{"id":3392,"date":"2022-06-15T14:58:14","date_gmt":"2022-06-15T14:58:14","guid":{"rendered":"https:\/\/713websites.com\/?page_id=3392"},"modified":"2022-06-15T14:58:16","modified_gmt":"2022-06-15T14:58:16","slug":"medical-concern-form","status":"publish","type":"page","link":"https:\/\/713websites.com\/medical-concern-form\/","title":{"rendered":"Medical Concern Form"},"content":{"rendered":"<script type=\"text\/javascript\">var 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form_sublabel_below description_below'><fieldset id=\"field_2_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_2_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_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_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_2_2\" ><label class='gfield_label gform-field-label' for='input_2_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_2_2' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_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_2_3\" ><label class='gfield_label gform-field-label' for='input_2_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_2_3' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_4\" 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_2_4\" ><label class='gfield_label gform-field-label' for='input_2_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_2_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_5\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\" ><legend class='gfield_label gform-field-label' >Who should we contact to make medical decisions today?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_5'>\n\t\t\t<div class='gchoice gchoice_2_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Owner (Named Above)'  id='choice_2_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_5_0' id='label_2_5_0' class='gform-field-label gform-field-label--type-inline'>Owner (Named Above)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Someone Else (Named Below)'  id='choice_2_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_5_1' id='label_2_5_1' class='gform-field-label gform-field-label--type-inline'>Someone Else (Named Below)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If you have any questions, please contact our team members prior to your arrival for assistance.<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_2_6'><div class='gchoice gchoice_2_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='I have read and understand.'  id='choice_2_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_6_1' id='label_2_6_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_7\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Reason for visit: (check all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_7'><div class='gchoice gchoice_2_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='Illness'  id='choice_2_7_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_1' id='label_2_7_1' class='gform-field-label gform-field-label--type-inline'>Illness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_7_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.2' type='checkbox'  value='Injury'  id='choice_2_7_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_2' id='label_2_7_2' class='gform-field-label gform-field-label--type-inline'>Injury<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_7_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.3' type='checkbox'  value='Other'  id='choice_2_7_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_3' id='label_2_7_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><button type=\"button\" id=\"button_7_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Select All\" data-label-deselect=\"Deselect All\">Select All<\/button><\/div><\/div><\/fieldset><div id=\"field_2_8\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\" ><label class='gfield_label gform-field-label' for='input_2_8'>What symptoms has your pet been experiencing?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_2_8' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_9\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are there any concerns for the following: (check all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_9'><div class='gchoice gchoice_2_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Increase in appetite'  id='choice_2_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_1' id='label_2_9_1' class='gform-field-label gform-field-label--type-inline'>Increase in appetite<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Decrease in appetite'  id='choice_2_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_2' id='label_2_9_2' class='gform-field-label gform-field-label--type-inline'>Decrease in appetite<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Increase in drinking'  id='choice_2_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_3' id='label_2_9_3' class='gform-field-label gform-field-label--type-inline'>Increase in drinking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Decrease in drinking'  id='choice_2_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_4' id='label_2_9_4' class='gform-field-label gform-field-label--type-inline'>Decrease in drinking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Weight Loss'  id='choice_2_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_5' id='label_2_9_5' class='gform-field-label gform-field-label--type-inline'>Weight Loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Weight Gain'  id='choice_2_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_6' id='label_2_9_6' class='gform-field-label gform-field-label--type-inline'>Weight Gain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.7' type='checkbox'  value='Itching\/Scratching'  id='choice_2_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_7' id='label_2_9_7' class='gform-field-label gform-field-label--type-inline'>Itching\/Scratching<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.8' type='checkbox'  value='Shaking Head'  id='choice_2_9_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_8' id='label_2_9_8' class='gform-field-label gform-field-label--type-inline'>Shaking Head<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.9' type='checkbox'  value='Bad Breath'  id='choice_2_9_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_9' id='label_2_9_9' class='gform-field-label gform-field-label--type-inline'>Bad Breath<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.11' type='checkbox'  value='Vomiting'  id='choice_2_9_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_11' id='label_2_9_11' class='gform-field-label gform-field-label--type-inline'>Vomiting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.12' type='checkbox'  value='Diarrhea'  