{"id":9,"date":"2018-04-17T17:14:29","date_gmt":"2018-04-17T21:14:29","guid":{"rendered":"http:\/\/www.gochenauerpetresort.com\/forms\/?page_id=9"},"modified":"2024-11-26T02:22:32","modified_gmt":"2024-11-26T07:22:32","slug":"medical-instructions-form","status":"publish","type":"page","link":"https:\/\/www.gochenauerpetresort.com\/forms\/medical-instructions-form\/","title":{"rendered":"Medical Instructions 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_2' style='display:none'>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\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_2'  action='\/forms\/wp-json\/wp\/v2\/pages\/9' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_65\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Pet Information<\/h3><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-text gf_left_half 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_2_6'><span class='gform-field-label__text'>Pet&#039;s Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_2_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_7\" class=\"gfield gfield--type-text gf_right_half 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_2_7'><span class='gform-field-label__text'>Owner Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_2_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_92\" class=\"gfield gfield--type-email 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_2_92'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_92' id='input_2_92' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_23\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_23'><span class='gform-field-label__text'>Does your pet have any allergies?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_2_23' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_24\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'><span class='gform-field-label__text'>What condition\/ailment is your pet being treated for?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_2_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_25\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Medication to be given in:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_25'>\n\t\t\t<div class='gchoice gchoice_2_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Peanut Butter'  id='choice_2_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_25_0' id='label_2_25_0' class='gform-field-label gform-field-label--type-inline'>Peanut Butter<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Canned Food'  id='choice_2_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_25_1' id='label_2_25_1' class='gform-field-label gform-field-label--type-inline'>Canned Food<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Pill Dough'  id='choice_2_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_25_2' id='label_2_25_2' class='gform-field-label gform-field-label--type-inline'>Pill Dough<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_25_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='gf_other_choice'  id='choice_2_25_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_25_3' id='label_2_25_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_2_25_other' class='gchoice_other_control' name='input_25_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_40\" 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\"  ><br><\/div><div id=\"field_2_62\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Medication #1<\/h3><\/div><div id=\"field_2_26\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_26'><span class='gform-field-label__text'>Medication Name:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_2_26' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_26\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_2_26'>All medications are given between 7am-6pm<\/div><\/div><div id=\"field_2_27\" class=\"gfield gfield--type-text gf_right_half 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_2_27'><span class='gform-field-label__text'>Dosage (ex: 1 tablet 50mg, 1 drop):<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_2_27' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_64\" 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\"  ><\/div><div id=\"field_2_85\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline 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_2_85'><span class='gform-field-label__text'>Start Date:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_2_85'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_85'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_2_85' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_2_85' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_2_85' aria-label='Start Date:: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_2_29\" class=\"gfield gfield--type-radio gfield--type-choice gf_inline gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class='gform-field-label__text'><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_29'>\n\t\t\t<div class='gchoice gchoice_2_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='AM'  id='choice_2_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_29_0' id='label_2_29_0' class='gform-field-label gform-field-label--type-inline'>AM<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Noon'  id='choice_2_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_29_1' id='label_2_29_1' class='gform-field-label gform-field-label--type-inline'>Noon<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='PM'  id='choice_2_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_29_2' id='label_2_29_2' class='gform-field-label gform-field-label--type-inline'>PM<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_87\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline 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_2_87'><span class='gform-field-label__text'>End Date:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_2_87'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_87'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_2_87' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_2_87' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_2_87' aria-label='End Date:: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_2_31\" class=\"gfield gfield--type-radio gfield--type-choice gf_inline gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class='gform-field-label__text'><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_31'>\n\t\t\t<div class='gchoice gchoice_2_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='AM'  id='choice_2_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_0' id='label_2_31_0' class='gform-field-label gform-field-label--type-inline'>AM<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Noon'  id='choice_2_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_1' id='label_2_31_1' class='gform-field-label