{"id":2862,"date":"2024-08-01T20:40:02","date_gmt":"2024-08-01T20:40:02","guid":{"rendered":"https:\/\/carevetdev.kinsta.cloud\/mulnix\/?page_id=2862"},"modified":"2024-08-01T20:40:02","modified_gmt":"2024-08-01T20:40:02","slug":"ultrasound-treatment-form","status":"publish","type":"page","link":"https:\/\/www.carevet.com\/mulnix\/ultrasound-treatment-form\/","title":{"rendered":"Ultrasound Treatment 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 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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_8' style='display:none'><div id='gf_8' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_8' id='gform_8'  action='\/mulnix\/wp-json\/wp\/v2\/pages\/2862#gf_8' data-formid='8' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_8_1\" class=\"gfield gfield--type-name gfield--input-type-name 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_8_1'>\n                            \n                            <span id='input_8_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_8_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_8_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_8_3\" 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_8_3'>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_3' id='input_8_3' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_4\" 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_8_4_container'>\n                                <span id='input_8_4_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_4' id='input_8_4' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_8_4' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_8_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_8_4_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_8_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><div id=\"field_8_5\" 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_8_5'>Pet 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_5' id='input_8_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_6\" 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_8_6'>Pet Breed<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_8_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_7\" 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_8_7'>Pet 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_7' id='input_8_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_8\" 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_8_8'>Pet 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_8' id='input_8_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_9\" 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>To: Dr. Thomas, Dr. Gaffney, Dr. McPalmer, Dr. Barrett, Dr. Hafey and the staff of CareVet Mulnix Animal Clinic,<\/p>\n<p>I am the owner or agent of the above-named animal and have authority to execute this consent.\nI hereby authorize the performance of the following procedure(s):<\/p><\/div><fieldset id=\"field_8_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Procedure(s)<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_8_11'><div class='gchoice gchoice_8_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Full Abdominal Ultrasound - $476.40'  id='choice_8_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_11_1' id='label_8_11_1' class='gform-field-label gform-field-label--type-inline'>Full Abdominal Ultrasound - $476.40<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='Recheck ultrasound (MUST be within 2 months of initial ultrasound) - $365.00'  id='choice_8_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_11_2' id='label_8_11_2' class='gform-field-label gform-field-label--type-inline'>Recheck ultrasound (MUST be within 2 months of initial ultrasound) - $365.00<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='Focused Ultrasound - $294.50'  id='choice_8_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_11_3' id='label_8_11_3' class='gform-field-label gform-field-label--type-inline'>Focused Ultrasound - $294.50<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_11_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.4' type='checkbox'  value='Echocardiogram - $591.50'  id='choice_8_11_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_11_4' id='label_8_11_4' class='gform-field-label gform-field-label--type-inline'>Echocardiogram - $591.50<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_11_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.5' type='checkbox'  value='Echocardiogram with ECG - $691.50'  id='choice_8_11_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_11_5' id='label_8_11_5' class='gform-field-label gform-field-label--type-inline'>Echocardiogram with ECG - $691.50<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_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>Sometimes a mild sedative is needed to help the patient relax during the ultrasound. This injection is $78.00.<\/p><\/div><fieldset id=\"field_8_13\" 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' >Sedative Choice<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_8_13'>\n\t\t\t<div class='gchoice gchoice_8_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='I authorize the use of a mild sedative if needed'  id='choice_8_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_13_0' id='label_8_13_0' class='gform-field-label gform-field-label--type-inline'>I authorize the use of a mild sedative if needed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='I do NOT authorize the use of a mild sedative'  id='choice_8_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_13_1' id='label_8_13_1' class='gform-field-label gform-field-label--type-inline'>I do NOT authorize the use of a mild sedative<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_14\" 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>If the above mild sedative is not enough to relax your pet we may need to use additional sedation during the procedure in order to accurately and safely perform the ultrasound. If additional sedation is deemed necessary for your pet, the following procedures would need to be performed:<\/p>\n<ul style=\"font-size:18px;\">\n<li>Additional sedation - $150.50<\/li>\n<li>Anesthetic Monitoring - $80.50<\/li>\n<li>Hospitalization \u2013 surgery\/sedation - $54.50<\/li>\n<\/ul>\n<p>Total: $285.50<\/p>\n\n<\/div><fieldset id=\"field_8_15\" 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' >Additional Sedative Choice<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_8_15'>\n\t\t\t<div class='gchoice gchoice_8_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='I agree to the above costs of additional sedation if deemed appropriate'  id='choice_8_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_15_0' id='label_8_15_0' class='gform-field-label gform-field-label--type-inline'>I agree to the above costs of additional sedation if deemed appropriate<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Do NOT proceed with additional sedation'  id='choice_8_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_15_1' id='label_8_15_1' class='gform-field-label gform-field-label--type-inline'>Do NOT proceed with additional sedation<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_16\" 