id='choice_2_9_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_12' id='label_2_9_12' class='gform-field-label gform-field-label--type-inline'>Diarrhea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.13' type='checkbox'  value='Urination Issues'  id='choice_2_9_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_13' id='label_2_9_13' class='gform-field-label gform-field-label--type-inline'>Urination Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.14' type='checkbox'  value='Excessive Sleeping'  id='choice_2_9_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_14' id='label_2_9_14' class='gform-field-label gform-field-label--type-inline'>Excessive Sleeping<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.15' type='checkbox'  value='Scooting'  id='choice_2_9_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_15' id='label_2_9_15' class='gform-field-label gform-field-label--type-inline'>Scooting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.16' type='checkbox'  value='Difficulty Rising'  id='choice_2_9_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_16' id='label_2_9_16' class='gform-field-label gform-field-label--type-inline'>Difficulty Rising<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.17' type='checkbox'  value='Skin Masses (explain below)'  id='choice_2_9_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_17' id='label_2_9_17' class='gform-field-label gform-field-label--type-inline'>Skin Masses (explain below)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.18' type='checkbox'  value='Car Sickness'  id='choice_2_9_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_18' id='label_2_9_18' class='gform-field-label gform-field-label--type-inline'>Car Sickness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.19' type='checkbox'  value='Behavioral Problem'  id='choice_2_9_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_19' id='label_2_9_19' class='gform-field-label gform-field-label--type-inline'>Behavioral Problem<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.21' type='checkbox'  value='Other (explain below)'  id='choice_2_9_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_21' id='label_2_9_21' class='gform-field-label gform-field-label--type-inline'>Other (explain below)<\/label>\n\t\t\t\t\t\t\t<\/div><button type=\"button\" id=\"button_9_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Select All\" data-label-deselect=\"Deselect All\">Select All<\/button><\/div><\/div><\/fieldset><div id=\"field_2_10\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\" ><label class='gfield_label gform-field-label' for='input_2_10'>When did the problem start?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_2_10' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_11\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_11\" ><legend class='gfield_label gform-field-label' >Have the symptoms worsened, improved, or stayed the same since you first noticed them?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_11'>\n\t\t\t<div class='gchoice gchoice_2_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No change'  id='choice_2_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_11_0' id='label_2_11_0' class='gform-field-label gform-field-label--type-inline'>No change<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Worsened'  id='choice_2_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_11_1' id='label_2_11_1' class='gform-field-label gform-field-label--type-inline'>Worsened<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_11_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Improved'  id='choice_2_11_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_11_2' id='label_2_11_2' class='gform-field-label gform-field-label--type-inline'>Improved<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_12\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_12\" ><legend class='gfield_label gform-field-label' >Has your pet experienced this problem in the past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_12'>\n\t\t\t<div class='gchoice gchoice_2_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Yes'  id='choice_2_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_12_0' id='label_2_12_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_2_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='No'  id='choice_2_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_12_1' id='label_2_12_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_13\" 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_2_13\" ><legend class='gfield_label gform-field-label' >Is your pet on any medications?<\/legend><div class='gfield_description' id='gfield_description_2_13'>This includes heartworm\/flea prevention, over the counter and prescription<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_13'>\n\t\t\t<div class='gchoice gchoice_2_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes'  id='choice_2_13_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_13\"   \/>\n\t\t\t\t\t<label for='choice_2_13_0' id='label_2_13_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_2_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_2_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_1' id='label_2_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_14\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_14\" ><label class='gfield_label gform-field-label' for='input_2_14'>What brand of food do you feed your pet?<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_15\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\" ><legend class='gfield_label gform-field-label' >How much do you feed?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_15'>\n\t\t\t<div class='gchoice gchoice_2_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Free fed (food is offered always\/whenever hungry)'  id='choice_2_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_15_0' id='label_2_15_0' class='gform-field-label gform-field-label--type-inline'>Free fed (food is offered always\/whenever hungry)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Measured amount (specify how much and how often below)'  id='choice_2_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_15_1' id='label_2_15_1' class='gform-field-label gform-field-label--type-inline'>Measured amount (specify how much and how often below)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_16\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_16\" ><label class='gfield_label gform-field-label' for='input_2_16'>Specified Amount<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_17\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_17\" ><legend class='gfield_label gform-field-label' >Have there been any changes in appetite?