][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_12_options__3\"\n\t\tvalue=\"3\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_12_options__3\" data-labelcon=\"&#xe18e;\">\n\t\t Don&#8217;t Know\t<\/label>\n<\/div>\n\t\t\t<div class=\"clear-both\"><\/div>\t\t<div class=\"clear-both\"><\/div>\t\t\t<\/div>\n<\/div>\n\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][11][m_type]\" id=\"ipt_fsqm_form_57_mcq_11_m_type\" value=\"mcq\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[mcq][11][type]\" id=\"ipt_fsqm_form_57_mcq_11_type\" value=\"radio\" class=\"ipt_fsqm_hf_type\" \/>\n\t\t\t\t<div class=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio\" id=\"ipt_fsqm_form_57_mcq_11\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div class=\"ipt_uif_question ipt_uif_question_vertical\">\n\t\t\t<div class=\"ipt_uif_question_label\">\n\t\t\t<label class=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_57_mcq_11\"> The Overall actions of CHRISTUS EMS personnel caused my situation to:<span class=\"ipt_uif_question_required\">*<\/span><\/label>\n\t\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"ipt_uif_question_content\">\n\t\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input checked=\"checked\"\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][11][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_11_options__0\"\n\t\tvalue=\"0\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_11_options__0\" data-labelcon=\"&#xe18e;\">\n\t\t Improve\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][11][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_11_options__1\"\n\t\tvalue=\"1\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_11_options__1\" data-labelcon=\"&#xe18e;\">\n\t\t Remain the Same\t<\/label>\n<\/div>\n\t\t\t<div class=\"ipt_uif_label_column column_1\">\n\t<input\t\t data-num=\"\"\t\t\t\ttype=\"radio\"\n\t\tclass=\"check_me validate[required] ipt_uif_radio with-gap\"\n\t\tname=\"ipt_fsqm_form_57[mcq][11][options][]\"\n\t\tid=\"ipt_fsqm_form_57_mcq_11_options__2\"\n\t\tvalue=\"2\" \/>\n\t<label class=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_57_mcq_11_options__2\" data-labelcon=\"&#xe18e;\">\n\t\t Worsen\t<\/label>\n<\/div>\n\t\t\t<div class=\"clear-both\"><\/div>\t\t<div class=\"clear-both\"><\/div>\t\t\t<\/div>\n<\/div>\n\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[freetype][3][m_type]\" id=\"ipt_fsqm_form_57_freetype_3_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[freetype][3][type]\" id=\"ipt_fsqm_form_57_freetype_3_type\" value=\"feedback_large\" class=\"ipt_fsqm_hf_type\" \/>\n\t\t\t\t<div class=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_large\" id=\"ipt_fsqm_form_57_freetype_3\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div class=\"ipt_uif_question ipt_uif_question_vertical\">\n\t\t\t<div class=\"ipt_uif_question_label\">\n\t\t\t<label class=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_57_freetype_3_value\">Additional Comments:<span class=\"ipt_uif_question_required\">*<\/span><\/label>\n\t\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"ipt_uif_question_content\">\n\t\t\t\t<div class=\"input-field\">\n\t<textarea class=\"ipt_uif_textarea materialize-textarea  check_me validate[required]\"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_57[freetype][3][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_57_freetype_3_value\"><\/textarea>\n\t\t\t\t<\/div>\n\n\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t<\/div>\n<\/div>\n\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[freetype][4][m_type]\" id=\"ipt_fsqm_form_57_freetype_4_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_57[freetype][4][type]\" id=\"ipt_fsqm_form_57_freetype_4_type\" value=\"feedback_small\" class=\"ipt_fsqm_hf_type\" \/>\n\t\t\t\t<div class=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small\" id=\"ipt_fsqm_form_57_freetype_4\">\n\t<div class=\"ipt_uif_column_inner side_margin\">\n\t\t<div class=\"ipt_uif_question ipt_uif_question_vertical\">\n\t\t\t<div class=\"ipt_uif_question_label\">\n\t\t\t<label class=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_57_freetype_4_value\">Run Number:<span class=\"ipt_uif_question_required\">*<\/span><\/label>\n\t\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"ipt_uif_question_content\">\n\t\t\t\t<div class=\"input-field\">\n\t<input class=\" check_me validate[required] ipt_uif_text\"\n\t\t\t\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\tname=\"ipt_fsqm_form_57[freetype][4][value]\"\n\t\tid=\"ipt_fsqm_form_57_freetype_4_value\"\n\t\tmaxlength=\"\"\t\tvalue=\"\" \/>\n\t\t\t\t\t\t<label for=\"ipt_fsqm_form_57_freetype_4_value\">Write Here<\/label>\n\t<\/div>\n\t\t\t\t<div class=\"clear-both\"><\/div>\t\t\t<\/div>\n<\/div>\n\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n<\/div>\n\t\t\t<\/div>\n\t\t\t\t<div class=\"clear-both\"><\/div>\t<\/div>\n\t<\/div>\n<div class=\"clear\"><\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n<div id=\"ipt_fsqm_form_57_button_container\" class=\"ipt_fsqm_form_button_container ipt_fsqm_form_button_container--classic ipt-eform-material-button-container\"><div class=\"eform-button-container-inner\">\n\t<button type=\"submit\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_submit medium primary-button\" name=\"ipt_fsqm_form_57_button_submit\" id=\"ipt_fsqm_form_57_button_submit\"> Submit<\/button>\n\t\t\n<\/div><\/div>\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"clear-both\"><\/div>\t\t<\/div> <!