<!-- Begin MailChimp Signup Form --><!-- [et_pb_line_break_holder] --><link href="//cdn-images.mailchimp.com/embedcode/classic-10_7.css" rel="stylesheet" type="text/css"><!-- [et_pb_line_break_holder] --><style type="text/css"><!-- [et_pb_line_break_holder] --> #mc_embed_signup{background:#fff; clear:left; font:14px Helvetica,Arial,sans-serif; }<!-- [et_pb_line_break_holder] --> /* Add your own MailChimp form style overrides in your site stylesheet or in this style block.<!-- [et_pb_line_break_holder] --> We recommend moving this block and the preceding CSS link to the HEAD of your HTML file. */<!-- [et_pb_line_break_holder] --></style><!-- [et_pb_line_break_holder] --><div id="mc_embed_signup"><!-- [et_pb_line_break_holder] --><form action="https://fortworthprimarycare.us12.list-manage.com/subscribe/post?u=5736cf1b5ef677f23111f777f&id=e4b240e0df" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate><!-- [et_pb_line_break_holder] --> <div id="mc_embed_signup_scroll"><!-- [et_pb_line_break_holder] --> <h2>Stay Up to Date</h2><!-- [et_pb_line_break_holder] --><div class="indicates-required"><span class="asterisk">*</span> indicates required</div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-EMAIL">Email Address <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="email" value="" name="EMAIL" class="required email" id="mce-EMAIL"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-FNAME">First Name </label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="FNAME" class="" id="mce-FNAME"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-LNAME">Last Name </label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="LNAME" class="" id="mce-LNAME"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-BIRTHDAY-month">Birthday </label><!-- [et_pb_line_break_holder] --> <div class="datefield"><!-- [et_pb_line_break_holder] --> <span class="subfield monthfield"><input class="birthday " type="text" pattern="[0-9]*" value="" placeholder="MM" size="2" maxlength="2" name="BIRTHDAY[month]" id="mce-BIRTHDAY-month"></span> / <!-- [et_pb_line_break_holder] --> <span class="subfield dayfield"><input class="birthday " type="text" pattern="[0-9]*" value="" placeholder="DD" size="2" maxlength="2" name="BIRTHDAY[day]" id="mce-BIRTHDAY-day"></span> <!-- [et_pb_line_break_holder] --> <span class="small-meta nowrap">( mm / dd )</span><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --></div> <div id="mce-responses" class="clear"><!-- [et_pb_line_break_holder] --> <div class="response" id="mce-error-response" style="display:none"></div><!-- [et_pb_line_break_holder] --> <div class="response" id="mce-success-response" style="display:none"></div><!-- [et_pb_line_break_holder] --> </div> <!-- real people should not fill this in and expect good things - do not remove this or risk form bot signups--><!-- [et_pb_line_break_holder] --> <div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text" name="b_5736cf1b5ef677f23111f777f_e4b240e0df" tabindex="-1" value=""></div><!-- [et_pb_line_break_holder] --> <div class="clear"><input type="submit" value="Subscribe" name="subscribe" id="mc-embedded-subscribe" class="button"></div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --></form><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!--End mc_embed_signup-->