{"id":2895,"date":"2024-05-16T16:02:19","date_gmt":"2024-05-16T16:02:19","guid":{"rendered":"https:\/\/carevetdev.kinsta.cloud\/fort-thomas\/?page_id=2895"},"modified":"2024-05-16T16:02:47","modified_gmt":"2024-05-16T16:02:47","slug":"new-client-form","status":"publish","type":"page","link":"https:\/\/www.carevet.com\/fort-thomas\/new-client-form\/","title":{"rendered":"New Client Form"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_6' ><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_6' id='gform_6'  action='\/fort-thomas\/wp-json\/wp\/v2\/pages\/2895#gf_6' data-formid='6' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_1\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"color--primary\">Owner Information<\/h2>\n<hr \/>\n<p><em>Authorized contacts will have permission to make medical decisions and have full access to the account.<\/em><\/p>\n\n<p><strong>Authorized Contact #1<\/strong><\/p><\/div><fieldset id=\"field_6_3\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_6_3'>\n                            \n                            <span id='input_6_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_6_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_6_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_6_4\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_6_4_1' value=''    aria-required='true'    \/>\n                                        <label for='input_6_4_1' id='input_6_4_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_4_2_container' >\n                                        <input type='text' name='input_4.2' id='input_6_4_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_4_2' id='input_6_4_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_6_4_3' value=''    aria-required='true'    \/>\n                                    <label for='input_6_4_3' id='input_6_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_4_4_container' >\n                                        <select name='input_4.4' id='input_6_4_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_6_4_4' id='input_6_4_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_6_4_5' value=''    aria-required='true'    \/>\n                                    <label for='input_6_4_5' id='input_6_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_6_4_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_5'>Phone Number<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_5' id='input_6_5' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_6\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_6_6_container'>\n                                <span id='input_6_6_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_6' id='input_6_6' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_6_6' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_6_6_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_6_2' id='input_6_6_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_6_6_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_6_7\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>Authorized Contact #2<\/strong><\/p><\/div><fieldset id=\"field_6_8\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/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_6_8'>\n                            \n                            <span id='input_6_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.3' id='input_6_8_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_8_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.6' id='input_6_8_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_8_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_6_9\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_6_9_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_9_1' id='input_6_9_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_9_2_container' >\n                                        <input type='text' name='input_9.2' id='input_6_9_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_9_2' id='input_6_9_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_9_3_container' >\n                                    <input type='text' name='input_9.3' id='input_6_9_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_9_3' id='input_6_9_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_9_4_container' >\n                                        <select name='input_9.4' id='input_6_9_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_6_9_4' id='input_6_9_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_9_5_container' >\n                                    <input type='text' name='input_9.5' id='input_6_9_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_9_5' id='input_6_9_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_9.6' id='input_6_9_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_10\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_10'>Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_6_10' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_11\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Email<\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_6_11_container'>\n                                <span id='input_6_11_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_11' id='input_6_11' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_6_11' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_6_11_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_11_2' id='input_6_11_2' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_6_11_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_6_12\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>Emergency Contact<\/strong> (In the event that the primary and secondary contacts cannot be reached)<\/p><\/div><fieldset id=\"field_6_13\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/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_6_13'>\n                            \n                            <span id='input_6_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_6_13_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_13_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_6_13_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_13_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_14\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_14'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_6_14' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >**Is this contact authorized to make medical decisions and have full access to this account?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_16'>\n\t\t\t<div class='gchoice gchoice_6_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes'  id='choice_6_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_16_0' id='label_6_16_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_6_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No'  id='choice_6_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_16_1' id='label_6_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_17\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"color--primary\">Patient Information<\/h2>\n<hr \/>\n<p><strong>Pet #1<\/strong><\/p><\/div><div id=\"field_6_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_18'>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_18' id='input_6_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_19'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_6_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_20'>Species<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_20' id='input_6_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_21'>Breed\/Color<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_21' id='input_6_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_23'>\n\t\t\t<div class='gchoice gchoice_6_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Male'  id='choice_6_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_0' id='label_6_23_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_6_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Male Neutered'  id='choice_6_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_1' id='label_6_23_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_6_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Female'  id='choice_6_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_2' id='label_6_23_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_6_23_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Female Spayed'  id='choice_6_23_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_3' id='label_6_23_3' class='gform-field-label