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>If abnormalities are found during the ultrasound, and an ultrasound guided needle aspirate and cytology, or Internal medicine review of the area is recommended, to aid in further diagnosis, I agree to the following optional procedures and understand that they will be performed at the provided costs:<\/p><\/div><fieldset id=\"field_8_17\" 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' >Optional Procedure(s)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_17'><div class='gchoice gchoice_8_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Ultrasound Guided Needle Aspirate and cytology (1 site) - $331.30'  id='choice_8_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_17_1' id='label_8_17_1' class='gform-field-label gform-field-label--type-inline'>Ultrasound Guided Needle Aspirate and cytology (1 site) - $331.30<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Ultrasound Guided Needle Aspirates and cytology (2 sites) - $523.40'  id='choice_8_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_17_2' id='label_8_17_2' class='gform-field-label gform-field-label--type-inline'>Ultrasound Guided Needle Aspirates and cytology (2 sites) - $523.40<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Internal Medicine review of Ultrasound - $160.00'  id='choice_8_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_17_3' id='label_8_17_3' class='gform-field-label gform-field-label--type-inline'>Internal Medicine review of Ultrasound - $160.00<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_18\" 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 authorize the use of such anesthetics as you deem advisable, as mentioned above, and performance of such therapeutic procedures as you determine to be indicated. I agree to indemnify and hold you harmless from and against any and all liability arising out of the performance of any of the procedures referred to above<\/p>\n\n<p>I understand full payment is due at the time services are rendered.<\/p>\n\n<p>I understand that shaving areas of fur (the abdomen and\/or chest) is necessary for accurate ultrasound results. Although rare, skin irritation may occur at shaved sites.<\/p>\n\n<p>We will take every precaution to keep your pet safe while under anesthesia. Occasionally an anesthetic emergency will arise and additional care will need to be administered. Please review the following options and select one option and initial.<\/p>\n\n\n\n<p>In the event an unlikely emergency should occur with your pet in our care I authorize CareVet Mulnix Animal Clinic to initiate emergency treatment. If unable to reach you at the given number below please:<\/p><\/div><fieldset id=\"field_8_19\" 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' >Resuscitation Options<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_8_19'>\n\t\t\t<div class='gchoice gchoice_8_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='proceed with resuscitation'  id='choice_8_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_19_0' id='label_8_19_0' class='gform-field-label gform-field-label--type-inline'>proceed with resuscitation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='do no proceed with resuscitation'  id='choice_8_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_19_1' id='label_8_19_1' class='gform-field-label gform-field-label--type-inline'>do no proceed with resuscitation<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_20\" 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' >Resuscitation Limit<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_8_20'>\n\t\t\t<div class='gchoice gchoice_8_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Up to $500 additional'  id='choice_8_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_20_0' id='label_8_20_0' class='gform-field-label gform-field-label--type-inline'>Up to $500 additional<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Up to $1000 additional'  id='choice_8_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_20_1' id='label_8_20_1' class='gform-field-label gform-field-label--type-inline'>Up to $1000 additional<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_21\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_21.1' id='input_8_21_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_8_21_1' >I accept and agree to the terms of this treatment plan.<\/label><input type='hidden' name='input_21.2' value='I accept and agree to the terms of this treatment plan.' class='gform_hidden' \/><input type='hidden' name='input_21.3' value='12' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_8_22\" 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_8_22'>\n                            \n                            <span id='input_8_22_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_22.3' id='input_8_22_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_22_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_22_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_22.6' id='input_8_22_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_22_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_8_23\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield 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' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_8_23' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_8_23_1_container'>\n                                            <input type='number' maxlength='2' name='input_23[]' id='input_8_23_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_8_23_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_8_23_2_container'>\n                                            <input type='number' maxlength='2' name='input_23[]' id='input_8_23_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_8_23_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_8_23_3_container'>\n                                            <input type='number' maxlength='4' name='input_23[]' id='input_8_23_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_8_23_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_8_24\" 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_8_24'>Primary 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_24' id='input_8_24' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_25\" 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_8_25'>Secondary 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_25' id='input_8_25' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_8' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=8&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=9ce958525440b038b009295196bbd689' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_8' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_8' id='gform_theme_8' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_8' id='gform_style_settings_8' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_8' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='8' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='mKnBHaUeMGZsnEz9YJufIeyY1Y1AdYIigTgnSBXu4ADt4p9S9bdeWGzsYqCWvt8RTnFoU7fq27dyrCZn4+xZ6KjrYr3F0LZFMU36tCtk78Pxmr4=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_8' 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