-- end .ipt-eform-content -->\n\t\t<\/div> <!-- end .ipt-eform-width-restrain -->\n\t\t\t\t\t\t<\/form>\n\t\t\t<\/div>\n\t\t<div style=\"display: none;\" class=\"ipt_fsqm_form_message_success ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\">\n\t\t<div class=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\">\n\t\t\t<h3><i title=\"\" class=\" ipt-icomoon-checkmark-circle ipticm prefix\"><\/i>\n\t\tYour form has been submitted<\/h3>\n\t\t<\/div>\n\t\t<div class=\"ui-widget-content ui-corner-all ipt_fsqm_success_wrap\">\n\t\t\t\t\t\t<p>Thank you for completing our survey. We have received your submission. Feel free to give us a call if you would like to discuss your survey results at 903-291-2600.  We appreciate your feedback!<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<div style=\"display: none;\" class=\"ipt_fsqm_form_message_error ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\">\n\t\t<div class=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\">\n\t\t\t<div><i title=\"\" class=\" ipt-icomoon-laptop ipticm prefix\"><\/i>\n\t\tServer Side Error<\/div>\n\t\t<\/div>\n\t\t<div class=\"ui-widget-content ui-corner-all\">\n\t\t\t<p>We faced problems while connecting to the server or receiving data from the server. Please wait for a few seconds and try again.<\/p>\n\t\t\t<p>If the problem persists, then check your internet connectivity. If all other sites open fine, then please contact the administrator of this website with the following information.<\/p>\n\t\t\t<p class=\"jqXHR\">\n\t\t\t\t<strong>TextStatus: <\/strong><span class=\"textStatus\">undefined<\/span><br \/>\n\t\t\t\t<strong>HTTP Error: <\/strong><span class=\"errorThrown\">undefined<\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div style=\"display: none\" class=\"ipt_uif_widget_box ipt_fsqm_form_message_process\">\n\t\t<div class=\"ui-widget ui-widget-header ui-corner-all\">\n\t\t\t\t\t<style type=\"text\/css\">\n\t\t\t.ipt_uif_ajax_loader,\n\t\t\t.ipt_uif_ajax_loader *,\n\t\t\tipt_uif_ajax_loader *::before,\n\t\t\tipt_uif_ajax_loader *::after {\n\t\t\t\tbox-sizing: border-box;\n\t\t\t}\n\t\t<\/style>\n\t\t<div class=\"ipt-eform-preloader-inline ipt_uif_ajax_loader\">\n\t\t\t<div class=\"ipt-eform-preloader-inner\">\n\t\t\t\t<div class=\"ipt-eform-preloader-circle\">\n\t\t\t\t\t<div class=\"preloader-wrapper active\">\n\t\t\t\t\t\t<div class=\"spinner-layer spinner-blue\">\n\t\t\t\t\t\t\t<div class=\"circle-clipper left\">\n\t\t\t\t\t\t\t\t<div class=\"circle\"><\/div>\n\t\t\t\t\t\t\t<\/div><div class=\"gap-patch\">\n\t\t\t\t\t\t\t\t<div class=\"circle\"><\/div>\n\t\t\t\t\t\t\t<\/div><div class=\"circle-clipper right\">\n\t\t\t\t\t\t\t\t<div class=\"circle\"><\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"spinner-layer spinner-red\">\n\t\t\t\t\t\t\t<div class=\"circle-clipper left\">\n\t\t\t\t\t\t\t\t<div class=\"circle\"><\/div>\n\t\t\t\t\t\t\t<\/div><div class=\"gap-patch\">\n\t\t\t\t\t\t\t\t<div class=\"circle\"><\/div>\n\t\t\t\t\t\t\t<\/div><div class=\"circle-clipper right\">\n\t\t\t\t\t\t\t\t<div class=\"circle\"><\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"spinner-layer spinner-yellow\">\n\t\t\t\t\t\t\t<div class=\"circle-clipper left\">\n\t\t\t\t\t\t\t\t<div class=\"circle\"><\/div>\n\t\t\t\t\t\t\t<\/div><div class=\"gap-patch\">\n\t\t\t\t\t\t\t\t<div class=\"circle\"><\/div>\n\t\t\t\t\t\t\t<\/div><div class=\"circle-clipper right\">\n\t\t\t\t\t\t\t\t<div class=\"circle\"><\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"spinner-layer spinner-green\">\n\t\t\t\t\t\t\t<div class=\"circle-clipper left\">\n\t\t\t\t\t\t\t\t<div class=\"circle\"><\/div>\n\t\t\t\t\t\t\t<\/div><div class=\"gap-patch\">\n\t\t\t\t\t\t\t\t<div class=\"circle\"><\/div>\n\t\t\t\t\t\t\t<\/div><div class=\"circle-clipper right\">\n\t\t\t\t\t\t\t\t<div class=\"circle\"><\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"ipt-eform-preloader-text\">\n\t\t\t\t\t<div class=\"ipt-eform-preloader-text-inner ipt_uif_ajax_loader_text\">Processing you request<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"clear\"><\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t<\/div>\n\t<div style=\"display: none;\" class=\"ipt_fsqm_form_validation_error ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\">\n\t\t<div class=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\">\n\t\t\t<div><i title=\"\" class=\" ipt-icomoon-warning2 ipticm prefix\"><\/i>\n\t\t <span class=\"fsqm_ve_text\">Error<\/span><\/div>\n\t\t<\/div>\n\t\t<div class=\"ui-widget-content ui-corner-all\">\n\t\t\t<p class=\"fsqm_ve_msg\">Some error has occured.<\/p>\n\t\t<\/div>\n\t<\/div>\n\t\n\t\n\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>FEEDBACK FORM: PATIENT\/FAMILY MEMBER(NON 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