{"id":2900,"date":"2024-05-16T16:37:14","date_gmt":"2024-05-16T16:37:14","guid":{"rendered":"https:\/\/carevetdev.kinsta.cloud\/fort-thomas\/?page_id=2900"},"modified":"2024-05-16T16:37:14","modified_gmt":"2024-05-16T16:37:14","slug":"surgical-drop-off-form","status":"publish","type":"page","link":"https:\/\/www.carevet.com\/fort-thomas\/surgical-drop-off-form\/","title":{"rendered":"Surgery Drop-Off 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_7' style='display:none'><div id='gf_7' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_7' id='gform_7'  action='\/fort-thomas\/wp-json\/wp\/v2\/pages\/2900#gf_7' data-formid='7' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_1\" class=\"gfield gfield--type-text gfield--input-type-text 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_7_1'>Please list phone numbers where you may be reached between 10am-4pm.<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_1' id='input_7_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_3\" 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' >Would you like to receive a text message update with a recovery photo of your pet following their procedure? If yes, place an asterisk next to the number(s) above to receive the text.<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_7_3'>\n\t\t\t<div class='gchoice gchoice_7_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Yes'  id='choice_7_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_3_0' id='label_7_3_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_7_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='No'  id='choice_7_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_3_1' id='label_7_3_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_4\" 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>**Please respond to the text message so we know that you received it.*<\/strong><\/p><\/div><div id=\"field_7_5\" class=\"gfield gfield--type-text gfield--input-type-text 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_7_5'>List any medications that your pet is currently taking<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_5' id='input_7_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_6\" class=\"gfield gfield--type-text gfield--input-type-text 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_7_6'>Time that medications were last given<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_7_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_7\" class=\"gfield gfield--type-text gfield--input-type-text 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_7_7'>What time was your pet&#039;s last meal?<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_7' id='input_7_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_8\" class=\"gfield gfield--type-text gfield--input-type-text 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_7_8'>Procedure to be performed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_7_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you have a doctor preference?<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_7_9'>\n\t\t\t<div class='gchoice gchoice_7_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_7_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_9_0' id='label_7_9_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_7_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_7_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_9_1' id='label_7_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_10\" 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_7_10'>Please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_7_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Please check the procedures that you authorize us to do prior\/during surgery: NOTE: costs vary based on procedures required. Please inquire at drop off.<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_7_12'><div class='gchoice gchoice_7_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Pre-op bloodwork (This will be required for all patients 8 years and older)'  id='choice_7_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_12_1' id='label_7_12_1' class='gform-field-label gform-field-label--type-inline'>Pre-op bloodwork (This will be required for all patients 8 years and older)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Laser Surgery'  id='choice_7_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_12_2' id='label_7_12_2' class='gform-field-label gform-field-label--type-inline'>Laser Surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='Vaccinations'  id='choice_7_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_12_3' id='label_7_12_3' class='gform-field-label gform-field-label--type-inline'>Vaccinations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='Extraction of diseased teeth'  id='choice_7_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_12_4' id='label_7_12_4' class='gform-field-label gform-field-label--type-inline'>Extraction of diseased teeth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='Other'  id='choice_7_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_12_5' id='label_7_12_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_13\" 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_7_13'>Please specify<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_13' id='input_7_13' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_14\" 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' >If we are unable to reach you, are we able to extract teeth if medically necessary?<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_7_14'>\n\t\t\t<div class='gchoice gchoice_7_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Yes'  id='choice_7_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_14_0' id='label_7_14_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_7_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='No'  id='choice_7_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_14_1' id='label_7_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_15\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Please check the items that apply to your pet\u2019s health history:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_15'><div class='gchoice gchoice_7_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='Does your pet have seizures?'  id='choice_7_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_15_1' id='label_7_15_1' class='gform-field-label gform-field-label--type-inline'>Does your pet have seizures?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='Does your pet have a heart condition?'  id='choice_7_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_15_2' id='label_7_15_2' class='gform-field-label gform-field-label--type-inline'>Does your pet have a heart condition?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='Does your pet have diabetes?'  id='choice_7_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_15_3' id='label_7_15_3' class='gform-field-label gform-field-label--type-inline'>Does your pet have diabetes?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='Has your pet had any significant illness in the past 30 days?'  id='choice_7_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_15_4' id='label_7_15_4' class='gform-field-label gform-field-label--type-inline'>Has your pet had any significant illness in the past 30 days?