{"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 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_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'>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_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'>Owner 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_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'>Email<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'>Does your pet have any allergies?<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'>What condition\/ailment is your pet being treated for?<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\"  ><legend class='gfield_label gform-field-label' >Medication to be given in:<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'>Medication 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_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'>Dosage (ex: 1 tablet 50mg, 1 drop):<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'>Start Date:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_85' id='input_2_85' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_85_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_85_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_85' class='gform_hidden' value='https:\/\/www.gochenauerpetresort.com\/forms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/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\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><\/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'>End Date:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_87' id='input_2_87' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_87_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_87_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_87' class='gform_hidden' value='https:\/\/www.gochenauerpetresort.com\/forms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/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\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><\/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\"  ><legend class='gfield_label gform-field-label' >Type of Medication:<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\"  ><legend class='gfield_label gform-field-label' >If Topical:<\/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'>Frequency (AM):<\/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'>Frequency (Noon):<\/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'>Frequency (PM):<\/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'>If medication is only to be given as needed, specify frequency, dosage, symptoms:<\/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'>Medication Name:<\/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'>Dosage (ex: 1 tablet 50mg, 1 drop):<\/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'>Start Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_88' id='input_2_88' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_88_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_88_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_88' class='gform_hidden' value='https:\/\/www.gochenauerpetresort.com\/forms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/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\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><\/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'>End Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_89' id='input_2_89' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_89_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_89_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_89' class='gform_hidden' value='https:\/\/www.gochenauerpetresort.com\/forms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/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\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><\/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\"  ><legend class='gfield_label gform-field-label' >Type of Medication:<\/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\"  ><legend class='gfield_label gform-field-label' >If Topical:<\/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'>Frequency (AM):<\/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'>Frequency (Noon):<\/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'>Frequency (PM):<\/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'>If medication is only to be given as needed, specify frequency, dosage, symptoms:<\/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'>Medication Name:<\/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'>Dosage (ex: 1 tablet 50mg, 1 drop):<\/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'>Start Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_90' id='input_2_90' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_90_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_90_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_90' class='gform_hidden' value='https:\/\/www.gochenauerpetresort.com\/forms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/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\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><\/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'>End Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_91' id='input_2_91' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_91_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_91_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_91' class='gform_hidden' value='https:\/\/www.gochenauerpetresort.com\/forms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/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\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><\/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\"  ><legend class='gfield_label gform-field-label' >Type of Medication:<\/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\"  ><legend class='gfield_label gform-field-label' >If Topical:<\/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'>Frequency (AM):<\/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'>Frequency (Noon):<\/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'>Frequency (PM):<\/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'>If medication is only to be given as needed, specify frequency, dosage, symptoms:<\/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'> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Sign Agreement'  \/> \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' 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