{"id":1840,"date":"2019-11-26T16:45:20","date_gmt":"2019-11-26T16:45:20","guid":{"rendered":"http:\/\/carevetdev.kinsta.cloud\/hutchinson\/?page_id=1840"},"modified":"2023-08-17T19:17:39","modified_gmt":"2023-08-17T19:17:39","slug":"new-client-form","status":"publish","type":"page","link":"https:\/\/www.carevet.com\/hutchinson\/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_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_5' id='gform_5'  action='\/hutchinson\/wp-json\/wp\/v2\/pages\/1840#gf_5' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_1\" class=\"gfield gfield--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\"  ><p style=\"text-align:center;\"><strong>Welcome to the CareVet of Hutchinson. Thank you for giving us the opportunity to care for your pet(s).\nSo that we may become better acquainted, please complete the following:<\/strong><\/p>\n\n<h1 class=\"color--primary\">Client Information<\/h2><\/div><fieldset id=\"field_5_3\" class=\"gfield gfield--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' >Primary Contact 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_5_3'>\n                            \n                            <span id='input_5_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_5_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_5_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_4\" class=\"gfield gfield--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 Address<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_5_4_container'>\n                                <span id='input_5_4_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_4' id='input_5_4' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_5_4' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_5_4_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_4_2' id='input_5_4_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_5_4_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><fieldset id=\"field_5_5\" class=\"gfield gfield--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' >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_5_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_5_5_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_5_1' id='input_5_5_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_5_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_5_5_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_5_2' id='input_5_5_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_5_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_5_5_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_5_3' id='input_5_5_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_5_5_4_container' >\n                                        <input type='text' name='input_5.4' id='input_5_5_4' value=''      aria-required='true'    \/>\n                                        <label for='input_5_5_4' id='input_5_5_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_5_5_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_5_5' id='input_5_5_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_5_5_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_13\" class=\"gfield gfield--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 list all contact numbers in the order you would prefer them to be used:<\/strong><\/p><\/div><div id=\"field_5_7\" class=\"gfield gfield--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_5_7'>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_7' id='input_5_7' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_10\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Type<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_5_10'>\n\t\t\t<div class='gchoice gchoice_5_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Mobile Cell'  id='choice_5_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_0' id='label_5_10_0' class='gform-field-label gform-field-label--type-inline'>Mobile Cell<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Home'  id='choice_5_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_1' id='label_5_10_1' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_10_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Work'  id='choice_5_10_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_2' id='label_5_10_2' class='gform-field-label gform-field-label--type-inline'>Work<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_9\" class=\"gfield gfield--type-phone 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_5_9'>Phone #<\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_5_9' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Type<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_11'>\n\t\t\t<div class='gchoice gchoice_5_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Mobile Cell'  id='choice_5_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_11_0' id='label_5_11_0' class='gform-field-label gform-field-label--type-inline'>Mobile Cell<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Home'  id='choice_5_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_11_1' id='label_5_11_1' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_11_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Work'  id='choice_5_11_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_11_2' id='label_5_11_2' class='gform-field-label gform-field-label--type-inline'>Work<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_8\" class=\"gfield gfield--type-phone 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_5_8'>Phone #<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_5_8' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Type<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_12'>\n\t\t\t<div class='gchoice gchoice_5_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Mobile Cell'  id='choice_5_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_0' id='label_5_12_0' class='gform-field-label gform-field-label--type-inline'>Mobile Cell<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Home'  id='choice_5_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_1' id='label_5_12_1' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Work'  id='choice_5_12_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_2' id='label_5_12_2' class='gform-field-label gform-field-label--type-inline'>Work<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_6\" class=\"gfield gfield--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_5_6'>What is the best time to reach you?<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_5_6' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--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\">Payment Information<\/h2><\/div><div id=\"field_5_16\" class=\"gfield gfield--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_5_16'>All fees are due at the time services are rendered. (Please insert your initials to confirm)<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_5_16' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--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>We have several financing programs that allow payment on time with little to no additional cost. If you need or are interested,\nplease ask any of our staff and we would be happy to help you find the best program for you and your pet.<\/strong><\/p><\/div><fieldset id=\"field_5_20\" class=\"gfield gfield--type-checkbox gfield--type-choice 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' >Please indicate your preferred choice of payment<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_5_20'><div class='gchoice gchoice_5_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Cash'  id='choice_5_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_1' id='label_5_20_1' class='gform-field-label gform-field-label--type-inline'>Cash<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Visa\/MasterCard\/Discover'  id='choice_5_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_2' id='label_5_20_2' class='gform-field-label gform-field-label--type-inline'>Visa\/MasterCard\/Discover<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='Wells Fargo Health Advantage'  id='choice_5_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_3' id='label_5_20_3' class='gform-field-label gform-field-label--type-inline'>Wells Fargo Health Advantage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='Care Credit'  id='choice_5_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_4' id='label_5_20_4' class='gform-field-label gform-field-label--type-inline'>Care Credit<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_21\" class=\"gfield gfield--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\">Misc Information<\/h2><\/div><div id=\"field_5_22\" class=\"gfield gfield--type-select 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_5_22'>How did you become aware of our clinic?<\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_5_22' class='small gfield_select'     aria-invalid=\"false\" ><option value='None' >None<\/option><option value='Drove By' >Drove By<\/option><option value='Yellow Pages' >Yellow Pages<\/option><option value='Internet\/Website' >Internet\/Website<\/option><option value='Personal Referral' >Personal Referral<\/option><\/select><\/div><\/div><div id=\"field_5_23\" class=\"gfield gfield--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_5_23'>Whom may we thank for your referral?<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_5_23' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_24\" class=\"gfield gfield--type-textarea 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_5_24'>Reason for visit?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_5_24' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_25\" class=\"gfield gfield--type-textarea 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_5_25'>Names of all pets in your home<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_5_25' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_26\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Are you planning on using us as your primary care provider?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_26'>\n\t\t\t<div class='gchoice gchoice_5_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_5_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_26_0' id='label_5_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_5_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_26_1' id='label_5_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_27\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Preferred method of reminders?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_27'>\n\t\t\t<div class='gchoice gchoice_5_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Mail'  id='choice_5_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_27_0' id='label_5_27_0' class='gform-field-label gform-field-label--type-inline'>Mail<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='E-Mail'  id='choice_5_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_27_1' id='label_5_27_1' class='gform-field-label gform-field-label--type-inline'>E-Mail<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Text'  id='choice_5_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_27_2' id='label_5_27_2' class='gform-field-label gform-field-label--type-inline'>Text<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_28\" class=\"gfield gfield--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_5_28' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_5_28_1_container'>\n                                            <input type='number' maxlength='2' name='input_28[]' id='input_5_28_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_5_28_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_5_28_2_container'>\n                                            <input type='number' maxlength='2' name='input_28[]' id='input_5_28_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_5_28_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_5_28_3_container'>\n                                            <input type='number' maxlength='4' name='input_28[]' id='input_5_28_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_5_28_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_5_29\" class=\"gfield gfield--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 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