{"id":3380,"date":"2022-06-15T14:44:33","date_gmt":"2022-06-15T14:44:33","guid":{"rendered":"https:\/\/713websites.com\/?page_id=3380"},"modified":"2022-06-15T14:46:24","modified_gmt":"2022-06-15T14:46:24","slug":"anesthesia-surgical-consent-form","status":"publish","type":"page","link":"https:\/\/713websites.com\/anesthesia-surgical-consent-form\/","title":{"rendered":"Anesthesia\/Surgical Consent Form"},"content":{"rendered":"<script type=\"text\/javascript\">var 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All anesthesia\/surgical procedures need to be dropped off between 7:00 AM and 8:00 AM the day of the procedure. Make sure your pet does not eat anything past  midnight the night before the procedure.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/wp-json\/wp\/v2\/pages\/3380' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_3_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_1'>\n                            \n                            <span id='input_3_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_3_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_2\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_2\" ><label class='gfield_label gform-field-label' for='input_3_2'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_2' id='input_3_2' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_3\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_3\" ><label class='gfield_label gform-field-label' for='input_3_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_3_3' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_4\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_4\" ><label class='gfield_label gform-field-label' for='input_3_4'>Pet&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_3_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_8\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_8\" ><label class='gfield_label gform-field-label' for='input_3_8'>Pet&#039;s Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_3_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_6\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_6\" ><label class='gfield_label gform-field-label' for='input_3_6'>Pet&#039;s Breed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_3_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_9\" ><legend class='gfield_label gform-field-label' >Sex<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_9'>\n\t\t\t<div class='gchoice gchoice_3_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Male'  id='choice_3_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_9_0' id='label_3_9_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Male (neutered)'  id='choice_3_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_9_1' id='label_3_9_1' class='gform-field-label gform-field-label--type-inline'>Male (neutered)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Female'  id='choice_3_9_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_9_2' id='label_3_9_2' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_9_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Female (spayed)'  id='choice_3_9_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_9_3' id='label_3_9_3' class='gform-field-label gform-field-label--type-inline'>Female (spayed)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_10\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_10\" ><label class='gfield_label gform-field-label' for='input_3_10'>Phone number at which owner can be reached today or tomorrow:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_3_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_61\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_61\" ><label class='gfield_label gform-field-label' for='input_3_61'>Additional Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_3_61' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_12\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_12\" ><label class='gfield_label gform-field-label' for='input_3_12'>Anesthetic and surgical procedure(s) to be performed:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_3_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_37\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_37\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I, the undersigned owner or agent of the pet identified above, authorize the staff of Your Veterinary Practice to perform the above procedure(s).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_37.1' id='input_3_37_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_37_1' >I have read and agree<\/label><input type='hidden' name='input_37.2' value='I have read and agree' class='gform_hidden' \/><input type='hidden' name='input_37.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_62\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_62\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >All anesthesia\/surgical procedures need to be dropped off between 7:00 AM and 8:00 AM the day of the procedure. Make sure your pet does not eat anything past midnight the night before the procedure.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_62.1' id='input_3_62_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_62_1' >I have read and agree<\/label><input type='hidden' name='input_62.2' value='I have read and agree' class='gform_hidden' \/><input type='hidden' name='input_62.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_21\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_21\" ><legend class='gfield_label gform-field-label' >Microchip:<\/legend><div class='gfield_description' id='gfield_description_3_21'>There is an additional fee for this<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_21'>\n\t\t\t<div class='gchoice gchoice_3_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_3_21_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_3_21\"   \/>\n\t\t\t\t\t<label for='choice_3_21_0' id='label_3_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_3_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_21_1' id='label_3_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_21_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Already has one'  id='choice_3_21_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_21_2' id='label_3_21_2' class='gform-field-label gform-field-label--type-inline'>Already has one<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_22\" ><legend class='gfield_label gform-field-label' >Nail Trim:<\/legend><div class='gfield_description' id='gfield_description_3_22'>There is an additional fee for this<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_22'>\n\t\t\t<div class='gchoice gchoice_3_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_3_22_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_3_22\"   \/>\n\t\t\t\t\t<label for='choice_3_22_0' id='label_3_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_3_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_22_1' id='label_3_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_23\" ><legend class='gfield_label gform-field-label' >Do you need heartworm or flea prevention:<\/legend><div class='gfield_description' id='gfield_description_3_23'>There is an additional fee for this<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_23'>\n\t\t\t<div class='gchoice gchoice_3_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_3_23_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_3_23\"   \/>\n\t\t\t\t\t<label for='choice_3_23_0' id='label_3_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_3_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_23_1' id='label_3_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_38\" ><legend class='gfield_label gform-field-label' >Does your pet have a history of seizures?