gform-field-label--type-inline'>Female Spayed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_24\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>Pet #2<\/strong><\/p><\/div><div id=\"field_6_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_25'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_6_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_26'>Age<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_6_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_27'>Species<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_6_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_28'>Breed\/Color<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_6_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_29'>\n\t\t\t<div class='gchoice gchoice_6_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Male'  id='choice_6_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_0' id='label_6_29_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_6_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Male Neutered'  id='choice_6_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_1' id='label_6_29_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_6_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Female'  id='choice_6_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_2' id='label_6_29_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_6_29_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Female Spayed'  id='choice_6_29_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_3' id='label_6_29_3' class='gform-field-label gform-field-label--type-inline'>Female Spayed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_30\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"color--primary\">Referral Information<\/h2>\n<hr \/><\/div><div id=\"field_6_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_31'>How did you hear about us?<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_6_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_32'>If referred by a client, please provide name and phone<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_6_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_34\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"text-center\">Financial Policy Statement<\/h2>\n<p>CareVet of Fort Thomas requires payment in full at the end of your pet's examination or services.<\/p>\n<p>We accept the following payment methods:<\/p>\n<ul style=\"font-size:18px;\">\n<li>Cash<\/li>\n<li>Major credit cards including: Visa\u00ae, MasterCard\u00ae, American Express\u00ae or Discover Card\u00ae<\/li>\n<li>Care Credit\u00ae Healthcare Credit Card(For more information ask our Customer care representatives, who can assist with the application process)<\/li>\n<li>Check<\/li>\n<\/ul>\n\n<p>Please provide information below regarding the party who is financially responsible for the pet(s) on this account:<\/p><\/div><fieldset id=\"field_6_35\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_6_35'>\n                            \n                            <span id='input_6_35_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.3' id='input_6_35_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_35_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_35_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.6' id='input_6_35_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_35_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_36\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_36'>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_36' id='input_6_36' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_37\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_37'>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_37' id='input_6_37' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_6_38\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>By signing below, you certify that the information above is correct, and that you understand and agree with the policy listed above <\/p><\/div><div id=\"field_6_48\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_48'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_6_48_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_6_48_valid' id='input_6_48_valid' \/><canvas id='input_6_48' width='300' height='180'><\/canvas><\/div><\/div><\/div><fieldset id=\"field_6_40\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_6_40' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_6_40_1_container'>\n                                            <input type='number' maxlength='2' name='input_40[]' id='input_6_40_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_6_40_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_6_40_2_container'>\n                                            <input type='number' maxlength='2' name='input_40[]' id='input_6_40_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_6_40_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_6_40_3_container'>\n                                            <input type='number' maxlength='4' name='input_40[]' id='input_6_40_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_6_40_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_6_41\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"text-center\">Record Release Authorization<\/h2><\/div><fieldset id=\"field_6_42\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Client Name<\/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_6_42'>\n                            \n                            <span id='input_6_42_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.3' id='input_6_42_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_42_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_42_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.6' id='input_6_42_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_42_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_43'>Pet&#039;s Name(s)<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_6_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_44\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>I, the owner or agent of the pet(s) listed above, authorize the release of my pet\u2019s medical records to the following:<\/p>\n<ul style=\"font-size:18px;\">\n<li>Veterinary Offices<\/li>\n<li>Boarding Facilities<\/li>\n<li>Daycare Facilities<\/li>\n<li>Grooming Facilities<\/li>\n<li>Shelters and Rescues (In the event I am applying to adopt or foster a pet)<\/li>\n<\/ul>\n<p>I understand that I may revoke this authorization at any time by contacting CareVet of Fort Thomas.<\/p><\/div><div id=\"field_6_46\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_46'>Signature of Owner<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_6_46_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_6_46_valid' id='input_6_46_valid' \/><canvas id='input_6_46' width='300' height='180'><\/canvas><\/div><\/div><\/div><fieldset id=\"field_6_47\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_6_47' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_6_47_1_container'>\n                                            <input type='number' maxlength='2' name='input_47[]' id='input_6_47_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_6_47_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_6_47_2_container'>\n                                            <input type='number' maxlength='2' name='input_47[]' id='input_6_47_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_6_47_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_6_47_3_container'>\n                                            <input type='number' maxlength='4' name='input_47[]' id='input_6_47_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_6_47_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_6_49\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_49'>CAPTCHA<\/label><div id='input_6_49' class='ginput_container ginput_recaptcha' data-sitekey='6Lfch2MpAAAAAB3fl2wjMx9Y_ph2b8uqYUXt-mR-'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_6' class='gform_button button' 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name='gform_target_page_number_6' id='gform_target_page_number_6' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"192\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_6' id='gform_ajax_frame_6' title='This iframe contains the logic required to handle Ajax powered 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