gform-field-label--type-inline'>Noon<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='PM'  id='choice_2_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_2' id='label_2_31_2' class='gform-field-label gform-field-label--type-inline'>PM<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_32\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Type of Medication:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_32'>\n\t\t\t<div class='gchoice gchoice_2_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Oral'  id='choice_2_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_32_0' id='label_2_32_0' class='gform-field-label gform-field-label--type-inline'>Oral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Topical'  id='choice_2_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_32_1' id='label_2_32_1' class='gform-field-label gform-field-label--type-inline'>Topical<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_42\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>If Topical:<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_42'>\n\t\t\t<div class='gchoice gchoice_2_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Right Ear'  id='choice_2_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_42_0' id='label_2_42_0' class='gform-field-label gform-field-label--type-inline'>Right Ear<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Left Ear'  id='choice_2_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_42_1' id='label_2_42_1' class='gform-field-label gform-field-label--type-inline'>Left Ear<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_42_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Both Ears'  id='choice_2_42_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_42_2' id='label_2_42_2' class='gform-field-label gform-field-label--type-inline'>Both Ears<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_42_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Right Eye'  id='choice_2_42_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_42_3' id='label_2_42_3' class='gform-field-label gform-field-label--type-inline'>Right Eye<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_42_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Left Eye'  id='choice_2_42_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_42_4' id='label_2_42_4' class='gform-field-label gform-field-label--type-inline'>Left Eye<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_42_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Both Eyes'  id='choice_2_42_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_42_5' id='label_2_42_5' class='gform-field-label gform-field-label--type-inline'>Both Eyes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_43\" 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\"  ><br><\/div><div id=\"field_2_33\" class=\"gfield gfield--type-text gf_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_33'><span class='gform-field-label__text'>Frequency (AM):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_2_33' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_38\" class=\"gfield gfield--type-text gf_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_38'><span class='gform-field-label__text'>Frequency (Noon):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_39\" class=\"gfield gfield--type-text gf_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_39'><span class='gform-field-label__text'>Frequency (PM):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_2_39' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_60\" 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\"  ><br><\/div><div id=\"field_2_37\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_37'><span class='gform-field-label__text'>If medication is only to be given as needed, specify frequency, dosage, symptoms:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_2_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_63\" 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\"  ><br><\/div><div id=\"field_2_21\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Medication #2<\/h3><\/div><div id=\"field_2_45\" class=\"gfield gfield--type-text gf_left_half gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_45'><span class='gform-field-label__text'>Medication Name:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_2_45' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_45\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_2_45'>All medications are given between 7am-6pm<\/div><\/div><div id=\"field_2_47\" class=\"gfield gfield--type-text gf_right_half 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_2_47'><span class='gform-field-label__text'>Dosage (ex: 1 tablet 50mg, 1 drop):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_2_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_48\" 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\"  ><\/div><div id=\"field_2_88\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_88'><span class='gform-field-label__text'>Start Date:<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_2_88'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_88'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_2_88' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_2_88' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_2_88' aria-label='Start Date:: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_2_50\" class=\"gfield gfield--type-radio gfield--type-choice gf_inline gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class='gform-field-label__text'><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_50'>\n\t\t\t<div class='gchoice gchoice_2_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='AM'  id='choice_2_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_50_0' id='label_2_50_0' class='gform-field-label gform-field-label--type-inline'>AM<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Noon'  id='choice_2_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_50_1' id='label_2_50_1' class='gform-field-label gform-field-label--type-inline'>Noon<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_50_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='PM'  id='choice_2_50_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_50_2' id='label_2_50_2' class='gform-field-label gform-field-label--type-inline'>PM<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_89\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_89'><span class='gform-field-label__text'>End Date:<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_2_89'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_89'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_2_89' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_2_89' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_2_89' aria-label='End