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_38'>\n\t\t\t<div class='gchoice gchoice_3_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_3_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_38_0' id='label_3_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_3_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_38_1' id='label_3_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_39\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_39\" ><label class='gfield_label gform-field-label' for='input_3_39'>If Yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_3_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_40\" ><legend class='gfield_label gform-field-label' >Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_40'>\n\t\t\t<div class='gchoice gchoice_3_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_3_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_40_0' id='label_3_40_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_3_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_40_1' id='label_3_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_41\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_41\" ><label class='gfield_label gform-field-label' for='input_3_41'>If Yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_3_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_42\" ><legend class='gfield_label gform-field-label' >Does your pet need vaccines, heartworm test, anal gland expression or fecal test?<\/legend><div class='gfield_description' id='gfield_description_3_42'>*There is an additional fee for this*<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_42'>\n\t\t\t<div class='gchoice gchoice_3_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_3_42_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_3_42\"   \/>\n\t\t\t\t\t<label for='choice_3_42_0' id='label_3_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_3_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_42_1' id='label_3_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_43\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_43\" ><label class='gfield_label gform-field-label' for='input_3_43'>If Yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_3_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_44\" ><legend class='gfield_label gform-field-label' >Have you given your pets any medications or supplements in the past week?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_44'>\n\t\t\t<div class='gchoice gchoice_3_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_3_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_44_0' id='label_3_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_3_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_44_1' id='label_3_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_45\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_45\" ><label class='gfield_label gform-field-label' for='input_3_45'>If Yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_3_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_46\" ><legend class='gfield_label gform-field-label' >Is your pet on any medications consistently?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_46'>\n\t\t\t<div class='gchoice gchoice_3_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Yes'  id='choice_3_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_46_0' id='label_3_46_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='No'  id='choice_3_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_46_1' id='label_3_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_47\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_47\" ><label class='gfield_label gform-field-label' for='input_3_47'>If Yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_3_47' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_48\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_48\" ><label class='gfield_label gform-field-label' for='input_3_48'>What time did you pet last eat? (example 7:00 pm yesterday)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_3_48' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_50\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_50\" ><label class='gfield_label gform-field-label' for='input_3_50'>Any other concerns or any other information we need to know?<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_3_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_51\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >After procedure:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_51'><div class='gchoice gchoice_3_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Text'  id='choice_3_51_1'   aria-describedby=\"gfield_description_3_51\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_51_1' id='label_3_51_1' class='gform-field-label gform-field-label--type-inline'>Text<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='Call'  id='choice_3_51_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_51_2' id='label_3_51_2' class='gform-field-label gform-field-label--type-inline'>Call<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_3_51'>Would you like us to text you after the procedure, or would you prefer a call?<\/div><\/fieldset><fieldset id=\"field_3_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_55\" ><legend class='gfield_label gform-field-label' >Social Media\/Photo Permission<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_55'>\n\t\t\t<div class='gchoice gchoice_3_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_3_55_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_3_55\"   \/>\n\t\t\t\t\t<label for='choice_3_55_0' id='label_3_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_3_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_55_1' id='label_3_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_3_55'>Do we have your permission to post photos of your pet online? Your pets&#8217; picture or video may be taken while they are with us and used for Your Veterinary Practice advertisement (www.truecompanionvetcare.com) or other social media purposes (Facebook, SnapChat, Instagram, Twitter, Tiktok, etc.). Please indicate if you authorize for their pictures\/videos to be posted or used. * If you do not authorize for your pet\u2019s picture to be included in our marketing materials\/venues, we may still use a picture of your pet in our patient records for our internal identification only*<\/div><\/fieldset><fieldset id=\"field_3_25\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_25\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Procedure Risks<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_25'>I understand that some risks always exist with anesthesia and\/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian or technician before the procedure(s) is\/are initiated. I acknowledge and understand that the above stated procedure(s) bear(s) certain known and unknown risks or unanticipated risks, which could result in injury to my pet, including, the possibility of its death.  I also understand and realize that additional risks of the procedure(s) may include adverse reactions to my pet, such as, but not limited to, allergic reactions from medications and\/or complications or death during (or after) surgery. <\/div><div class='ginput_container ginput_container_consent'><input name='input_25.1' id='input_3_25_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_3_25\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_25_1' >I have read and agree<\/label><input type='hidden' name='input_25.2' value='I have read and agree' class='gform_hidden' \/><input type='hidden' name='input_25.