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_17'>\n\t\t\t<div class='gchoice gchoice_2_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Increased'  id='choice_2_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_17_0' id='label_2_17_0' class='gform-field-label gform-field-label--type-inline'>Increased<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Decreased'  id='choice_2_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_17_1' id='label_2_17_1' class='gform-field-label gform-field-label--type-inline'>Decreased<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No change'  id='choice_2_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_17_2' id='label_2_17_2' class='gform-field-label gform-field-label--type-inline'>No change<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_20\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\" ><label class='gfield_label gform-field-label' for='input_2_20'>If there has, for how long? Please elaborate.<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_19\" 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_2_19\" ><legend class='gfield_label gform-field-label' >Any increase or decrease in water consumption?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_19'>\n\t\t\t<div class='gchoice gchoice_2_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Increased'  id='choice_2_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_19_0' id='label_2_19_0' class='gform-field-label gform-field-label--type-inline'>Increased<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Decreased'  id='choice_2_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_19_1' id='label_2_19_1' class='gform-field-label gform-field-label--type-inline'>Decreased<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_19_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No change'  id='choice_2_19_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_19_2' id='label_2_19_2' class='gform-field-label gform-field-label--type-inline'>No change<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_21\" 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_2_21\" ><legend class='gfield_label gform-field-label' >Any change in bowel movements?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_21'>\n\t\t\t<div class='gchoice gchoice_2_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_2_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_21_0' id='label_2_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_2_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_2_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_21_1' id='label_2_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_2_21_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Unsure'  id='choice_2_21_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_21_2' id='label_2_21_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_22\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_22\" ><label class='gfield_label gform-field-label' for='input_2_22'>If Yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_2_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_23\" 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_2_23\" ><legend class='gfield_label gform-field-label' >Does your pet spend time outside, even for walks or in the yard?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_23'>\n\t\t\t<div class='gchoice gchoice_2_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_2_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_23_0' id='label_2_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_2_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_2_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_24\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Does your pet come into contact with other dogs?<\/legend><div class='gfield_description' id='gfield_description_2_24'> Please check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_24'><div class='gchoice gchoice_2_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Boarding'  id='choice_2_24_1'   aria-describedby=\"gfield_description_2_24\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_1' id='label_2_24_1' class='gform-field-label gform-field-label--type-inline'>Boarding<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Grooming'  id='choice_2_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_2' id='label_2_24_2' class='gform-field-label gform-field-label--type-inline'>Grooming<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Dog Parks'  id='choice_2_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_3' id='label_2_24_3' class='gform-field-label gform-field-label--type-inline'>Dog Parks<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Other'  id='choice_2_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_4' id='label_2_24_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='None of the above'  id='choice_2_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_5' id='label_2_24_5' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><button type=\"button\" id=\"button_24_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Select All\" data-label-deselect=\"Deselect All\">Select All<\/button><\/div><\/div><\/fieldset><fieldset id=\"field_2_25\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\" ><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_2_25'>\n\t\t\t<div class='gchoice gchoice_2_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_2_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_25_0' id='label_2_25_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_2_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_2_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_25_1' id='label_2_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_26\" 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_2_26\" ><legend class='gfield_label gform-field-label' >Is your pet on any medications?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_26'>\n\t\t\t<div class='gchoice gchoice_2_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_2_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_26_0' id='label_2_26_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_2_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_2_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_26_1' id='label_2_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_27\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_27\" ><label class='gfield_label gform-field-label' for='input_2_27'>If Yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_2_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_28\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_28\" ><legend class='gfield_label gform-field-label' >Is your pet current on vaccines?