Date:: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_2_52\" class=\"gfield gfield--type-radio gfield--type-choice gf_inline gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class='gform-field-label__text'><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_52'>\n\t\t\t<div class='gchoice gchoice_2_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='AM'  id='choice_2_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_52_0' id='label_2_52_0' class='gform-field-label gform-field-label--type-inline'>AM<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Noon'  id='choice_2_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_52_1' id='label_2_52_1' class='gform-field-label gform-field-label--type-inline'>Noon<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_52_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='PM'  id='choice_2_52_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_52_2' id='label_2_52_2' class='gform-field-label gform-field-label--type-inline'>PM<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_53\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Type of Medication:<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_53'>\n\t\t\t<div class='gchoice gchoice_2_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Oral'  id='choice_2_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_53_0' id='label_2_53_0' class='gform-field-label gform-field-label--type-inline'>Oral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Topical'  id='choice_2_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_53_1' id='label_2_53_1' class='gform-field-label gform-field-label--type-inline'>Topical<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_54\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>If Topical:<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_54'>\n\t\t\t<div class='gchoice gchoice_2_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Right Ear'  id='choice_2_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_54_0' id='label_2_54_0' class='gform-field-label gform-field-label--type-inline'>Right Ear<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Left Ear'  id='choice_2_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_54_1' id='label_2_54_1' class='gform-field-label gform-field-label--type-inline'>Left Ear<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_54_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Both Ears'  id='choice_2_54_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_54_2' id='label_2_54_2' class='gform-field-label gform-field-label--type-inline'>Both Ears<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_54_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Right Eye'  id='choice_2_54_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_54_3' id='label_2_54_3' class='gform-field-label gform-field-label--type-inline'>Right Eye<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_54_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Left Eye'  id='choice_2_54_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_54_4' id='label_2_54_4' class='gform-field-label gform-field-label--type-inline'>Left Eye<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_54_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Both Eyes'  id='choice_2_54_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_54_5' id='label_2_54_5' class='gform-field-label gform-field-label--type-inline'>Both Eyes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_55\" 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\"  ><br><\/div><div id=\"field_2_56\" class=\"gfield gfield--type-text gf_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_56'><span class='gform-field-label__text'>Frequency (AM):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_2_56' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_57\" class=\"gfield gfield--type-text gf_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_57'><span class='gform-field-label__text'>Frequency (Noon):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_2_57' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_58\" class=\"gfield gfield--type-text gf_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_58'><span class='gform-field-label__text'>Frequency (PM):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_2_58' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_61\" 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\"  ><br><\/div><div id=\"field_2_59\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_59'><span class='gform-field-label__text'>If medication is only to be given as needed, specify frequency, dosage, symptoms:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_2_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_69\" 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\"  ><br><\/div><div id=\"field_2_68\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Medication #3<\/h3><\/div><div id=\"field_2_84\" class=\"gfield gfield--type-text gf_left_half gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_84'><span class='gform-field-label__text'>Medication Name:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_2_84' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_84\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_2_84'>All medications are given between 7am-6pm<\/div><\/div><div id=\"field_2_83\" class=\"gfield gfield--type-text gf_right_half 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_2_83'><span class='gform-field-label__text'>Dosage (ex: 1 tablet 50mg, 1 drop):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_2_83' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_75\" 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\"  ><br><\/div><div id=\"field_2_90\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_90'><span class='gform-field-label__text'>Start Date:<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_2_90'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_90'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_2_90' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_2_90' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_2_90' aria-label='Start Date:: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_2_80\" class=\"gfield gfield--type-radio gfield--type-choice gf_inline gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class='gform-field-label__text'><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_80'>\n\t\t\t<div class='gchoice gchoice_2_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='AM'  id='choice_2_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_80_0' id='label_2_80_0' class='gform-field-label gform-field-label--type-inline'>AM<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Noon'  id='choice_2_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_80_1' id='label_2_80_1' class='gform-field-label