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_63\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_63\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Post &#8211; Procedure Risks<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_63'>While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions.<\/div><div class='ginput_container ginput_container_consent'><input name='input_63.1' id='input_3_63_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_3_63\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_63_1' >I have read and agree<\/label><input type='hidden' name='input_63.2' value='I have read and agree' class='gform_hidden' \/><input type='hidden' name='input_63.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_64\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_64\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Financial Responsibility<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_64'>I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. <\/div><div class='ginput_container ginput_container_consent'><input name='input_64.1' id='input_3_64_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_3_64\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_64_1' >I have read and agree<\/label><input type='hidden' name='input_64.2' value='I have read and agree' class='gform_hidden' \/><input type='hidden' name='input_64.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_65\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_65\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am at least 18 years of age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_65'>I verify I am at least 18 years of age and I am the owner or authorized agent of the above pet. <\/div><div class='ginput_container ginput_container_consent'><input name='input_65.1' id='input_3_65_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_3_65\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_65_1' >I have read and agree<\/label><input type='hidden' name='input_65.2' value='I have read and agree' class='gform_hidden' \/><input type='hidden' name='input_65.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_66\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_66\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Emergency Medical Attention<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_66'>If your pet needs emergency medical attention or becomes ill, our staff will make every effort to contact you. However, if we cannot contact you, we will proceed with minimal acceptable medical care until you can be reached. You will be responsible for any incurred expenses. <\/div><div class='ginput_container ginput_container_consent'><input name='input_66.1' id='input_3_66_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_3_66\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_66_1' >I have read and agree<\/label><input type='hidden' name='input_66.2' value='I have read and agree' class='gform_hidden' \/><input type='hidden' name='input_66.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_67\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_67\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Hospitalization Authorization<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_67'>I hereby consent and authorize Your Veterinary Practice to receive and hospitalize my pet. I understand the hospital will use all reasonable precautions for the safekeeping of the described pet, but the hospital will not be held responsible in any manner whatsoever on account of medical situations that may arise, as it is thoroughly understood that I assume all risks. I also understand that hospital personnel are not present continuously after normal business hours. I have read, understand and agree to all provisions of this agreement. <\/div><div class='ginput_container ginput_container_consent'><input name='input_67.1' id='input_3_67_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_3_67\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_67_1' >I have read and agree<\/label><input type='hidden' name='input_67.2' value='I have read and agree' class='gform_hidden' \/><input type='hidden' name='input_67.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_53\" ><legend class='gfield_label gform-field-label' >CPR PERMISSION<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_53'>I understand Your Veterinary Practice- requires a CPR status prior to the start of any and all procedures so immediate action can take place in the event of cardiopulmonary arrest during, before, or after anesthesia or anytime in our care. I acknowledge that the attending veterinarian or staff members of Your Veterinary Practice will make every effort to contact me regarding treatment in the case of this unforeseen event. The starting cost of CPR is approximately $400. I understand that there is no guarantee of successful resuscitation.\u00a0<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_53'>\n\t\t\t<div class='gchoice gchoice_3_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Yes, please perform CPR on my pet.'  id='choice_3_53_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_3_53\"   \/>\n\t\t\t\t\t<label for='choice_3_53_0' id='label_3_53_0' class='gform-field-label gform-field-label--type-inline'>Yes, please perform CPR on my pet.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='No, do not perform CPR on my pet.\u00a0'  id='choice_3_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_53_1' id='label_3_53_1' class='gform-field-label gform-field-label--type-inline'>No, do not perform CPR on my pet.\u00a0<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_69\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_69\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cancelation Policy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_69.1' id='input_3_69_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_69_1' >I understand that appointment cancellations less than 24 hours before appointment and\/or no shows will incur a $30.00 cancellation fee.<\/label><input type='hidden' name='input_69.2' value='I understand that appointment cancellations less than 24 hours before appointment and\/or no shows will incur a $30.00 cancellation fee.' class='gform_hidden' \/><input type='hidden' name='input_69.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_26\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_3_26\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >TERMS AND CONDITIONS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_26'>While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above.<\/div><div class='ginput_container ginput_container_consent'><input name='input_26.1' id='input_3_26_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_3_26\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_26_1' >I have read and agree<\/label><input type='hidden' name='input_26.2' value='I have read and agree' class='gform_hidden' \/><input type='hidden' name='input_26.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_3_54\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_54\" ><h3 class=\"gsection_title\">For Dental procedures only:<\/h3><\/div><fieldset id=\"field_3_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_59\" ><legend class='gfield_label gform-field-label' >Would you like a call before dental extractions?