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_28'>\n\t\t\t<div class='gchoice gchoice_2_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Yes'  id='choice_2_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_28_0' id='label_2_28_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_2_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_2_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_28_1' id='label_2_28_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_2_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Unsure'  id='choice_2_28_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_28_2' id='label_2_28_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_29\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_29\" ><label class='gfield_label gform-field-label' for='input_2_29'>If Yes, please specify which vaccine and expiration date<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_2_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_30\" ><legend class='gfield_label gform-field-label' >Microchip:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_30'>\n\t\t\t<div class='gchoice gchoice_2_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_2_30_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_30\"   \/>\n\t\t\t\t\t<label for='choice_2_30_0' id='label_2_30_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_2_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_2_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_30_1' id='label_2_30_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_2_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Unsure'  id='choice_2_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_30_2' id='label_2_30_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_2_30'>*There is an additional fee for this<\/div><\/fieldset><fieldset id=\"field_2_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_31\" ><legend class='gfield_label gform-field-label' >Nail Trim:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_31'>\n\t\t\t<div class='gchoice gchoice_2_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_2_31_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_31\"   \/>\n\t\t\t\t\t<label for='choice_2_31_0' id='label_2_31_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_2_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_2_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_1' id='label_2_31_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_2_31'>*There is an additional fee for this<\/div><\/fieldset><fieldset id=\"field_2_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_32\" ><legend class='gfield_label gform-field-label' >Do you need heartworm or flea prevention:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_32'>\n\t\t\t<div class='gchoice gchoice_2_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Yes'  id='choice_2_32_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_32\"   \/>\n\t\t\t\t\t<label for='choice_2_32_0' id='label_2_32_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_2_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_2_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_32_1' id='label_2_32_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_2_32'>*There is an additional fee for this<\/div><\/fieldset><div id=\"field_2_33\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_33\" ><label class='gfield_label gform-field-label' for='input_2_33'>If Yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_2_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_52\" 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_2_52\" ><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_2_52'>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_2_52'>\n\t\t\t<div class='gchoice gchoice_2_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Yes, please perform CPR on my pet.'  id='choice_2_52_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_52\"   \/>\n\t\t\t\t\t<label for='choice_2_52_0' id='label_2_52_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_2_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='No, do not perform CPR on my pet.\u00a0'  id='choice_2_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_52_1' id='label_2_52_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_2_34\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_34\" ><legend class='gfield_label gform-field-label' >Was your pet last seen by a veterinarian at Your Veterinary Practice?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_34'>\n\t\t\t<div class='gchoice gchoice_2_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_2_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_0' id='label_2_34_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_2_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_2_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_35\" class=\"gfield gfield--type-consent gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_35\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >PAYMENT:<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_2_35'>Payment in full is required at the end of your visit today. Once your pet\u2019s exam is completed, we will contact you to go over the exam findings and recommendations. We accept Visa, Mastercard, American Express, Discover, CareCredit and Scratchpay for payment. Should you opt for CareCredit or Scratchpay as your form of payment, we ask that you apply prior to your visit to streamline your appointment. We do not accept checks and strongly discourage the use of cash due to the global pandemic.<\/div><div class='ginput_container ginput_container_consent'><input name='input_35.1' id='input_2_35_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_35\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_35_1' >I understand.<\/label><input type='hidden' name='input_35.2' value='I understand.' class='gform_hidden' \/><input type='hidden' name='input_35.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_2_36\" 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_2_36\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >APPOINTMENTS:<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_2_36'>To ensure your appointment is as timely as possible, we strongly recommend that the pet parent (responsible party) attend or bring the pet to the exam with the Veterinarian. A cancelation fee deposit of $54, will be collected when scheduling your pet\u2019s next exam if you cancel, reschedule or miss the appointment in less than 24 hours. When appointments are not kept or canceled in a timely fashion, it prevents us from scheduling patients that need medical attention. The deposit will be applied towards your pet&#39;s exam fees at the time of discharge. If you&#39;re unable to cancel the appointment with a 24-hour notice, the deposit will be forfeited. We offer appointments 6 days a week, including 9am \u2013 3:30pm on Saturdays &#8211; please take advantage of our extended hours to make sure you are available for your pet&#39;s exam.