1. { binding displayValue, mode=oneTime }
{ binding firstError.message }

You can erase this number and Type In how much you want to pay for your first Exam & X-ray

Are You a New Patient {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Do You Have Insurance {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

PLEASE NOTE: If you have insurance, you don't qualify for this special. Your insurance will usually pay for the Exam & X-ray at 100%. 

Insert and format text, links, and images here.
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{# pageNumbers}
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{# pageNumbers}
IMPORTANT: There are No Refunds for Cancellations. You can reschedule your appointment for another date but not cancel it. 

{~ Payment_Block_Label}

{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}{binding displayValue}
{binding Name}:{binding displayValue}---
{{ Cognito.resources['payment-amount-due'] + ":" }} {binding displayValue}
{# pageNumbers}

{{ Cognito.resources['order-transaction-details-header'] }}

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}
{{ Cognito.resources['order-date-label'] }}: {binding displayValue}
{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}
{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}{binding displayValue}
{binding Name}:{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:{binding displayValue}

{{ Cognito.resources['order-transaction-details-header'] }}

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}
{{ Cognito.resources['order-date-label'] }}: {binding displayValue}
{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}
{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}{binding displayValue}
{binding Name}:{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:{binding displayValue}
How Much Would You Like To Pay? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are You a New Patient {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do You Have Insurance {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

PLEASE NOTE: If you have insurance, you don't qualify for this special. Your insurance will usually pay for the Exam & X-ray at 100%. 

Insert and format text, links, and images here.
What Insurance Do You Have? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Choose Your Office {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
When Do You Want Your Appointment? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
WHAT TIME {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date Of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
IMPORTANT: There are No Refunds for Cancellations. You can reschedule your appointment for another date but not cancel it.