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_59'>\n\t\t\t<div class='gchoice gchoice_3_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Yes'  id='choice_3_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_59_0' id='label_3_59_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_3_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_59_1' id='label_3_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_59_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='N\/A'  id='choice_3_59_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_59_2' id='label_3_59_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_71\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_71\" ><label class='gfield_label gform-field-label' for='input_3_71'>If Yes, What Number?<\/label><div class='ginput_container ginput_container_phone'><input name='input_71' id='input_3_71' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_72\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_72\" ><h3 class=\"gsection_title\">Covid Pre-Cautions<\/h3><\/div><fieldset id=\"field_3_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_56\" ><legend class='gfield_label gform-field-label' >Have you or anyone that you have had close contact with tested positive for COVID-19 in the past 14 days?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_56'>\n\t\t\t<div class='gchoice gchoice_3_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Yes'  id='choice_3_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_56_0' id='label_3_56_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='No'  id='choice_3_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_56_1' id='label_3_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_57\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_57\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you or anyone in your house experienced the following symptoms in the past 14 days?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_57'><div class='gchoice gchoice_3_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Cough'  id='choice_3_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_1' id='label_3_57_1' class='gform-field-label gform-field-label--type-inline'>Cough<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Shortness of Breath'  id='choice_3_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_2' id='label_3_57_2' class='gform-field-label gform-field-label--type-inline'>Shortness of Breath<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='Fever'  id='choice_3_57_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_3' id='label_3_57_3' class='gform-field-label gform-field-label--type-inline'>Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.4' type='checkbox'  value='Sore Throat'  id='choice_3_57_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_4' id='label_3_57_4' class='gform-field-label gform-field-label--type-inline'>Sore Throat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.5' type='checkbox'  value='Chills'  id='choice_3_57_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_5' id='label_3_57_5' class='gform-field-label gform-field-label--type-inline'>Chills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.6' type='checkbox'  value='Muscle Pain'  id='choice_3_57_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_6' id='label_3_57_6' class='gform-field-label gform-field-label--type-inline'>Muscle Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.7' type='checkbox'  value='Headache'  id='choice_3_57_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_7' id='label_3_57_7' class='gform-field-label gform-field-label--type-inline'>Headache<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.8' type='checkbox'  value='New loss of taste or smell'  id='choice_3_57_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_8' id='label_3_57_8' class='gform-field-label gform-field-label--type-inline'>New loss of taste or smell<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_58\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_58\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Who experienced these symptoms?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_58'><div class='gchoice gchoice_3_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='Self'  id='choice_3_58_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_58_1' id='label_3_58_1' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_58_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.2' type='checkbox'  value='Someone else'  id='choice_3_58_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_58_2' id='label_3_58_2' class='gform-field-label gform-field-label--type-inline'>Someone else<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_58_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.3' type='checkbox'  value='No Symptoms'  id='choice_3_58_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_58_3' id='label_3_58_3' class='gform-field-label gform-field-label--type-inline'>No Symptoms<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_36\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_36\" ><h3 class=\"gsection_title\">If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring  your pet to their appointment<\/h3><\/div><fieldset id=\"field_3_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_60\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cancellation Policy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_60'><div class='gchoice gchoice_3_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='I understand that appointment cancellations less than 24 hours before appointment and\/or no shows will incur a $30.00 cancellation fee.'  id='choice_3_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_1' id='label_3_60_1' class='gform-field-label gform-field-label--type-inline'>I understand that appointment cancellations less than 24 hours before appointment and\/or no shows will incur a $30.00 cancellation fee.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_70\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_70\" ><label class='gfield_label gform-field-label' for='input_3_70'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_70' id='input_3_70' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_34\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_34\" ><label class='gfield_label gform-field-label' for='input_3_34'>Please type your initials.<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_3_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_35\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_35\" ><label class='gfield_label gform-field-label' for='input_3_35'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_35' id='input_3_35' type='text' value='03\/21\/2024' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_35_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_35_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_35' class='gform_hidden' value='https:\/\/713websites.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_73\" class=\"gfield gfield--type-signature field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_73\" ><label class='gfield_label gform-field-label' for='input_3_73'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_73_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_3_73_valid' id='input_3_73_valid' \/><canvas id='input_3_73' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_74\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_74\" ><label class='gfield_label gform-field-label' for='input_3_74'>Email<\/label><div class='ginput_container'><input name='input_74' id='input_3_74' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_74'>This field is for validation purposes and should be left unchanged.<\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input 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