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_15_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.5' type='checkbox'  value='Are there any medications your pet could not tolerate in the past or has an allergy\/sensitivity to?'  id='choice_7_15_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_15_5' id='label_7_15_5' class='gform-field-label gform-field-label--type-inline'>Are there any medications your pet could not tolerate in the past or has an allergy\/sensitivity to?<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_16\" class=\"gfield gfield--type-text gfield--input-type-text 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_7_16'>What time was insulin last given and how many units did you give?<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_16' id='input_7_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_17\" class=\"gfield gfield--type-text gfield--input-type-text 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_7_17'>What significant illness has your pet had in the last 30 days?<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_17' id='input_7_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_18\" class=\"gfield gfield--type-text gfield--input-type-text 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_7_18'>What medications can your pet not tolerate or have a sensitivity to?<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_7_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_19\" 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>For Dental procedures:<\/strong> The Doctor will determine which teeth need to be extracted and\/or if oral radiographs are necessary, unless otherwise instructed by owner.<\/p>\n<p><strong>NOTE:<\/strong> Additional fees may apply<\/p>\n<p>During surgery your pet will receive a pain relief injection, which will last 6-8 hours. Post-op pain medication is recommended for all procedures, unless otherwise instructed. Pain medication will be sent home with your pet if the Veterinarian feels that it is warranted.<\/p>\n\n<p><strong>Owner Release:<\/strong> Ft. Thomas Animal Hospital will use all reasonable precautions for the well being of your pet. I understand that anesthesia involves some risk to my pet. FTAH will not be held responsible or liable in any manner in connection therewith. I assume all responsibility.<\/p>\n\n<p><strong>NOTE:<\/strong> Full Payment is expected at the time of pick up.<\/p><\/div><div id=\"field_7_20\" 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_7_20'>Owner 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_7_20_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_7_20_valid' id='input_7_20_valid' \/><canvas id='input_7_20' width='300' height='180'><\/canvas><\/div><\/div><\/div><fieldset id=\"field_7_21\" 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_7_21' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_7_21_1_container'>\n                                            <input type='number' maxlength='2' name='input_21[]' id='input_7_21_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_7_21_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_7_21_2_container'>\n                                            <input type='number' maxlength='2' name='input_21[]' id='input_7_21_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_7_21_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_7_21_3_container'>\n                                            <input type='number' maxlength='4' name='input_21[]' id='input_7_21_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_7_21_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_7_22\" 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\">Advanced Directive Form<\/h2>\n<p>To allow for optimal treatment, all hospitalized Patients are assigned a CPR code which enables us to carry out your wishes if it should become\nnecessary during or following an emergency or surgical procedure. In the event that my pet arrests (stops breathing or their heart stops) while at CareVet of Fort Thomas, I authorize the following level of CPR (please initial your choice):<\/p><\/div><div id=\"field_7_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_23'>Do Not Resuscitate (or DNR)<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_7_23' type='text' value='' class='large'  aria-describedby=\"gfield_description_7_23\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_7_23'>I understand that if my pet stops breathing and\/or his\/her heart stops beating, CareVet of Fort Thomas will not attempt resuscitation or any\nfurther life saving measures.<\/div><\/div><div id=\"field_7_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_24'>Normal CPR \u2013 involving chest compressions, oxygen therapy and medications such as epinephrine, atropine, etc<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_7_24' type='text' value='' class='large'  aria-describedby=\"gfield_description_7_24\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_7_24'>Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $200.00 to pay for the\nservices performed while staff members pursue treatment and try to reach me for further directions. I agree to pay this fee in addition to fees\nalready incurred or for other non-emergency services that may be performed in the event that my pet survives. I also agree that if the Fort\nThomas Animal Hospital staff is unable to reach me within 15 minutes after the initiation of CPR procedures, and after a veterinarian\ndetermines that further resuscitation efforts are not warranted, CPR procedures will cease.<\/div><\/div><div id=\"field_7_26\" class=\"gfield gfield--type-text gfield--input-type-text 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_7_26'>Patient&#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_26' id='input_7_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_27\" 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' >Owner&#039;s 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_7_27'>\n                            \n                            <span id='input_7_27_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_27.3' id='input_7_27_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_27_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_7_27_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_27.6' id='input_7_27_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_27_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_7_28\" 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_7_28'>Owner 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_7_28_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_7_28_valid' id='input_7_28_valid' \/><canvas id='input_7_28' width='300' height='180'><\/canvas><\/div><\/div><\/div><fieldset id=\"field_7_29\" 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_7_29' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_7_29_1_container'>\n                                            <input type='number' maxlength='2' name='input_29[]' id='input_7_29_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_7_29_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_7_29_2_container'>\n                                            <input type='number' maxlength='2' name='input_29[]' id='input_7_29_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        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