<\/div><div class='ginput_container ginput_container_consent'><input name='input_36.1' id='input_2_36_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_36\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_36_1' >I understand.<\/label><input type='hidden' name='input_36.2' value='I understand.' class='gform_hidden' \/><input type='hidden' name='input_36.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_2_37\" 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_2_37\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >MEDICAL EXAMS:<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_2_37'> If you are requesting that we vaccinate your pet, please be advised by state law, we can only vaccinate pets healthy enough to receive a vaccine. To determine if they are healthy, we require a physical exam performed by our Veterinarian to ensure we are only vaccinating healthy pets. If we administer vaccines you will be charged for a Exam ($54.00 plus vaccine costs) annually as well as any needed tests. If one of our Doctors has examined your pet over 30 days ago we will require another  exam, to ensure your pet is healthy enough to receive a vaccine. Other fees will apply for pets that are sick or Injured as well as for Work-In Appointments or Emergencies.<\/div><div class='ginput_container ginput_container_consent'><input name='input_37.1' id='input_2_37_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_37\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_37_1' >I understand.<\/label><input type='hidden' name='input_37.2' value='I understand.' class='gform_hidden' \/><input type='hidden' name='input_37.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_2_38\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_38\" ><legend class='gfield_label gform-field-label' >Social Media\/Photo Permission<\/legend><div class='gfield_description' id='gfield_description_2_38'>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, 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><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_38'>\n\t\t\t<div class='gchoice gchoice_2_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_2_38_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_38\"   \/>\n\t\t\t\t\t<label for='choice_2_38_0' id='label_2_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_2_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_2_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_38_1' id='label_2_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_39\" 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_2_39\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Once the doctor has completed your pet\u2019s exam, we will contact you to go over the recommended treatment plan.<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_2_39'> I understand that financial responsibilities for services are rendered at the time of discharge.<\/div><div class='ginput_container ginput_container_consent'><input name='input_39.1' id='input_2_39_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_39\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_39_1' >I have read and understand.<\/label><input type='hidden' name='input_39.2' value='I have read and understand.' class='gform_hidden' \/><input type='hidden' name='input_39.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_2_40\" 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_2_40\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I give Your Veterinary Practice authorization to treat as discussed above.<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_40.1' id='input_2_40_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_2_40_1' >I have read and agree.<\/label><input type='hidden' name='input_40.2' value='I have read and agree.' class='gform_hidden' \/><input type='hidden' name='input_40.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_2_41\" 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_2_41\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If Curbside care is elected:<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_2_41'>If Curbside care is elected: During the duration of the exam, your pet will be in the care of one of our team members. A team member will collect your pet from outside the building and support them through the exam, any services required, and then bring them back to your vehicle, when your pet is ready to go home. We strongly recommend you head home and a veterinarian or nurse will call you to discuss your pet\u2019s exam and discuss recommended treatments, preventative measures and give an estimated discharge time.<\/div><div class='ginput_container ginput_container_consent'><input name='input_41.1' id='input_2_41_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_41\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_41_1' >I have read and understand.<\/label><input type='hidden' name='input_41.2' value='I have read and understand.' class='gform_hidden' \/><input type='hidden' name='input_41.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_2_42\" 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_2_42\" ><label class='gfield_label gform-field-label' for='input_2_42'>Please type your initials.<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_42' id='input_2_42' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_43\" 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_2_43\" ><label class='gfield_label gform-field-label' for='input_2_43'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_43' id='input_2_43' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_43_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_43_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_43' class='gform_hidden' value='https:\/\/713websites.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_44\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_44\" ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_2_44'>Please text photos of your pet&#8217;s records to 555-555-1212 and\/or email records to info@YourVetPractice.com so that your veterinarian knows which vaccines or treatments have already been started. We need records before your appointment.