{"id":3396,"date":"2022-06-15T15:00:56","date_gmt":"2022-06-15T15:00:56","guid":{"rendered":"https:\/\/713websites.com\/?page_id=3396"},"modified":"2022-06-15T15:00:59","modified_gmt":"2022-06-15T15:00:59","slug":"new-patient-new-client-form","status":"publish","type":"page","link":"https:\/\/713websites.com\/new-patient-new-client-form\/","title":{"rendered":"New Patient \/ New Client Form"},"content":{"rendered":"<script type=\"text\/javascript\">var 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form_sublabel_below description_below'><fieldset id=\"field_1_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_1_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_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_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_1_2\" ><label class='gfield_label gform-field-label' for='input_1_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_1_2' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_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_1_3\" ><label class='gfield_label gform-field-label' for='input_1_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_1_3' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_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_1_4\" ><label class='gfield_label gform-field-label' for='input_1_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_1_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_5\" 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_1_5\" ><legend class='gfield_label gform-field-label' >Species<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_5'>\n\t\t\t<div class='gchoice gchoice_1_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Dog'  id='choice_1_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_5_0' id='label_1_5_0' class='gform-field-label gform-field-label--type-inline'>Dog<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Cat'  id='choice_1_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_5_1' id='label_1_5_1' class='gform-field-label gform-field-label--type-inline'>Cat<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_6\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><label class='gfield_label gform-field-label' for='input_1_6'>Breed<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><label class='gfield_label gform-field-label' for='input_1_7'>Color<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\" ><label class='gfield_label gform-field-label' for='input_1_8'>Age \/ Date of Birth<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_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_1_9\" ><legend class='gfield_label gform-field-label' >Sex<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_9'>\n\t\t\t<div class='gchoice gchoice_1_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Male'  id='choice_1_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_0' id='label_1_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_1_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Male (neutered)'  id='choice_1_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_1' id='label_1_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_1_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Female'  id='choice_1_9_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_2' id='label_1_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_1_9_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Female (spayed)'  id='choice_1_9_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_3' id='label_1_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_1_10\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><label class='gfield_label gform-field-label' for='input_1_10'>When did you get your pet?<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_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_1_11\" ><legend class='gfield_label gform-field-label' >Where did you get your pet?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_11'>\n\t\t\t<div class='gchoice gchoice_1_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Shelter'  id='choice_1_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_0' id='label_1_11_0' class='gform-field-label gform-field-label--type-inline'>Shelter<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Breeder'  id='choice_1_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_1' id='label_1_11_1' class='gform-field-label gform-field-label--type-inline'>Breeder<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Pet Store'  id='choice_1_11_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_2' id='label_1_11_2' class='gform-field-label gform-field-label--type-inline'>Pet Store<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Online'  id='choice_1_11_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_3' id='label_1_11_3' class='gform-field-label gform-field-label--type-inline'>Online<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Friend'  id='choice_1_11_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_4' id='label_1_11_4' class='gform-field-label gform-field-label--type-inline'>Friend<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Other'  id='choice_1_11_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_5' id='label_1_11_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\" ><label class='gfield_label gform-field-label' for='input_1_12'>Please Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\" ><label class='gfield_label gform-field-label' for='input_1_13'>What kind of food do you feed your pet?<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_14\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\" ><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_1_14'>\n\t\t\t<div class='gchoice gchoice_1_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Free Fed (food is offered always\/whenever hungry)'  id='choice_1_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_14_0' id='label_1_14_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_1_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Measured Amount'  id='choice_1_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_14_1' id='label_1_14_1' class='gform-field-label gform-field-label--type-inline'>Measured Amount<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_15\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><label class='gfield_label gform-field-label' for='input_1_15'>Please specify how often and how much<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_16\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\" ><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_1_16'><div class='gchoice gchoice_1_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Sneezing'  id='choice_1_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_1' id='label_1_16_1' class='gform-field-label gform-field-label--type-inline'>Sneezing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Coughing'  id='choice_1_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_2' id='label_1_16_2' class='gform-field-label gform-field-label--type-inline'>Coughing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Vomiting'  id='choice_1_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_3' id='label_1_16_3' class='gform-field-label gform-field-label--type-inline'>Vomiting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Diarrhea'  id='choice_1_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_4' id='label_1_16_4' class='gform-field-label gform-field-label--type-inline'>Diarrhea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Eating'  id='choice_1_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_5' id='label_1_16_5' class='gform-field-label gform-field-label--type-inline'>Eating<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='Drinking'  id='choice_1_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_6' id='label_1_16_6' class='gform-field-label gform-field-label--type-inline'>Drinking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Other'  id='choice_1_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_7' id='label_1_16_7' 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_16_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_1_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_1_17\" ><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_1_17'>\n\t\t\t<div class='gchoice gchoice_1_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_1_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_0' id='label_1_17_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_1_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_1_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_1' id='label_1_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_18\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\" ><label class='gfield_label gform-field-label' for='input_1_18'>If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_1_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_19\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\" ><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_1_19'>\n\t\t\t<div class='gchoice gchoice_1_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_1_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_0' id='label_1_19_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_1_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_1_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_1' id='label_1_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_20\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\" ><label class='gfield_label gform-field-label' for='input_1_20'>If Yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_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_1_21\" ><legend class='gfield_label gform-field-label' >Microchip:<\/legend><div class='gfield_description' id='gfield_description_1_21'>There is an additional fee for this<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_21'>\n\t\t\t<div class='gchoice gchoice_1_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_1_21_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_21\"   \/>\n\t\t\t\t\t<label for='choice_1_21_0' id='label_1_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_1_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_1_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_1' id='label_1_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_1_21_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Already has one'  id='choice_1_21_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_2' id='label_1_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_1_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_1_22\" ><legend class='gfield_label gform-field-label' >Nail Trim:<\/legend><div class='gfield_description' id='gfield_description_1_22'>There is an additional fee for this<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_22'>\n\t\t\t<div class='gchoice gchoice_1_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_1_22_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_22\"   \/>\n\t\t\t\t\t<label for='choice_1_22_0' id='label_1_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_1_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_1_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_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_1_23\" ><legend class='gfield_label gform-field-label' >Do you need heartworm or flea prevention:<\/legend><div class='gfield_description' id='gfield_description_1_23'>There is an additional fee for this<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_23'>\n\t\t\t<div class='gchoice gchoice_1_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_1_23_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_23\"   \/>\n\t\t\t\t\t<label for='choice_1_23_0' id='label_1_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_1_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_1_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_24\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\" ><label class='gfield_label gform-field-label' for='input_1_24'>If Yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_1_24' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_38\" 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_1_38\" ><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_1_38'>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.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_38'>\n\t\t\t<div class='gchoice gchoice_1_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes, please perform CPR on my pet.'  id='choice_1_38_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_38\"   \/>\n\t\t\t\t\t<label for='choice_1_38_0' id='label_1_38_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_1_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No, do not perform CPR on my pet.\u00a0'  id='choice_1_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_1' id='label_1_38_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_1_25\" 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_1_25\" ><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_1_25'>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_25.1' id='input_1_25_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_25\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_25_1' >I understand<\/label><input type='hidden' name='input_25.2' value='I understand' class='gform_hidden' \/><input type='hidden' name='input_25.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_1_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_1_26\" ><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_1_26'>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_26.1' id='input_1_26_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_26\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_26_1' >I understand<\/label><input type='hidden' name='input_26.2' value='I understand' class='gform_hidden' \/><input type='hidden' name='input_26.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_1_27\" 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_1_27\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >VACCINE NOTIFICATION &amp; DISCLOSURE:<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_1_27'>Vaccines are administered to your pet to produce antibodies (to build up their immunity) against certain diseases. These  vaccines are an important part of your pet\u2019s well-being and protection. It is critical during their first few months to get this done as quickly and consistently as possible. Puppies &amp; kittens do require vaccines to be boosted every 3-4 weeks during their first few months. Our staff will be providing you with our recommended vaccines, tests and preventatives. If your pet has passed the puppy\/kitten stage they will still require their vaccines to be updated. Any time a new vaccine is introduced to your pet&#39;s immune system it will need to be boosted in a 3-4-week time frame. Please keep that in mind so your pet can be as protected as possible.<\/div><div class='ginput_container ginput_container_consent'><input name='input_27.1' id='input_1_27_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_27\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_27_1' >I understand<\/label><input type='hidden' name='input_27.2' value='I understand' class='gform_hidden' \/><input type='hidden' name='input_27.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_1_28\" 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_1_28\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >WELLNESS 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_1_28'>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 Wellness 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_28.1' id='input_1_28_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_28\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_28_1' >I understand<\/label><input type='hidden' name='input_28.2' value='I understand' class='gform_hidden' \/><input type='hidden' name='input_28.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_1_29\" 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_1_29\" ><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_checkbox'><div class='gfield_checkbox' id='input_1_29'><div class='gchoice gchoice_1_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='I authorize'  id='choice_1_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_29_1' id='label_1_29_1' class='gform-field-label gform-field-label--type-inline'>I authorize<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_37\" 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_1_37\" ><legend class='gfield_label gform-field-label' >Social Media\/Photo Permission<\/legend><div class='gfield_description' id='gfield_description_1_37'>Do we have your permission to post photos of your pet online? Your pets&#39; 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_1_37'>\n\t\t\t<div class='gchoice gchoice_1_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes'  id='choice_1_37_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_37\"   \/>\n\t\t\t\t\t<label for='choice_1_37_0' id='label_1_37_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_1_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_1_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_1' id='label_1_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_33\" 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_1_33\" ><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_1_33'>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_33.1' id='input_1_33_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_33\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_33_1' >I have read and understand.<\/label><input type='hidden' name='input_33.2' value='I have read and understand.' class='gform_hidden' \/><input type='hidden' name='input_33.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_1_39\" 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_1_39\" ><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_1_39'><div class='gchoice gchoice_1_39_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.1' 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_1_39_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_39_1' id='label_1_39_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_1_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_1_34\" ><label class='gfield_label gform-field-label' for='input_1_34'>Please type your initials.<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_1_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_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_1_35\" ><label class='gfield_label gform-field-label' for='input_1_35'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_35' id='input_1_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_1_35_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_35_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_35' class='gform_hidden' value='https:\/\/713websites.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_1_36'>Please text photos of your pet&#39;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. 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