{"id":1840,"date":"2019-11-26T16:45:20","date_gmt":"2019-11-26T16:45:20","guid":{"rendered":"http:\/\/carevetdev.kinsta.cloud\/hh\/?page_id=1840"},"modified":"2022-05-31T20:37:28","modified_gmt":"2022-05-31T20:37:28","slug":"new-client-form","status":"publish","type":"page","link":"https:\/\/www.carevet.com\/west-central-minnesota\/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' >\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/west-central-minnesota\/wp-json\/wp\/v2\/pages\/1840' 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_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Thank you for considering our hospital as your pet\u2019s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.<\/p>\n<p>Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.<\/p><\/div><fieldset id=\"field_6_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' >Owner&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/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--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_asterisk\">*<\/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--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'>Day-Time Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/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><div id=\"field_6_6\" class=\"gfield gfield--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_6'>Evening Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_6_6' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_7\" class=\"gfield gfield--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_7'>Mobile Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_6_7' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_8\" 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<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_6_8_container'>\n                                <span id='input_6_8_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_8' id='input_6_8' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_6_8' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_6_8_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_8_2' id='input_6_8_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_6_8_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_6_10\" class=\"gfield gfield--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' >Co-owner&#039;s 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_10'>\n                            \n                            <span id='input_6_10_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.3' id='input_6_10_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_10_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_10_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.6' id='input_6_10_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_10_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_11\" class=\"gfield gfield--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_11'>Co-owner&#039;s Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_6_11' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_12\" 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' >How did you find out about our practice?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_12'>\n\t\t\t<div class='gchoice gchoice_6_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Clinic Location'  id='choice_6_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_12_0' id='label_6_12_0' class='gform-field-label gform-field-label--type-inline'>Clinic Location<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Personal Referral'  id='choice_6_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_12_1' id='label_6_12_1' class='gform-field-label gform-field-label--type-inline'>Personal Referral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_12_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Internet Search \/ Website'  id='choice_6_12_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_12_2' id='label_6_12_2' class='gform-field-label gform-field-label--type-inline'>Internet Search \/ Website<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_12_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Yellow Pages'  id='choice_6_12_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_12_3' id='label_6_12_3' class='gform-field-label gform-field-label--type-inline'>Yellow Pages<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_12_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Clinic Sign'  id='choice_6_12_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_12_4' id='label_6_12_4' class='gform-field-label gform-field-label--type-inline'>Clinic Sign<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_12_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Newspaper \/ Print Media'  id='choice_6_12_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_12_5' id='label_6_12_5' class='gform-field-label gform-field-label--type-inline'>Newspaper \/ Print Media<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_12_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='gf_other_choice'  id='choice_6_12_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_12_6' id='label_6_12_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_6_12_other' class='gchoice_other_control' name='input_12_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_13\" 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_6_13'>If personal referral, is there someone we can thank for this referral?<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_6_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_14\" 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_6_14'>Please use this area to give us any other relevant information about yourself or your family<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_6_14' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_15\" 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--secondary\">Pet Information<\/h2><\/div><div id=\"field_6_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_6_16'>Pet&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_6_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_17\" class=\"gfield gfield--type-select 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_17'>Species<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_6_17' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Dog' >Dog<\/option><option value='Cat' >Cat<\/option><option value='Rabbit' >Rabbit<\/option><option value='Ferret' >Ferret<\/option><option value='Bird' >Bird<\/option><option value='Reptile' >Reptile<\/option><\/select><\/div><\/div><div id=\"field_6_18\" 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_6_18'>Or if other species<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_6_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_19\" 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_6_19'>Breed (if known)<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_6_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_20\" 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_6_20'>Color<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_6_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_21\" 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_6_21'>Pet&#039;s Date of Birth or Age (if known)<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_6_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_22\" 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_6_22'>Special Identification (tattoo, microchip, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_6_22' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_23\" 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_6_23'>Sex<\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_6_23' class='large gfield_select'     aria-invalid=\"false\" ><option value='Neutered Male' selected='selected'>Neutered Male<\/option><option value='Spayed Female' >Spayed Female<\/option><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Unknown' >Unknown<\/option><\/select><\/div><\/div><div id=\"field_6_24\" 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_6_24'>Previous Veterinary Practice (if any)<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_6_24' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_27\" 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_6_27'>Previous Veterinarian (if any)<\/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_26\" 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_6_26'>Date of last vaccines (if known)<\/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_25\" 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_6_25'>What vaccines were given at this time<\/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><fieldset id=\"field_6_28\" 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' >Is your pet on any medication or supplement?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_28'>\n\t\t\t<div class='gchoice gchoice_6_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Yes'  id='choice_6_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_28_0' id='label_6_28_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_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_6_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_28_1' id='label_6_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_29\" 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_6_29'>If Yes, please list the medication or supplement<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_6_29' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_30\" 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_6_30'>What food does your pet eat?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_6_30' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_6_31\" 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' >Does your pet have allergies or drug reactions?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_31'>\n\t\t\t<div class='gchoice gchoice_6_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_6_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_31_0' id='label_6_31_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_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_6_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_31_1' id='label_6_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_32\" 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_6_32'>If Yes, please list the allergies and reactions<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_6_32' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_6_33\" 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 there any current or past medical conditions of which we should be aware?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_33'>\n\t\t\t<div class='gchoice gchoice_6_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_6_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_33_0' id='label_6_33_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_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_6_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_33_1' id='label_6_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_34\" 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_6_34'>If Yes, please comment on the condition(s) and indicate if they are current or past conditions<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_6_34' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_35\" 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_6_35'>Please use the following box to give us any other relevant information about your pet<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_6_35' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_6_37\" class=\"gfield gfield--type-consent gfield--type-choice field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >SMS Text Messages Opt-In<\/legend><div class='ginput_container ginput_container_consent'><input name='input_37.1' id='input_6_37_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_6_37\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_37_1' >I agree to receive SMS text messages.<\/label><input type='hidden' name='input_37.2' value='I agree to receive SMS text messages.' class='gform_hidden' \/><input type='hidden' name='input_37.3' value='6' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_6_37' tabindex='0'>By providing my phone number, I consent to receive SMS text messages from CareVet of West Central Minnesota for appointment reminders, marketing messages, and general two-way communication. 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