<\/div><\/div><fieldset id=\"field_2_45\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_45\" ><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_2_45'>\n\t\t\t<div class='gchoice gchoice_2_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Yes'  id='choice_2_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_45_0' id='label_2_45_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_2_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='No'  id='choice_2_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_45_1' id='label_2_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_46\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_46\" ><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_2_46'><div class='gchoice gchoice_2_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Cough'  id='choice_2_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_46_1' id='label_2_46_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_2_46_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.2' type='checkbox'  value='Shortness of breath'  id='choice_2_46_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_46_2' id='label_2_46_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_2_46_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.3' type='checkbox'  value='Fever'  id='choice_2_46_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_46_3' id='label_2_46_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_2_46_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.4' type='checkbox'  value='Sore throat'  id='choice_2_46_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_46_4' id='label_2_46_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_2_46_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.5' type='checkbox'  value='Chills'  id='choice_2_46_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_46_5' id='label_2_46_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_2_46_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.6' type='checkbox'  value='Muscle pain'  id='choice_2_46_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_46_6' id='label_2_46_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_2_46_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.7' type='checkbox'  value='Headache'  id='choice_2_46_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_46_7' id='label_2_46_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_2_46_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.8' type='checkbox'  value='New loss of taste or smell'  id='choice_2_46_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_46_8' id='label_2_46_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><button type=\"button\" id=\"button_46_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Select All\" data-label-deselect=\"Deselect All\">Select All<\/button><\/div><\/div><\/fieldset><fieldset id=\"field_2_47\" 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_2_47\" ><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_2_47'><div class='gchoice gchoice_2_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Self'  id='choice_2_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_47_1' id='label_2_47_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_2_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Someone else in the house'  id='choice_2_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_47_2' id='label_2_47_2' class='gform-field-label gform-field-label--type-inline'>Someone else in the house<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='No symptoms'  id='choice_2_47_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_47_3' id='label_2_47_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><fieldset id=\"field_2_49\" class=\"gfield gfield--type-consent gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_49\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >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*<\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_2_49'>If Curbside care is elected: During the duration of the exam, your pet will be in the care of one of our team members. A team member will collect your pet from outside the building and support them through the exam, any services required, and then bring them back to your vehicle, when your pet is ready to go home. We strongly recommend you head home and a veterinarian or nurse will call you to discuss your pet\u2019s exam and  discuss recommended treatments, preventative measures and give an estimated discharge time.<\/div><div class='ginput_container ginput_container_consent'><input name='input_49.1' id='input_2_49_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_49\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_49_1' >I have read and understand.<\/label><input type='hidden' name='input_49.2' value='I have read and understand.' class='gform_hidden' \/><input type='hidden' name='input_49.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_2_53\" class=\"gfield gfield--type-checkbox 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_2_53\" ><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_2_53'><div class='gchoice gchoice_2_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' 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_2_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_53_1' id='label_2_53_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_2_50\" 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_2_50\" ><label class='gfield_label gform-field-label' for='input_2_50'>Please type your initials.<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_50' id='input_2_50' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_51\" 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_2_51\" ><label class='gfield_label gform-field-label' for='input_2_51'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_51' id='input_2_51' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_51_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_51_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_51' class='gform_hidden' value='https:\/\/713websites.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_54\" class=\"gfield gfield--type-signature field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_54\" ><label class='gfield_label gform-field-label' for='input_2_54'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_54_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_2_54_valid' id='input_2_54_valid' \/><canvas id='input_2_54' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_2_55\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_55\" ><label class='gfield_label gform-field-label' for='input_2_55'>Name<\/label><div class='ginput_container'><input name='input_55' id='input_2_55' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_2_55'>This field is for validation purposes and should be left unchanged.<\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_2\"]){return false;}  if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  jQuery(\"#gform_2\").trigger(\"submit\",[true]); 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