gform-field-label--type-inline'>Noon<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_80_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='PM'  id='choice_2_80_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_80_2' id='label_2_80_2' class='gform-field-label gform-field-label--type-inline'>PM<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_91\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_91'><span class='gform-field-label__text'>End Date:<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_2_91'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_91'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_2_91' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_2_91' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_2_91' aria-label='End Date:: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_2_78\" class=\"gfield gfield--type-radio gfield--type-choice gf_inline gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class='gform-field-label__text'><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_78'>\n\t\t\t<div class='gchoice gchoice_2_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='AM'  id='choice_2_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_78_0' id='label_2_78_0' class='gform-field-label gform-field-label--type-inline'>AM<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Noon'  id='choice_2_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_78_1' id='label_2_78_1' class='gform-field-label gform-field-label--type-inline'>Noon<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_78_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='PM'  id='choice_2_78_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_78_2' id='label_2_78_2' class='gform-field-label gform-field-label--type-inline'>PM<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_77\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Type of Medication:<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_77'>\n\t\t\t<div class='gchoice gchoice_2_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Oral'  id='choice_2_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_0' id='label_2_77_0' class='gform-field-label gform-field-label--type-inline'>Oral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Topical'  id='choice_2_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_1' id='label_2_77_1' class='gform-field-label gform-field-label--type-inline'>Topical<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_76\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>If Topical:<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_76'>\n\t\t\t<div class='gchoice gchoice_2_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Right Ear'  id='choice_2_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_76_0' id='label_2_76_0' class='gform-field-label gform-field-label--type-inline'>Right Ear<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Left Ear'  id='choice_2_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_76_1' id='label_2_76_1' class='gform-field-label gform-field-label--type-inline'>Left Ear<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_76_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Both Ears'  id='choice_2_76_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_76_2' id='label_2_76_2' class='gform-field-label gform-field-label--type-inline'>Both Ears<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_76_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Right Eye'  id='choice_2_76_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_76_3' id='label_2_76_3' class='gform-field-label gform-field-label--type-inline'>Right Eye<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_76_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Left Eye'  id='choice_2_76_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_76_4' id='label_2_76_4' class='gform-field-label gform-field-label--type-inline'>Left Eye<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_76_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Both Eyes'  id='choice_2_76_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_76_5' id='label_2_76_5' class='gform-field-label gform-field-label--type-inline'>Both Eyes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_82\" 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\"  ><br><\/div><div id=\"field_2_74\" class=\"gfield gfield--type-text gf_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_74'><span class='gform-field-label__text'>Frequency (AM):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_2_74' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_73\" class=\"gfield gfield--type-text gf_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_73'><span class='gform-field-label__text'>Frequency (Noon):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_2_73' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_72\" class=\"gfield gfield--type-text gf_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_72'><span class='gform-field-label__text'>Frequency (PM):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_2_72' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_71\" 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\"  ><br><\/div><div id=\"field_2_70\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_70'><span class='gform-field-label__text'>If medication is only to be given as needed, specify frequency, dosage, symptoms:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_2_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_67\" 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\"  ><br><\/div><div id=\"field_2_66\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Digital Signature<\/h3><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Sign Agreement<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='niAKOb2mY+B0D3RqubEwaUMcwdOUK6rSKTjkYuAdMGEfzD5I7bzXwoNzGkPqFzn\/c9o\/nYN9LD3PfneknAbYYVR6d7QUDaZDCB3AwJN8oflHQG0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-9","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.gochenauerpetresort.com\/forms\/wp-json\/wp\/v2\/pages\/9","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.gochenauerpetresort.com\/forms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.gochenauerpetresort.com\/forms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.gochenauerpetresort.com\/forms\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.gochenauerpetresort.com\/forms\/wp-json\/wp\/v2\/comments?post=9"}],"version-history":[{"count":10,"href":"https:\/\/www.gochenauerpetresort.com\/forms\/wp-json\/wp\/v2\/pages\/9\/revisions"}],"predecessor-version":[{"id":106,"href":"https:\/\/www.gochenauerpetresort.com\/forms\/wp-json\/wp\/v2\/pages\/9\/revisions\/106"}],"wp:attachment":[{"href":"https:\/\/www.gochenauerpetresort.com\/forms\/wp-json\/wp\/v2\/media?parent=9"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}